Military Medicine Needs Reliable Clinical Signs and Tests to Guide Prognosis and Management

Abstract

During missions abroad, military physicians face very special circumstances to provide care for wounded and ill comrades. These circumstances are defined by the need to provide the best possible, state-of-the-art care, which is undoubtedly the main goal of their duty. However, the clinical setting situated in or near the combat zone has several limitations, all of which must to be taken into account. This is especially relevant to military medicine as working with notoriously scarce resources has always been one of the main challenges since its beginnings. However, this burden is not unique to military physicians. Limited resources, especially in developing countries and rural areas, affect medical personnel around the world in various manners. The diagnostic possibilities in a military medical facility are limited. For example, the German role 3 field hospital in Mazar-e-Sharif, International SecurityAssistance Force (ISAF), is comparably well equipped with 1 computed tomography unit in addition to standard X-ray devices. However, when it comes to soft-tissue diagnostics, the borders of radiological capabilities are quickly reached. Magnetic resonance imaging as the accepted gold standard for most of these entities (e.g., muscle trauma) is not available. This limitation also affects the local population, which is a major stakeholder for the mission’s success and in many cases dependent on the care of ISAF-medical facilities. In smaller combat care units, such as forward surgical teams or airborne rescue stations, the situation is sharpened because these facilities are even less equipped attributable to tactical demands. German patrols in the deep hinterlands, e.g., in ISAF Observation Post North, are mostly covered by an embedded emergency physician. This physician is responsible for the provision of combat care as well as the provision of care to the local population in areas that are sometimes unattended by a modern physician for decades. Thus, the physical examination skills of the modern military physician must be broad and well trained. This means that the military medical community is desperately in need of reliable and accurate clinical signs and tests, which can compensate the aforementioned limitations to the highest possible degree. However, it is not enough to introduce and train a variety of clinical tests and signs. To provide the best possible care for military personnel and the local population, tests and signs have to be evidence-based and should be developed and validated with a data-driven and statistically sound, highquality approach.Well-designed diagnostic studies are needed to validate the current set of clinical tests and signs and to further develop and introduce new tests. Surprisingly, the manner of carrying out these studies is still a matter of controversy. In 2003, Bossuyt et al introduced a set of well-chosen approaches, which are summarized as the “STAndards for the Reporting of Diagnostic Accuracy Studies” (STARD)-guidelines. These guidelines provide useful advice for the analysis and publication of data, but the biostatistical “tool-box” is not clearly outlined. This is perhaps one of the reasons why a recent investigation revealed no changes in the reporting of diagnostic accuracy studies since the introduction of the STARD-guidelines. Hess et al recently published a recommended summary focusing primarily on biostatistical methods. The authors presented strategies to determine the sample size or study population that are necessary for critical prospective power (more than 90%) and presented methods for the evaluation of new diagnostic tests in the absence of a gold standard. Taken together, the main key factors which have to be considered before starting a diagnostic study are as follows: