Comparison of the Scope of Practice of the Army Combat Medic Specialist and Civilian National EMS Certification Levels.

INTRODUCTION: The transition of Army Combat Medic Specialists (Military Occupational Specialty Code: 68W) from military to civilian emergency medical services (EMS) is challenging, and the pathway is not clearly defined. Our objective was to evaluate the current military requirements for 68W and how they compare to the 2019 EMS National Scope of Practice Model (SoPM) for the civilian emergency medical technician (EMT) and advanced emergency medical technician (AEMT). METHODS: This was a cross-sectional evaluation of the 68W skill floor as defined by the Soldier's Manual and Trainer's Guide Healthcare Specialist and Medical Education and Demonstration of Individual Competence in comparison to the 2019 SoPM, which categorizes EMS tasks into seven skill categories. Military training documents were reviewed and extracted for specific information on military scope of practice and task-specific training requirements. Descriptive statistics were calculated. RESULTS: Army 68Ws were noted to perform all (59/59) tasks that coincide with the EMT SoPM. Further, Army 68W practiced above scope in the following skill categories: airway/ventilation (3 tasks); medication administration route (7 tasks); medical director approved medication (6 tasks); intravenous initiation maintenance fluids (4 tasks); and miscellaneous (1 task). Army 68W perform 96% (74/77) of tasks aligned with the AEMT SoPM, excluding tracheobronchial suctioning of an intubated patient, end-tidal CO2 monitoring or waveform capnography, and inhaled nitrous oxide monitoring. Additionally, the 68W scope included six tasks that were above the SoPM for AEMT; airway/ventilation (2 tasks); medication administration route (2 tasks); and medical director approved medication (2 tasks). CONCLUSIONS: The scope of practice of U.S. Army 68W Combat Medics aligns well with the civilian 2019 Scope of Practice Model for EMTs and AEMTs. Based on the comparative scope of practice analysis, transitioning from Army 68W Combat Medic to civilian AEMT would require minimal additional training. This represents a promising potential workforce to assist with EMS workforce challenges. Although aligning the scope of practice is a promising first step, future research is needed to assess the relationship of Army 68Ws training with state licensure and certification equivalency to facilitate this transition.

Results of combat medic junctional tourniquet training: a prospective, single-blind, randomized, cross-over study.

BACKGROUND: Bleeding remains the leading cause of potentially preventable deaths both in military and civilian pre-hospital trauma settings. Conventional extremity tourniquets do not control bleeding if an iliac artery or a common femoral artery is injured. Stopping junctional bleeding is particularly challenging and requires the use of specifically designed junctional tourniquets. SAM® Junctional Tourniquet (SJT®, United States of America) and Tactical Abdominal Junctional Tourniquet (T-AJT®, Fora Group Türkiye) have been actively used by Turkish security forces. This study questioned the effect of training on combat medics' successful junctional tourniquet applications and application times (AT). METHODS: Our research on two different junctional tourniquet models was designed as a prospective randomized, crossover, single-blinded study. All 40 participants in the study were attendees of a 12-week combat medic training course with updated medical approvals, which were used as an eligibility criterion. Randomization was performed by drawing T-AJT®-SJT cards. The study consisted of pretraining and after-training tourniquet application phases. In each study phase, all participants' AT and the presence or absence of arterial flow were recorded for each group. Finally, the combat medics were presented with a 6-question survey. RESULTS: Although training increased successful T-AJT® application rates, training was not statistically significantly associated with successful applications for any tourniquet types (p>0.05). The pretraining phase ATs for SJT® and T-AJT® were 55±11.8 and 93.8±2.9 seconds, respectively, and the difference was statistically significantly different (p<0.001). Likewise, after-training phase ATs for SJT® and T-AJT® were 49±22.6 and 79.2±17.5 seconds, respectively, and participants' SJT® ATs were significantly shorter (p<0.001). Overall, when participants' applied any of the tourniquet unsuccessfully, the odds of participants' lower Visual Analogue Scale scores were 0.2 (95% CI [0.08, 0.49]. p<0.001). CONCLUSION: Our study basically investigates the effects of training on effective tourniquet application. Unfortunately, our after-training success rates remained unsatisfactory when compared to other studies. This is also the first study on T-AJT® tourniquet application, and further studies on its efficacy are also required.

Combat Medics' Preparedness to Serve as Behavioral Health Extenders in Forward Environments.

