Low-Cost Model for Battlefield Wound and Hemorrhage Training

ABSTRACT Introduction Exsanguination is the leading cause of preventable death on the battlefield and in austere environments. Multiple courses have been developed to save lives by stopping hemorrhage. Training for this requires simulation models; however, many models are expensive, preventing the further expansion of this life-saving training. We present a low-cost model for hemorrhage training and realistic moulage based on simple medical supplies and grocery store meats. Materials and Methods Wound packing training was completed by use of a block of pork shoulder roast with an incision simulating a wound and IV tubing connected to a syringe with fake blood. Hemostasis was obtained with proper wound packing by the student, causing the bleeding to be tamponaded. Wound moulage utilized remaining supplies of pork roast being attached to patient actors or mannequins and adorned with fake blood creating wounds with the appearance and feel of real tissues. Results Tactical Combat Casualty Care (TCCC) training was completed at a small military medical facility with a start-up cost of less than $70 and a single course as cheap as $15. These methods have been utilized to establish other TCCC training centers while keeping costs low. Conclusions We present low-cost models for simulating massive hemorrhage for wound packing with pork roast and realistic moulage. These methods can be utilized for other hemorrhage training courses such as TCCC, Advanced Wilderness Life Support, and Stop the Bleed.

Impact of Civilian Patient Care on Major Amputation Case Volume in the Military Health System

ABSTRACT Background Sustaining critical wartime skills (CWS) during interwar periods is a recurrent and ongoing challenge for military surgeons. Amputation surgery for major extremity trauma is exceptionally common in wartime, so maintenance of surgical skills is necessary. This study was designed to examine the volume and distribution of amputation surgery performed in the military health system (MHS). Study Design All major amputations performed in military treatment facilities (MTF) for calendar years 2017–2019 were identified by current procedural terminology (CPT) codes. The date of surgery, operating surgeon National Provider Identifier, CPT code(s), amputation etiology (traumatic versus nontraumatic), and beneficiary status (military or civilian) were recorded for each surgical case. Results One thousand one hundred and eighty-four major amputations at 16 of the 49 military’s inpatient facilities were identified, with two MTFs accounting for 46% (548/1,184) of the total. Six MTFs performed 120 major amputations for the treatment of acute traumatic injuries. Seventy-three percent (87/120) of traumatic amputations were performed at MTF1, with the majority of patients (86%; 75/87) being civilians emergently transported there after injury. Orthopedic and vascular surgeons performed 78% of major amputations, but only 9.7% (152/1,570) of all military surgeons performed any major amputation, with only 3% (52) involved in amputations for trauma. Nearly all (87%; 26/30) of the orthopedic surgeons at MTF1 performed major amputations, including those for trauma. Conclusion This study highlights the importance of civilian patient care to increase major amputation surgical case volume and complexity to sustain critical wartime skills. The preservation and strategic expansion of effective military–civilian partnerships is essential for sustaining the knowledge and skills for optimal combat casualty care.

Applying Pharmacogenomic Guidelines to Combat Medical Care

ABSTRACT Pharmacogenomics is a pillar of personalized medicine that has the potential to deliver optimized treatment in many medical settings. Military medicine in the deployed setting is unique and therefore warrants separate assessment pertaining to its potential capabilities and impact. Pharmacogenomics for United States Active Duty Service Members medical care in the deployed setting has not, to our knowledge, been previously reviewed. We present potential applications of pharmacogenomics to forward medical care through two comprehensive references for deployed medical care, the Tactical Combat Casualty Care Guidelines (TCCC) and Emergency War Surgery (EWS) fifth edition. All drugs within the deployment manuals, TCCC guidelines and EWS book, were identified and the list was cross-referenced to the Clinical Pharmacogenetics Implementation Consortium guidelines and genes–drugs interactions list as well as the Food and Drug Administration Table of Pharmacogenomics Biomarkers in Drug Labeling. Ten pharmacologic categories were identified, consisting of 15 drugs, along with the classes, aminogylcosides, beta-blockers, and volatile anesthetics. Drugs and pharmacogenomics liabilities were tabulated. Eight specific drugs or classes are expounded upon given the belief of the authors of their potential for impacting future treatment on the battlefield in the setting of prolonged field care. This review outlines several genes with liabilities in the prolonged field care setting and areas that may produce improved care with further study.

