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OBJECTIVE: As the United States Navy transitions from Operation Iraqi Freedom/Operation Enduring Freedom to preparing for a near-peer competition, an increasing focus of wartime strategy relies upon a network of distributed naval assets for total sea control, known as Distributed Maritime Operations (DMO). Historically, embedded medical personnel have provided care at sea in times of war. Recent reviews of shipboard and evacuated mass casualty incidents have alluded to weaknesses in the existing Navy Medicine approach that will require advances in care provision to sustain high-quality care that would benefit from industry and civilian academic collaboration. To gain input from civilian prehospital expertise and insight, the current DMO and Navy En-Route Care (ERC) systems must be plainly described for non-Navy military and civilian leaders, clinicians, and researchers to understand. METHODS: N/A. RESULTS: In this review, we translate US Navy structure and vernacular into common civilian and non-Navy language, describe the maritime role-tiered ERC system, elucidate the medical assets on each naval warship, and discuss clinician levels and capabilities while deployed to help communicate the inherent challenges of US Navy maritime medical care during routine operations, casualty treatment, stabilization, and evacuation. CONCLUSIONS: We describe the roles of care, clinician levels, and medical assets within the Navy ERC system for researchers and military leaders who aim to mitigate the inherent challenges of future maritime trauma care in the age of Distributed Maritime Operations. This paper lays the framework of the Navy deployed medical system to enable research in maritime en-route care, and prompt inclusion of identified solutions into common use in the US Navy.
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Serviços Médicos de Emergência , Incidentes com Feridos em Massa , Medicina Militar , Militares , Humanos , Estados Unidos , Guerra do Iraque 2003-2011RESUMO
INTRODUCTION: Eliminating points in the continuum of care that do not change management is a safe strategy for cost containment and workflow efficiency in health systems. As a process improvement initiative, we sought to identify whether routine, outpatient follow-up changes management in laparoscopic appendectomy in a military hospital. METHODS: We performed a retrospective chart review of adult patients undergoing laparoscopic appendectomy during a one-year period. The primary outcome was identification of a change in management during routine in person follow-up. Secondary outcomes included location of patient presentation with a post-operative event (clinic, emergency department, primary care provider), and if those visits changed management. Events were defined as any deviation from the typical post-operative course within 6 weeks of surgery, including abnormal specimen pathology. RESULTS: One-hundred and seventy-six appendectomies were performed over one year, and 148 patients met inclusion criteria (median age = 27, 66.9% male). Perforation was identified in 10.1% of patients. Seventeen-point-five percent of patients had a post-operative event, of which persistent pain was the most common. Only 2.0% of all patients saw a change in management at their routine in person follow-up appointment. Eighty percent of patients with any post-operative events sought care outside of their routine in person follow up appointments. No variable was independently associated with a change in management. CONCLUSION: Routine in-person clinical follow-up for laparoscopic appendectomy almost never changes management. Perforated appendicitis may be an indication for in-person follow-up. Considering a telemedicine model for post-operative follow-up of laparoscopic appendectomy patients will provide a safe and effective alternative to in-person clinic visits, while saving patients time and allowing providers the clinic freedom to prioritize more urgent and new patients.
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Apendicite , Laparoscopia , Adulto , Apendicectomia , Apendicite/cirurgia , Feminino , Seguimentos , Humanos , Masculino , Estudos RetrospectivosRESUMO
Throughout history, the maritime nations of the world have employed surgeons in sea-going service. The history of women in surgery and the military is well described, but no previous report exists describing the gender breakdown of past and current sea-going US Navy general surgeons. Using literature review, primary sources, personal interviews, and correspondence with Navy Medicine administrative leaders, this historical review describes the evolution of women providing surgical care at sea. During the 1800s and early 1900s, some of the earliest women surgeons in England, America, and Russia began their surgical careers in military service or providing combat casualty care. Women at sea served unpaid nursing roles in the 1700s and provided informal medical care in the 1800s. In 1913 and 1941, 2 different women held medical leadership roles aboard sea-going vessels. Four years after Congress allowed women to serve aboard combatant vessels, Dr Beth Jaklic became the first woman to serve as Ship's Surgeon aboard a US Navy warship in 1997. From 1997 to 2020, 19% of surgeons serving on aircraft carriers were women and one-half of the 20 general surgeons assigned to maritime surgical billets were women in 2022. War and the military environment historically have offered opportunities for women to break boundaries in the world of surgery. Navy Medicine's experience with women surgeons at sea serves as a positive example to the broader surgical community, especially "austere" practices and subspecialties with limited female representation.
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Militares , Cirurgiões , Feminino , HumanosRESUMO
The current United States Navy and North Atlantic Treaty Organization (NATO) maritime strategy is coalescing around the concept of Distributed Maritime Operations (DMOs) to prepare for future large-scale combat operations with peer or near-peer competitors. As a result, individual components of naval forces will be more geographically dispersed and oper- ating at a significant time and distance from higher levels of medical care. We developed a series of educational scenarios informed by real-world events to enhance the ability of Role 1 medical caregivers to apply the principles of Prolonged Ca- sualty Care during current routine, crisis, and contingency DMOs.
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INTRODUCT ION: The demands of future large-scale combat operations may require medics and corpsmen to increasingly perform expectant casualty care (ECC). However, no detailed guidelines currently exist for providing ECC within military medicine. To guide the development of education and training guidelines and advance team training of both medics and non-medics, an in-depth understanding is first needed regarding caregivers' experiences providing ECC in recent conflicts as well as perceived training gaps. Therefore, this study explored the experiences of medics and physicians providing ECC and investigated their perceptions of training needs in this area for future conflicts characterized by large-scale combat operations and prolonged casualty care operational settings. MATERIALS AND METHODS: We conducted an engaged qualitative phenomenological study to explore ECC training needs for future conflicts. We interviewed 9 senior health care professionals (medics and physicians) who had extensive combat and deployment experiences and served primarily in the Role 1 environment. The interviews averaged 45 min each and were conducted via phone. To analyze this interview data, we reviewed the interview transcripts and then noted terms, phrases, and concepts within the interview transcripts that we found to be salient to answering the research question. Our team then met to review these codes and grouped them into categories. These categories served as the themes of this study that illustrated the participants' perceptions and experiences. RESULTS: Five themes emerged from our data: (1) There is a current gap in ECC training for enlisted Role 1 caregivers throughout the military; (2) ECC training is needed to shift organizational culture; (3) ECC training should be comprehensive; (4) ECC training should be deliberate; and (5) Time is the greatest challenge to implementing ECC training. Our participants noted that developing guidelines and filling training gaps is not only critical for preparing Role 1 providers for effective and ethical military medical decision-making but also for addressing death and dying on the battlefield and building moral resilience across the medical corps. CONCLUSION: Our results provide direction for development of ECC clinical guidance and collective team training recommendations. Following these guidelines may increase life-saving capabilities on the far-forward battlefield and equip medical directors and medics to provide ethical and compassionate care to those who cannot be saved in the setting of limited resources and evacuation opportunities.
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Management of the patient with moderate to severe brain injury in any environment can be time consuming and resource intensive. These challenges are magnified while forward deployed in austere or hostile environments. This Joint Trauma System Clinical Practice Guideline provides recommendations for the treatment and medical management of casualties with moderate to severe head injuries in an environment where personnel, resources, and follow-on care are limited. These guidelines have been developed by acknowledging commonly recognized recommendations for neurosurgical and neuro-critical care patients and augmenting those evaluations and interventions based on the experience of neurosurgeons, trauma surgeons, and intensivists who have delivered care during recent coalition conflicts.
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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.