INTRODUCTION: Future multidomain operational combat environments will require combat medics to play a larger role in managing behavioral health (BH) conditions in forward environments, as soldiers in small teams may have them as their sole medical support for extended periods of time. Previously they were not expected to serve in this role, and thus, they receive minimal BH training. It is unknown to what extent combat medics consider BH tasks as falling within their scope of practice and how often they engage with their soldiers currently related to BH. Qualitative research suggests that many medics feel inadequately prepared to handle BH problems. Our aim is to further assess medic attitudes and behaviors related to BH to better understand the landscape of medic preparedness to fill an expanded role. MATERIALS AND METHODS: Data from 292 medics were collected before their participation in the BH Guidelines for mEdic Assessment and Response training, a day-long training for medics expected to deploy to far-forward environments. We investigated whether combat medics engage with their soldiers in areas related to BH, the extent to which they consider BH-related tasks as part of their scope of practice, and how confident they feel engaging in various BH-related tasks. We explored associations between medics' attitudes related to BH scope of practice and confidence performing BH tasks with gender, rank, component (National Guard vs. Active Duty), work-related BH experience, having suicide training in the past year, and having ever sought help for BH. RESULTS: Results indicated that in the past month, 61.4% of medics discussed BH issues, 48.3% assessed BH problems, and 41.3% provided interventions for BH problems with at least one soldier in their unit. Assessment tasks were more frequently endorsed as falling within medic's scope of practice (75%-95%) than intervention tasks (62%-83%). More medics felt confident doing assessments (39%-49% moderately confident or greater) than providing interventions (31%-37% moderately confident or greater). Medics expressed highest confidence in assessing for suicide risk (49% moderate confidence or greater). Medics with a lot of prior BH work experience and non-commissioned officers (as compared to junior enlisted) reported greater confidence in most tasks. Receiving suicide training in the past year was associated with greater confidence assessing for suicide, as well as providing interventions for suicide, general BH problems, and substance abuse. CONCLUSIONS: Most medics agreed that numerous BH tasks fell within the scope of their work, but few felt confident engaging in those tasks. These findings support a need for additional training in BH-related tasks across the force. Exploring ways to provide medics BH-related work rotations would augment their general proficiency as first-line treatment providers for soldiers in combat units, and increased training in BH-related tasks should be studied to determine its ability to increase competency and confidence. If medics can learn to assess and recognize BH concerns before they escalate to needing specialty BH care, this could potentially reduce the burden on BH clinics, as well as strengthen the overall force.

Telemedicine-Guided Two-Incision Lower Leg Fasciotomy Performed by Combat Medics During Tactical Combat Casualty Care: A Feasibility Study.

INTRODUCTION: During tactical combat casualty care, life- and limb-saving procedures might also be performed by combat medics. This study assesses whether it is feasible to use a head-mounted display (HMD) to provide telemedicine (TM) support from a consulted senior surgeon for combat medics when performing a two-incision lower leg fasciotomy. MATERIALS AND METHODS: Nine combat medics were randomized into groups to perform a two-incision lower leg fasciotomy. One group used the Vuzix M400 and the second group used the RealWear HMT-1Z1. A third, control, group received no guidance. In the Vuzix M400 group and RealWear HMT-1Z1 group, a senior surgeon examined the results after the two-incision lower leg fasciotomy was finished to assess the release of compartments, possible collateral damage, and performance of the combat medics. In the control group, these results were examined by a surgical resident with expertise in two-incision lower leg fasciotomies. The resident's operative performance questionnaire was used to score the performance of the combat medics. The telehealth usability questionnaire was used to evaluate the usability of the HMDs as perceived by the combat medics. RESULTS: Combat medics using an HMD were considered competent in performing a two-incision lower leg fasciotomy (Vuzix: median 3 [range 0], RealWear: median 3 [range 1]). These combat medics had a significantly better score in their ability to adapt to anatomical variances compared to the control group (Vuzix: median 3 [range 0], RealWear: median 3 [range 0], control: median 1 [range 0]; P = .018). Combat medics using an HMD were faster than combat medics in the control group (Vuzix: mean 14:14 [SD 3:41], RealWear: mean 15:42 [SD 1:58], control: mean 17:45 [SD 2:02]; P = .340). The overall satisfaction with both HMDs was 5 out of 7 (Vuzix: median 5 [range 0], RealWear: median 5 [range 1]; P = .317). CONCLUSIONS: This study shows that it is feasible to use an HMD to provide TM support performance from a consulted senior surgeon for combat medics when performing a two-incision lower leg fasciotomy. The results of this study suggest that TM support might be useful for combat medics during tactical combat casualty care when performing life- and limb-saving procedures.