Performance gains from adaptive eXtended Reality training fueled by artificial intelligence

While virtual, augmented, and mixed reality technologies are being used for military medical training and beyond, these component technologies are oftentimes utilized in isolation. eXtended Reality (XR) combines these immersive form factors to support a continuum of virtual training capabilities to include full immersion, augmented overlays that provide multimodal cues to personalize instruction, and physical models to support embodiment and practice of psychomotor skills. When combined, XR technologies provide a multi-faceted training paradigm in which the whole is greater than the sum of the constituent capabilities in isolation. When XR applications are adaptive, and thus vary operational stressors, complexity, learner assistance, and fidelity as a function of trainee proficiency, substantial gains in training efficacy are expected. This paper describes a continuum of XR technologies and how they can be coupled with numerous adaptation strategies and supportive artificial intelligence (AI) techniques to realize personalized, competency-based training solutions that accelerate time to proficiency. Application of this training continuum is demonstrated through a Tactical Combat Casualty Care training use case. Such AI-enabled XR training solutions have the potential to support the military in meeting their growing training demands across military domains and applications, and to provide the right training at the right time.

Trends in Prehospital Blood, Crystalloid, and Colloid Administration in Accordance With Changes in Tactical Combat Casualty Care Guidelines

ABSTRACT Introduction Hemorrhage is the leading threat to the survival of battlefield casualties. This study aims to investigate the types of fluids and blood products administered in prehospital trauma encounters to discover the effectiveness of Tactical Combat Casualty Care (TCCC) recommendations. Materials and Methods This is a secondary analysis of a previously described dataset from the Department of Defense Trauma Registry with a focus on prehospital fluid and blood administration in conjunction with changes in the TCCC guidelines. We collected demographic information on each patient. We categorized receipt of each fluid type and blood product as a binary variable for each casualty and evaluated trends over 2007–2020 both unadjusted and controlling for injury severity and mechanism of injury. Results Our original dataset comprised 25,897 adult casualties from January 1, 2007 through March 17, 2020. Most (97.3%) of the casualties were male with a median age of 25. Most (95.5%) survived to hospital discharge, and 12.2% of the dataset received fluids of any kind. Medical personnel used crystalloids in 7.4% of encounters, packed red blood cells in 2.0%, and whole blood in 0.5% with very few receiving platelets or freeze-dried plasma. In the adjusted model, we noted significant year-to-year increases in intravenous fluid administration from 2014 to 2015 and 2018 to 2019, with significant decreases noted in 2008–2009, 2010–2012, and 2015–2016. We noted no significant increases in Hextend used, but we did note significant decreases in 2010–2012. For any blood product, we noted significant increases from 2016 to 2017, with decreases noted in 2009–2013, 2015–2016, and 2017–2018. Overall, we noted a general spike in all uses in 2011–2012 that rapidly dropped off 2012–2013. Crystalloids consistently outpaced the use of blood products. We noted a small upward trend in all blood products from 2017 to 2019. Conclusions Changes in TCCC guidelines did not immediately translate into changes in prehospital fluid administration practices. Crystalloid fluids continue to dominate as the most commonly administered fluid even after the 2014 TCCC guidelines changed to use of blood products over crystalloids. There should be future studies to investigate the reasons for delay in guideline implementation and efforts to improve adherence.

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

ABSTRACT 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.

Nigeria's north-east military strategy is failing

Significance This marks the highest-ranking combat casualty suffered by the Nigerian army to date and is part of a series of recent ISWAP attacks as the group transitions into another fighting season following the end of the rainy season. Impacts The military will soon look to launch another major operation into ISWAP-held territory. Absent more robust and flexible ground capabilities, newly delivered A-29 Super Tucano aircraft will have limited effect against ISWAP. Humanitarian services will be confronted by increasing risks.

An Analysis of Ketamine Doses Administrated to Nonintubated Casualties Prehospital