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Medicina Naval , Sepse , Humanos , Sepse/terapia , Navios , Militares/educação , Choque Séptico/terapia , Medicina Militar/métodos , Fatores de Tempo , Estados UnidosRESUMO
Introduction: Graduate Medical Education plays a critical role in training the next generation of military physicians, ensuring they are ready to uphold the dual professional requirements inherent to being both a military officer and a military physician. This involves executing the operational duties as a commissioned leader while also providing exceptional medical care in austere environments and in harm's way. The purpose of this study is to review prior efforts at developing and implementing military unique curricula (MUC) in residency training programs. Methods: We performed a literature search in PubMed (MEDLINE), Embase, Web of Science, and the Defense Technical Information Center through August 8, 2023, including terms "graduate medical education" and "military." We included articles if they specifically addressed military curricula in residency with terms including "residency and operational" or "readiness training", "military program", or "military curriculum". Results: We identified 1455 articles based on title and abstract initially and fully reviewed 111. We determined that 64 articles met our inclusion criteria by describing the history or context of MUC, surveys supporting MUC, or military programs or curricula incorporated into residency training or military-specific residency programs. Conclusion: We found that although there have been multiple attempts at establishing MUC across training programs, it is difficult to create a uniform curriculum that can be implemented to train residents to a single standard across services and specialties.
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BACKGROUND: Extremity tourniquets have proven to be lifesaving in both civilian and military settings and should continue to be used by first responders for trauma patients with life-threatening extremity bleeding. This is especially true in combat scenarios in which both the casualty and the first responder may be confronted by the imminent threat of death from hostile fire as the extremity hemorrhage is being treated. Not every extremity wound, however, needs a tourniquet. One of the most important aspects of controlling life-threatening extremity bleeding with tourniquets is to recognize what magnitude of bleeding requires this intervention and what magnitude of bleeding does not. Multiple studies, both military and civilian, have shown that tourniquets are often applied when they are not medically indicated. Overuse of extremity tourniquets has not caused excess morbidity in either the recent conflicts in Iraq and Afghanistan or in the US urban civilian setting. In the presence of prolonged evacuation, however, applying a tourniquet when it is not medically indicated changes tourniquet application from being a lifesaving intervention to one that may cause an avoidable amputation and the development of an array of metabolic derangements and acute kidney injury collectively called prolonged tourniquet application syndrome. METHODS: The recent literature was reviewed for papers that documented the complications of tourniquet use resulting from the prolonged casualty evacuation times being seen in the current Russo-Ukrainian war. The literature was also reviewed for the incidence of tourniquet application that was found to not be medically indicated, in both the US civilian setting and from Ukraine. Finally, an in-person meeting of the US/Ukraine Tourniquet Working Group was held in Warsaw, Poland, in December of 2023. RESULTS: Unnecessary loss of extremities and life-threatening episodes of prolonged tourniquet application syndrome are currently occurring in Ukrainian combat forces because of nonindicated tourniquet use combined with the prolonged evacuation time seen in the Russo-Ukrainian war. Specific numbers of the complications experienced as a result of tourniquet use by Ukrainian forces in the current conflict are treated as classified information and are not available, but multiple sources from the Ukrainian military medical personnel and from the US advisors providing medical assistance to Ukraine have all agreed that the problem is substantial. CONCLUSION: Unnecessary tourniquet morbidity might also occur in US forces in a variety of potential future combat scenarios in which evacuation to surgical care is delayed. Prehospital trauma training programs, including but not limited to tactical combat casualty care, place insufficient emphasis on the need to avoid leaving tourniquets in place when they are not medically indicated. This aspect of training should receive emphasis in future Tactical Combat Casualty Care (TCCC) and civilian first responder curriculum development. An interim ad hoc training solution on this topic is available at the websites noted in this articles. Additional training modalities may follow in the near future. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level V.
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Hemorragia , Torniquetes , Humanos , Hemorragia/terapia , Hemorragia/etiologia , Ucrânia , Lesões Relacionadas à Guerra/terapia , Guerra , Medicina Militar , Extremidades/irrigação sanguínea , Extremidades/lesõesRESUMO
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.