Designing Novel Physiologic Monitor Displays for Combat Medics.

INTRODUCTION: Combat medics who are responsible for the care of injured warfighters face challenges from their reliance on medical alarms that exceed the noise levels recommended by the WHO. This is because the elevated noise levels in military facilities, particularly from vehicular units and weaponry, compromise the combat medics' effectiveness and attentiveness to medical alarms. We previously designed a graphical ("configural") display to communicate patients' vital signs and found that when the configural display and traditional numerical display were concurrently presented to participants, it produced the fastest identification of patient vital signs and triggered the fewest number of alarms. This study used eye tracking to assess how participants direct visual attention to and engage with concurrently presented numerical and configural vital sign displays. MATERIALS AND METHODS: We recruited 30 undergraduate students with normal hearing and vision for this study. Subjects were tasked with monitoring a simulated patient's vital signals using simultaneously presented numerical and configural vital sign displays. Concurrently, they performed an N-back task to simulate the multitasking required in a military environment. We manipulated the eccentricity and display position of the numerical and configural displays through 4 orientations, with each orientation being used in a monitoring block lasting 12 minutes. Continuous eye tracking was utilized to collect physiological data about participant display preference. RESULTS: We used eye tracking to analyze several metrics: Total display viewing time, total viewing time percentage, number of dwells (groups of eye fixations), mean fixations per dwell, and fixation patterns during an emergency event. Participants spent more time looking at the configural display than the numerical display during nominal monitoring and emergency events. During emergencies, the percentage of time individuals spent looking at the configural display increased from 30 to 50%, while there was no corresponding increase in the participants' looking at the numerical display. When there were 2 concurrent emergency events instead of 1, total viewing time did not increase, suggesting that participants did not need to change their viewing strategy when the emergency situation complexity increased. Also, during emergencies, participants directed nearly half of their fixations to the configural display during the first 2 seconds of an emergency, while only directing fewer than 5% of fixations to the numerical display during that same period. The average response time for an emergency event was around 2 seconds, which suggests that participants obtained relevant information from the configural display in this time period. CONCLUSIONS: We found that when a patient monitor contains both a configural display and a numerical display, participants look at the configural display. Furthermore, during time-sensitive situations, participants utilize the configural display to provide important information. We suggest this because the configural display integrates the relevant vital signs into one display. These findings provide justification for pursuing integrated vital sign displays to efficiently communicate patient conditions in complex environments. On the battlefield, swift decision-making is essential, as combat medics must minimize the time required to assess and act in critical situations.

Telemedicine Improves Performance of a Two-Incision Lower Leg Fasciotomy by Combat Medics: A Randomized Controlled Trial.

INTRODUCTION: The primary aim of this randomized controlled trial was to assess if a head-mounted display (HMD) providing telemedicine support improves performance of a two-incision lower leg fasciotomy by a NATO special operations combat medic (combat medic). MATERIALS AND METHODS: Thirty-six combat medics were randomized into two groups: One group performed a two-incision lower leg fasciotomy with the assistance of an HMD, while the control group completed the procedure without guidance. A Mann-Whitney U test was used to determine the possible differences in release of compartments and performance scores, as assessed by a supervising medical specialist. A Fisher's exact test was used to compare the proportions of collateral damage between groups. An independent-samples t-test was used to interpret total procedure times. The usability and technical factors involving HMD utilization were also assessed. RESULTS: Combat medics in the HMD group released the anterior compartment (P ≤ .001) and deep posterior compartment (P = .008) significantly better. There was significantly more iatrogenic muscle (P ≤ .001) and venous damage (P ≤ .001) in the control group. The overall performance of combat medics in the HMD group was significantly better than that of the control group (P < .001). Combat medics in the control group were significantly faster (P = .012). The combat medics were very satisfied with the HMD. The HMD showed no major technical errors. CONCLUSIONS: This randomized controlled trial shows that a HMD providing telemedicine support leads to significantly better performance of a two-incision lower leg fasciotomy by a combat medic with less iatrogenic muscle and venous damage.

Usability Enhancements to a Prototype Clinical Decision Support System for Combat Medics.