ABSTRACT Introduction Previous studies demonstrate that a significant proportion of casualties do not receive pain medication prehospital after traumatic injuries. To address possible reasons, the U.S. Military has sought to develop novel delivery methods to aid in administration of pain medications prehospital. We sought to describe the dose and route of ketamine administered prehospital to help inform materiel solutions. Materials and Methods This is a secondary analysis of a previously described dataset focused on prehospital data within the Department of Defense Trauma Registry from 2007 to 2020. We isolated encounters in which ketamine was administered along with the amount dosed and the route of administration in nonintubated patients. Results Within our dataset, 862 casualties met inclusion for this analysis. The median age was 28 and nearly all (98%) were male. Most were battle injuries (88%) caused by explosives (54%). The median injury severity score was 10 with the extremities accounting to the most frequent seriously injured body region (38%). The mean dose via intravenous route was 50.4 mg (n = 743, 95% CI 46.5-54.3), intramuscular was 66.7 mg (n = 234, 95% CI 60.3-73.1), intranasal was 56.5 mg (n = 10, 39.1-73.8), and intraosseous was 83.3 mg (n = 34, 66.3-100.4). Most had a medic or CLS in their chain of care (87%) with air evacuation as the primary mechanism of evacuation (86%). Conclusions The average doses administered were generally larger than the doses recommended by Tactical Combat Casualty Care guidelines. Currently, guidelines may underdose analgesia. Our data will help inform materiel solutions based on end-user requirements.

Immersive Virtual Reality: A Safe, Scalable, Non-opioid Analgesic for Military and Veteran Patients

In Iraq and Afghanistan over 75% of the combat casualties suffered by U.S. troops have involved explosive devices. Improvements in body armor and advances in military medicine have significantly reduced the number of combat-related fatalities, but have greatly increased the number of U.S. active component personnel suffering painful trauma injuries. Unfortunately, so far, advances in pharmacologic analgesia pain medications have not kept pace with advances in survivability. For many active component personnel and Veterans, pain is a top health complaint from patients. The opioid epidemic has increased the urgency of developing powerful non-pharmacologic approaches for the management of pain. Immersive VR is proving to be a powerful non-opioid pain management technique for acute pain. However, the cost and usability limitations of pre-2016 VR clinical products resulted in limited treatment adoption rates for clinical use. In recent years, VR technology has become increasingly immersive, portable, and miniaturized, requiring minimal technical expertise to operate, and low-cost, factors that are likely contributing to the recent increase in the clinical use of VR analgesia. VR is greatly benefitting from a growing string of major technological breakthroughs and VR treatment improvements that will likely continue to increase the effectiveness and suitability of VR analgesia for military and VA patients. Regarding acute pain, we propose that the next revision to the current Tactical Combat Casualty Care guidelines consider including VR as an effective and hemodynamically safe approach to the current management of acute trauma pain in military personnel during medical procedures. With recent miniaturization and ruggedization, VR can potentially be used closer to the battlefield in the future. Beyond distraction, innovative VR therapy techniques designed to help reduce chronic pain are discussed. Recent breakthroughs in the mass production of inexpensive, highly immersive lightweight stand alone VR systems and augmented reality systems increase the potential for widespread dissemination of VR analgesia for acute and potentially for chronic pain. For example, the U.S. military recently purchased 22 billion dollar’s worth of Microsoft Hololens mixed reality systems (e.g., for training). Expanded research and development of VR analgesia customized for the unique needs of military and VA patients is recommended.

Evaluating the Tactical Combat Casualty Care principles in civilian and military settings: systematic review, knowledge gap analysis and recommendations for future research

ObjectivesThe Tactical Combat Casualty Care (TCCC) guidelines detail resuscitation practices in prehospital and austere environments. We sought to review the content and quality of the current TCCC and civilian prehospital literature and characterize knowledge gaps to offer recommendations for future research.MethodsMEDLINE, EMBASE, CINAHL, and Cochrane Central Register of Controlled Trials were searched for studies assessing intervention techniques and devices used in civilian and military prehospital settings that could be applied to TCCC guidelines. Screening and data extraction were performed according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Quality appraisal was conducted using appropriate tools.ResultsNinety-two percent (n=57) of studies were observational. Most randomized trials had low risk of bias, whereas observational studies had higher risk of bias. Interventions of massive hemorrhage control (n=17) were wound dressings and tourniquets, suggesting effective hemodynamic control. Airway management interventions (n=7) had high success rates with improved outcomes. Interventions of respiratory management (n=12) reported low success with needle decompression. Studies assessing circulation (n=18) had higher quality of evidence and suggested improved outcomes with component hemostatic therapy. Hypothermia prevention interventions (n=2) were generally effective. Other studies identified assessed the use of extended focused assessment with sonography in trauma (n=3) and mixed interventions (n=2).ConclusionsThe evidence was largely non-randomized with heterogeneous populations, interventions, and outcomes, precluding robust conclusions in most subjects addressed in the review. Knowledge gaps identified included the use of blood products and concentrate of clotting factors in the prehospital setting.Level of evidenceSystematic review, level III.