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Transfusão de Sangue , Medicina Militar , Humanos , Medicina Militar/métodos , Transfusão de Sangue/métodos , Estados Unidos , Bancos de Sangue , Ferimentos e Lesões/terapia , Militares , Lesões Relacionadas à Guerra/terapia , GuerraRESUMO
BACKGROUND: Several studies have indicated a decline in the number, types, and complexity of surgical procedures within military treatment facilities (MTFs). This study aims to determine what effect, if any, these downward trends have had on the relationship between the military health system (MHS) and surgical graduate medical education. METHODS: Graduating chief resident final ACGME case logs from 4 of thirteen military general surgery programs were evaluated from 2015 to 2020. The proportion of total cases performed by residents at military institutions were compared on a year over year basis. RESULTS: The proportion of cases performed within the military hospitals declined 3.27% each year between 2015 and 2020 (P < .0001) in 4 MTFs. All individual hospitals had significant declines in case volume except one (William Beaumont Army Medical Center) which increased 6.05% with each year, but also increased the number of MTF partnerships within its program (P < .0001). CONCLUSIONS: There has been a statistically significant decline over time in the proportion of cases logged by residents within the studied military treatment facilities. Investment into military hospitals to increase case numbers, case diversity, and complexity and/or acceptance of this gradual decline with greater shifting of educational workload onto civilian hospitals is required.
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Cirurgia Geral , Internato e Residência , Humanos , Estudos Retrospectivos , Competência Clínica , Educação de Pós-Graduação em Medicina , Carga de Trabalho , Cirurgia Geral/educaçãoRESUMO
BACKGROUND: Maritime activities have been associated with unique dangers to civilian and military sailors. We performed a retrospective cohort study analyzing injury mechanisms and clinical outcomes of casualties onboard US naval ships to determine common injury mechanisms, trends, and outcomes. We hypothesized there would be a downward trend of injuries and fatalities on US naval ships during the study period. METHODS: All mishaps recorded by the Naval Safety Command aboard active service US naval ships from 1970 through 2020 were reviewed. Only mishaps resulting in injury or fatality were included. Over time, injury mechanisms and casualty incidence rates were trended and compared based on medical capabilities. Ships without surgical capabilities were categorized as Role 1, and those with surgical capabilities as Role 2. RESULTS: There were a total of 3,127 casualties identified and analyzed, with 1,048 fatalities and 2,079 injuries. The injury mechanisms associated with the highest mortality included electrocution, blunt head trauma, fall from height, man overboard, and explosion. There was a decrease in the trend of mishaps resulting in casualties, fatalities, and injuries over the 50-year study period. The mortality rate for select severe injury mechanisms was higher on Role 1 capable platforms, compared with Role 2 (0.334 vs. 0.250, p < 0.05). CONCLUSION: Casualty incidences decreased over 50 years. However, mortality still remains high for certain mechanisms no matter the operational platform. Furthermore, Role 1 capable vessels have a higher overall mortality rate for severe injuries compared with Role 2. The authors propose training, process improvement, and technology-related solutions to improve outcomes on Role 1 capable naval vessels. LEVEL OF EVIDENCE: Prognostic and Epidemiological; Level IV.
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Militares , Navios , Masculino , Humanos , Estudos Retrospectivos , Incidência , Acidentes por QuedasRESUMO
Across disciplines, mentorship has been recognized as a key to success. Acute care surgeons, focused on the care of trauma surgery, emergency general surgery and surgical critical care, practice in a wide variety of settings and have unique mentorship needs across all phases of their career. Recognizing the need for robust mentorship and professional development, the American Association for the Surgery of Trauma (AAST) convened an expert panel entitled 'The Power of Mentorship' at the 81st annual meeting in September 2022 (Chicago, Illinois). This was a collaboration between the AAST Associate Member Council (consisting of surgical resident, fellow and junior faculty members), the AAST Military Liaison Committee, and the AAST Healthcare Economics Committee. Led by two moderators, the panel consisted of five real-life mentor-mentee pairs. They addressed the following realms of mentorship: clinical, research, executive leadership and career development, mentorship through professional societies, and mentorship for military-trained surgeons. Recommendations, as well as pearls and pitfalls, are summarized below.
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BACKGROUND: Experiences over the last three decades of war have demonstrated a high incidence of traumatic brain injury (TBI) resulting in a persistent need for a neurosurgical capability within the deployed theater of operations. Despite this, no doctrinal requirement for a deployed neurosurgical capability exists. Through an iterative process, the Joint Trauma System Committee on Surgical Combat Casualty Care (CoSCCC) developed a position statement to inform medical and nonmedical military leaders about the risks of the lack of a specialized neurosurgical capability. METHODS: The need for deployed neurosurgical capability position statement was identified during the spring 2021 CoSCCC meeting. A triservice working group of experienced forward-deployed caregivers developed a preliminary statement. An extensive iterative review process was then conducted to ensure that the intended messaging was clear to senior medical leaders and operational commanders. To provide additional context and a civilian perspective, statement commentaries were solicited from civilian clinical experts including a recently retired military trauma surgeon boarded in neurocritical care, a trauma surgeon instrumental in developing the Brain Injury Guidelines, a practicing neurosurgeon with world-renowned expertise in TBI, and the chair of the Committee on Trauma. RESULTS: After multiple revisions, the position statement was finalized, and approved by the CoSCCC membership in February 2023. Challenges identified include (1) military neurosurgeon attrition, (2) the lack of a doctrinal neurosurgical capabilities requirement during deployed combat operations, and (3) the need for neurosurgical telemedicine capability and in-theater computed tomography scans to triage TBI casualties requiring neurosurgical care. CONCLUSION: Challenges identified regarding neurosurgical capabilities within the deployed trauma system include military neurosurgeon attrition and the lack of a doctrinal requirement for neurosurgical capability during deployed combat operations. To mitigate risk to the force in a future peer-peer conflict, several evidence-based recommendations are made. The solicited civilian commentaries strengthen these recommendations by putting them into the context of civilian TBI management. This neurosurgical capabilities position statement is intended to be a forcing function and a communication tool to inform operational commanders and military medical leaders on the use of these teams on current and future battlefields. LEVEL OF EVIDENCE: Prognostic and Epidemiological; Level V.
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Lesões Encefálicas Traumáticas , Lesões Encefálicas , Medicina Militar , Militares , Humanos , Lesões Encefálicas Traumáticas/cirurgiaRESUMO
INTRODUCTION: The U.S. Navy routinely deploys aircraft carriers and amphibious assault ships throughout the world in support of U.S. strategic interests, each with an embarked single surgeon team. Surgeons and their teams are required to participate in lengthy pre-deployment shipboard certifications before each deployment. Given the well-established relationship of surgeon volume to patient outcome, we aim to compare the impact of land vs. maritime deployments on Navy general surgeon practice patterns. MATERIALS AND METHODS: Case logs and pre-deployment training initiation of land-based (n = 8) vs. maritime-based (n = 7) U.S. Navy general surgeons over a 3-year period (2017-2020) were compared. Average cases per week were plotted over 26 weeks before deployment. Student's t-test was utilized for all comparisons. RESULTS: Cases declined for both groups in the weeks before deployment. At 6 months (26 weeks) before deployment, land-based surgeons performed significantly more cases than their maritime colleagues (50.3 vs. 14.0, P = .009). This difference persisted at 16 weeks (13.1 vs. 1.9, P = .011) and 12 weeks (13.1 vs. 1.9, P = .011). Overall, surgeon operative volume fell off earlier for maritime surgeons (16 weeks) than land-based surgeons (8 weeks). Within 8 weeks of deployment, both groups performed a similarly low number of cases as they completed final deployment preparations. CONCLUSIONS: Surgeons are a critical component of combat causality care teams. In this analysis, we have demonstrated that both land- and maritime-based U.S. Navy surgeons have prolonged periods away from clinical care before and during deployments; for shipboard surgeons, this deficit is large and may negatively impact patient outcomes in the deployed maritime environment. The authors describe this discrepancy and provide practical doctrinal solutions to close this readiness gap.