INTRODUCTION: A Clinical Decision Support System that provides just-in-time medical guidance at the point of injury is being developed. To develop a user interface, a user-centered design approach was taken. MATERIALS AND METHODS: To evaluate the system, personas of the users were created, a comparative analysis of the system against the Tactical Combat Casualty Care Card and Battlefield Assisted Trauma Distributed Observation Kit was completed, and user testing was performed. RESULTS: Many design recommendations were gathered from the user-centered design approach including replacing buttons with a homunculus, replacing prompts with a tree and node system, and allowing more user freedom in working with the system. CONCLUSIONS: Through multiple different evaluations, design recommendations for a clinical decision support system were implemented in an iterative process. More iterations and more formalized user testing are planned to maximize the usability of the system.

Abdominal Aortic Junctional Tourniquet - Stabilized (AAJTS) can be applied both successfully and rapidly by Combat Medical Technicians (CMTs).

BACKGROUND: 'Non-compressible' haemorrhage is the leading cause of preventable battlefield death, often requiring surgical or radiological intervention, which is precluded in the pre-hospital environment. One-fifth of such bleeds are junctional and therefore potentially survivable. We examine the use of the Abdominal Aortic Junctional Tourniquet - Stabilized (AAJTS) among UK Combat Medical Technicians (CMTs) as a device to control junctional haemorrhage with external compression of the abdominal aorta-compression of junctional haemorrhage previously considered 'non-compressible.' This follows animal studies showing that the AAJTS achieves control of haemorrhage and improves physiological parameters. METHODS: CMTs were selected and applied the AAJTS to each other following a 1-hour training package. A consultant radiologist-operated hand-held ultrasound monitored flow changes in the subjects' common femoral artery. CMTs were then surveyed for their opinions as to utility and function. RESULTS: 21 CMTs were screened and 17 CMTs participated with 34 total applications (16 day and 18 low-light). 27/34 (79%) achieved a successful application. The median application time was 75 s in daylight and 57 s in low-light conditions. There was no significant difference in Body Mass Index (p=0.23), median systolic blood pressure (p=0.19), nor class of CMT (p=0.10) between successful and unsuccessful applications. Higher systolic blood pressure was associated with longer application times (p=0.03). Users deemed the device easy to use (median score 4.4 on a 5-point Likert scale). CONCLUSION: CMTs can use AAJTS successfully after a 1-hour training session in the majority of applications. Application was successful in both daylight and low-light conditions. Self-reported usability ratings were high.

Assessing Baseline Proficiency of National Guard Combat Medics Due for Recertification: A Pilot Study.

INTRODUCTION: Combat medics, or 68W Healthcare Specialists in the Army, are an early part of a combat casualty's chain of survival. Their job requires a high degree of competency in emergency medical guidelines established by the Committee of Tactical Combat Casualty Care (CoTCCC) as well as basic bleeding control skills. The American Warfighting Experience for the last two decades highlights just how important these skills are in preventing death on the battlefield. A recent Government Office of Accountability suggests sustainment for critical wartime skills is lacking. This is especially concerning for National Guard Soldiers who must juggle their military obligations with their civilian ones. It is unknown how well-prepared National Guard combat medics are in fulfilling their most critical combat care responsibilities. The current study attempts to address this gap in knowledge by assessing National Guard Soldiers due for their annual recertification. MATERIALS AND METHODS: Nine medics due for their annual recertification were recruited for the study. First, they were given a questionnaire intended to gather basic demographic information about their experience and a six-question quiz on current CoTCCC guidelines. The medics were then evaluated on their ability to place a Combat Application Tourniquet on a live person, which was verified by a Doppler microphone. The medics were finally evaluated on their ability to pack a wound with a hemostatic dressing. Statistical analysis was used to determine if experience or frequency of practice over the previous year could predict success. RESULTS: Medics, on average, were only able to answer an average of 2.2 questions on the quiz correctly. The overall success rate for tourniquet application was 44.4%, and the overall success rate for wound packing was 22.2%. Statistical analysis showed that experience or frequency of practice could not adequately explain the success rates. CONCLUSIONS: A soldier's experience alone could not predict if the soldier will be successful in performing bleeding control tasks or if they will demonstrate higher levels of casualty care knowledge. Future research is needed in this area to better define recertification and refresher training issues.

Development of Training to Prepare Army Medics to Address Behavioral Health Needs of Soldiers in Far-Forward Environments Utilizing Mobile App Technology.