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INTRODUCTION: Trauma surgery skills sustainment and maintenance of combat readiness present a major problem for military general surgeons. The Military Health System (MHS) utilizes the knowledge, skills, and abilities (KSA) threshold score of 14,000 as a measure of annual deployment readiness. Only 9% of military surgeons meet this threshold. Most military-civilian partnerships (MCPs) utilize just-in-time training models before deployment rather than clinical experiences in trauma at regular intervals (skills sustainment model). Our aim is to evaluate an established skills sustainment MCP utilizing KSAs and established military metrics. MATERIALS AND METHODS: Three U.S. Navy active duty general surgeons were embedded into an urban level-1 trauma center taking supervised trauma call at regular intervals prior to deployment. Operative density (procedures/call), KSA scores, trauma resuscitation exposure, and combat casualty care relevant cases (CCC-RCs) were reviewed. RESULTS: During call shifts with a Navy surgeon present an average 16.4 trauma activations occurred; 32.1% were category-1, 27.6% were penetrating, 72.4% were blunt, and 33.8% were admitted to the intensive care unit. Over 24 call shifts of 24 hours in length, 3 surgeons performed 39 operative trauma cases (operative density of 1.625), generating 11,683 total KSA points. Surgeons 1, 2, and 3 generated 5109, 3167, and 3407 KSA points, respectively. The three surgeons produced a total of 11,683 KSA points, yielding an average of 3,894 KSA points/surgeon. In total, 64.1% of operations fulfilled CCC-RC criteria. CONCLUSIONS: Based on this initial evaluation, a military surgeon taking two calls/month over 12 months through our regional skills sustainment MCP can generate more than 80% of the KSA points required to meet the MHS KSA threshold for deployment readiness, with the majority being CCC-RCs. Intangible advantages of this model include exposure to multiple trauma resuscitations while possibly eliminating just-in-time training and decreasing pre-deployment requirements.
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Background: The Military Health System must develop and sustain experienced surgical trauma teams while facing decreased surgical volumes both during and between deployments. Military trauma resources may enhance local trauma systems by accepting civilian patients for care at military treatment facilities (MTFs). Some MTFs may be able to augment their regional trauma systems by developing trauma center (TC) capabilities. The aim of this study was to evaluate the geographical proximity of MTFs to the continental US (CONUS) population and relative to existing civilian adult TCs, and then to determine which MTFs might benefit most from TC development. Methods: Publicly available data were used to develop a list of CONUS adult civilian level 1 and level 2 TCs and also to generate a list of CONUS MTFs. Census data were used to estimate adult population densities across zip codes. Distances were calculated between zip codes and civilian TCs and MTFs. The affected population sizes and reductions in distance were tabulated for every zip code that was found to be closer to an MTF than an existing TC. Results: 562 civilian adult level 1 and level 2 TCs and 33 military medical centers and hospitals were identified. Compared with their closest civilian TCs, MTFs showed mean reductions in distance ranging from 0 to 30 miles, affecting populations ranging from 12 000 to over 900 000 adults. Seven MTFs were identified that would offer clinically significant reductions in distance to relatively large population centers. Discussion: Some MTFs may offer decreased transit times and improved care to large adult populations within their regional trauma systems by developing level 1 or level 2 TC capabilities. The results of this study provide recommendations to focus further study on seven MTFs to identify those that merit further development and integration with their local trauma systems. Level of evidence: IV.
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BACKGROUND: Military involvement in Afghanistan ended in 2021, and while low-intensity troop engagements continue globally, casualty numbers are dwindling. To understand the clinical and operational connections between blood utilization and clinical paradigm shifts in resuscitation strategies, a review of blood product utilization and the changes in the last decade was conducted within the US Central Command area of responsibility. The intent of this review was to assess patterns of blood use during the last decade of the United States' involvement in the most recent major conflicts to potentially inform future blood requirements. METHODS: Blood product and types transfused between January 1, 2011, and December 31, 2020, were acquired from the Medical Situational Awareness in Theater blood reports. All reported blood usage data in the US Central Command area of responsibility were queried. RESULTS: Packed red blood cells and fresh frozen plasma (FFP) usage showed no statistically significant change over time ( τb = 0.24, p = 0.3252; τb = -0.47, p = 0.0603). Fresh and stored whole blood (SWB) use increased overtime ( τb = 0.69, p = 0.0056; τb = 0.83, p = 0.0015). A strong inverse relationship was found between SWB and FFP usage ( r = -0.68, p = 0.0309) and liquid plasma and FFP usage ( r = -0.65, p = 0.0407) over time. CONCLUSION: Whole blood usage increased significantly over time with a preference for SWB. Component therapy is anticipated to remain a critical element of resuscitation in the event of large-scale combat operations secondary to supply chain and longer storage times. LEVEL OF EVIDENCE: Therapeutic/care management; Level III.
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Medicina Militar , Militares , Transfusão de Sangue , Humanos , Plasma , Ressuscitação , Estados UnidosRESUMO
Purpose of Review: The US Navy has a long history of responding to disasters around the globe. US Navy ships have unique characteristics and capabilities that determine their capacity for a disaster response. This paper discusses common considerations and lessons learned from three distinct disaster missions. Recent Findings: The 2010 earthquake in Haiti had a robust response with multiple US Navy ship platforms. It was best assessed in three phases: an initial mass casualty response, a subacute response, and a humanitarian response. The 2017 response to Hurricane Maria had a significant focus on treating patients with acute needs secondary to chronic illnesses to decrease the burden on the local healthcare system. The COVID-19 response brought distinctive challenges as it was the first mission where hospital ships were utilized in an infectious disease deployment. Summary: The first ships to respond to a disaster will need to focus on triage and acute traumatic injury. After this first phase, the ship's medical assets will need to focus on providing care in a disrupted health care system which most often includes acute exacerbations of chronic disease. Surgeons must be ready to be flexible in their responsibilities, be competent with end-of-life care, and negotiate technical and cultural communication challenges.
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BACKGROUND: Most telemedicine modalities have limited ability to enhance procedural and operative care. We developed a novel system to provide synchronous bidirectional expert mixed reality-enabled virtual procedural mentoring. In this feasibility study, we evaluated mixed reality mentoring of combat casualty care related procedures in a re-perfused cadaver model. METHODS: Novices received real-time holographic mentoring from experts using augmented reality via Hololens (Microsoft Inc, Redmond, WA). The experts maintained real-time awareness of the novice's operative environment using virtual reality via HTC-Vive (HTC Corp, Xindian District, Taiwan). Additional cameras (both environments) and novel software created the immersive, shared, 3-dimensional mixed reality environment in which the novice and expert collaborated. The novices were prospectively randomized to either mixed reality or audio-only mentoring. Blinded experts independently evaluated novice procedural videos using a 5-point Likert scale-based questionnaire. Nonparametric variables were evaluated using the Wilcoxon rank-sum test and comparisons using the χ2 analysis; significance was defined at P < .05. RESULTS: Surgeon and nonsurgeon novices (14) performed 69 combat casualty care-related procedures (38 mixed reality, 31 audio), including various vascular exposures, 4-compartment lower leg fasciotomy, and emergency neurosurgical procedures; 85% were performed correctly with no difference in either group. Upon video review, mixed reality-mentored novices showed no difference in procedural flow and forward planning (3.67 vs 3.28, P = .21) or the likelihood of performing individual procedural steps correctly (4.12 vs 3.59, P = .06). CONCLUSION: In this initial feasibility study, our novel mixed reality-based mentoring system successfully facilitated the performance of a wide variety of combat casualty care relevant procedures using a high fidelity re-perfused cadaver model. The small sample size and limited variety of novice types likely impacted the ability of holographically mentored novices to demonstrate improvement over the audio-only control group. Despite this, using virtual, augmented, and mixed reality technologies for procedural mentoring demonstrated promise, and further study is needed.