INTRODUCTION: Multi-domain operational combat environments will likely restrict key components of current behavioral health (BH) service delivery models. Combat teams in far-forward outposts or extended missions may need to rely on their own internal assets to manage combat and operational stress reactions for extended periods of time. As such, combat medics are expected to take on additional responsibilities as providers of BH support for isolated teams. As they receive limited BH training, medics require additional training to sufficiently respond to combat and operational stress reactions in their assigned teams. This study provided combat medics with a BH training and a mobile application-based support tool that would assist them in identifying and responding to BH concerns in their soldiers. The current analysis examines pre- to post-training changes in attitudes related to utilizing BH skills. MATERIALS AND METHODS: We created a brief training aimed to increase medics' ability and confidence regarding managing BH issues. Its development was part of a study on the feasibility of the Soldier and Medic Autonomous Connectivity Independent System for Remote Environments (AIRE) apps (NOCTEM, LLC), a digital system designed for far-forward BH and sleep monitoring and management. Participants were combat medics from two Army combat brigades preparing for a training rotation through a combat training center (CTC). A total of 16 medics consented to participation with nine medics available at the follow-up after the field exercise. Medics were surveyed before the training and after their return from the CTC. RESULTS: In pre-training surveys, most medics indicated it was within their scope to assess for stress/anxiety, suicidal risk, stress reaction, and sleep problems; assist soldiers with optimizing work performance; and provide interventions for BH concerns and sleep problems. Less than half believed it was within their scope to assess and address team communication issues or provide intervention for stress reactions. After the CTC rotation, more medics endorsed that it was in their scope to provide interventions for acute stress reactions to traumatic events. Before the CTC rotation, at most 60% of the group felt at least moderately confident in utilizing the BH skills of discussing problems, assessing for concerns, and providing interventions. After CTC, the confidence levels for each skill increased or remained the same for most medics. Intervention skills had the highest proportion of medics (66%) reporting increased confidence in using the skills. CONCLUSIONS: A larger proportion of medics believed it was within their scope of work and felt confident in assessing BH problems, and a smaller proportion believed it is within their scope of work and felt confident in applying interventions. The training increased most medics' confidence to administer interventions for BH and team communication issues. Similar training programs can help medics serve as support for a wide variety of circumstances when the brigade's mental health teams are inaccessible. Additionally, the Medic AIRE app expanded the ability to evaluate and provide interventions without extensive training in treatment modalities or BH conditions. This concept shows promise for providing medics with actionable tools when training time is limited such as during preparation for extended deployments.

Eduardo Odio Pérez, un médico cubano que combatió al fascismo en España / Eduardo Odio Pérez, a Cuban doctor who fought fascism in Spain

En la Guerra Civil Española participaron médicos cubanos que integraron la sanidad militar de las fuerzas republicanas; un tema que ha suscitado diversos estudios, pero del que quedan aún aspectos por investigar. El presente trabajo se enfoca en un médico cubano que participó en la gesta internacionalista en España, el doctor Eduardo Odio Pérez. Nació en Santiago de Cuba y se graduó de médico en los EE. UU. El objetivo es contribuir al conocimiento de los médicos cubanos que participaron en la lucha contra el fascismo en España. Los resultados hacen referencia a su participación como integrante de la sanidad militar de la XV Brigada Internacional Abraham Lincoln. Prestó servicios en hospitales militares, donde se atendieron las bajas sanitarias de importantes acciones combativas del conflicto armado, como la batalla del Jarama. Alcanzó el grado de capitán y solicitó el ingreso al Partido Comunista Español. Su contribución a la lucha contra el fascismo en España es una muestra de internacionalismo y un modelo referencial para el trabajo educativo en la formación médica.

Cuban doctors participated in the Spanish Civil War as part of the military health service of the Republican forces; a topic that has been the subject of several studies, but aspects of which still remain to be investigated. The present work focuses on a Cuban physician who participated in the internationalist heroic deed in Spain, Dr. Eduardo Odio Perez. He was born in Santiago de Cuba, and graduated as a doctor in the U.S.A. The objective is to contribute to the knowledge of Cuban doctors who participated in the fight against fascism in Spain. The results refer to his participation as a member of the military health service of the XV International Abraham Lincoln Brigade. He served in military hospitals, where he attended the medical casualties of important combat actions of the armed conflict, such as the battle of Jarama. He reached the rank of captain and applied to join the Spanish Communist Party. His contribution to the fight against fascism in Spain is an example of internationalism and a reference model for educational work in medical training.