After-action Reports Research Articles

Case Series on 2g Tranexamic Acid Flush From the 75th Ranger Regiment Casualty Database.

Early tranexamic acid (TXA) administration for resuscitation of critically injured warfighters provides a mortality benefit. The 2019 Tactical Combat Casualty Care (TCCC) recommendations of a 1g drip over 10 minutes, followed by 1g drip over 8 hours, is intended to limit potential TXA side effects, including hypotension, seizures, and anaphylaxis. However, this slow and cumbersome TXA infusion protocol is difficult to execute in the tactical care environment. Additionally, the side effect cautions derive from studies of elderly or cardiothoracic surgery patients, not young healthy warfighters. Therefore, the 75th Ranger Regiment developed and implemented a 2g intravenous or intraosseous (IV/IO) TXA flush protocol. We report on the first six cases of this protocol in the history of the Regiment. After-action reports (AARs) revealed no incidences of post-TXA hypotension, seizures, or anaphylaxis. Combined, the results of this case series are encouraging and provide a foundation for larger studies to fully determine the safety of the novel 2g IV/IO TXA flush protocol toward preserving the lives of traumatically injured warfighters.

Life and Limb In-Flight Surgical Intervention: Fifteen Years of Experience by Joint Medical Augmentation Unit Surgical Resuscitation Teams.

Expedient resuscitation and emergent damage control interventions remain critical tools of modern combat casualty care. Although fortunately rare, the requirement for life and limb salvaging surgical intervention prior to arrival at traditional deployed medical treatment facilities may be required for the care of select casualties. The optimal employment of a surgical resuscitation team (SRT) may afford life and limb salvage in these unique situations. Fifteen years of after-action reports (AARs) from a highly specialized SRTs were reviewed. Patient demographics, specific details of encounter, team role, advanced emergent life and limb interventions, and outcomes were analyzed. Data from 317 casualties (312 human, five canines) over 15 years were reviewed. Among human casualties, 20 had no signs of life at intercept, with only one (5%) surviving to reach a Military Treatment Facility (MTF). Among the 292 casualties with signs of life at intercept, SRTs were employed in a variety of roles, including MTF augmentation (48.6%), as a transport capability from other aeromedical platforms, critical care transport (CCT) between MTFs (27.7%), or as an in-flight damage control capability directly to point of injury (POI) (18.2%). In the context of these roles, the SRT performed in-flight life and limb preserving surgery for nine patients. Procedures performed included resuscitative thoracotomy (7/9; 77.8%), damage control laparotomy (1/9; 11.1%) and extremity fasciotomy for acute lower extremity compartment syndrome (1/11; 11%). Survival following in-flight resuscitative thoracotomy was 33% (1/3) when signs of life (SOL) were absent at intercept and 75% (3/4) among patients who lost SOL during transport. In-flight surgery by a specifically trained and experienced SRT can salvage life and limb for casualties of major combat injury. Additional research is required to determine optimal SRT utilization in present and future conflicts.

Isfahan COvid-19 REgistry (I-CORE): Design and methodology.

Health authorities usually exploit after-action reports to collect data on their experience in responding to public health emergencies. To develop an effective approach to manage and learning from health emergencies, we have launched Isfahan COvid-19 REgistry for data collection during routine clinical care as a first “critical incident registry” in Iran. Registries can be employed to explain the natural history of the disease, learn about a particular disease in terms of patient outcomes, the cost-effectiveness of clinical management, monitoring the quality of health-care service, and developing research hypotheses.

The Introduction of New German Defensive Tactics in 1916-1917

Responding to the crisis posed by the battle of the Somme, in late 1916 the German army introduced new defensive tactics. It has been suggested that formal, top-down doctrine was a less important driver of this change than the bottom-up system of after-action reports, and that once initial resistance was overcome the new tactics were successfully adopted throughout the army. This article draws on little-studied archival material to reveal how doctrine evolved by stages in a complex combination of action, after-action reports, personalities and the high command’s desire to impose greater top-down control. Throughout this period, doctrine remained key to tactical change, but its implementation was patchier than the German army’s reputation suggests.

Five Legal Takeaways from the Syrian War

The U.S. Army regularly uses after action reports (AAR) to record observations and capture lessons learned from military operations. While not strictly an AAR, the following list of five takeaways is intended to memorialize some of the legal trends that arose during the military campaigns in Syria and Iraq. Our hope is that this admittedly non-exhaustive list will stimulate a broader conversation about the legal consequences of the Syrian War.

The August 24, 2016, Central Italy Earthquake: Validation of the "Modified Utstein Template for Hospital Disaster Response Reporting" As a New Tool for Reporting Hospitals' Response to Disasters.

After-action reports analyze events and improve knowledge about how to prevent and react to unexpected situations. Anyway, there is no consensus among the templates developed for disaster events reporting, and there is not a specific model for reporting hospital disaster response. The study was aimed to pilot the use of a new assessment tool for hospital response to natural disasters. A data collection tool, focused on hospital disaster response to natural disasters, was created modifying the "Utstein-Style Template for Uniform Data Reporting of Acute Medical Response in Disasters" and tested the reaction of the nearest hospitals to the epicenter after the August 24, 2016, Central Italy earthquake. Four hospitals were included. The completion rate of the tool was 97.10%. A total of 613 patients accessed the 4 emergency departments, most of them in Rieti Hospital (178; 29.04%). Three hundred thirty-six (54.81%) patients were classified as earthquake-related, most with trauma injuries (260; 77.38%). This template seemed to be a valid instrument for hospital disaster management reporting and could be used for better comprehension of hospital disaster reaction, debriefing activities, and hospital disaster plan revisions.

Effect of mass shootings on gun sales-A 20-year perspective.

Granular data on gun sales has been historically difficult to obtain. In 2016, California (CA) made monthly data from 1996 to 2015 publically available. Control charts are a method to analyze how a process changes over time in response to nonroutine events. We utilized this technique to study the impact of US mass shootings on CA gun sales. Monthly gun sales were provided by the CA Department of Justice and monthly fatalities from the CDC Wonder Death Certificate Registry. Mass shooting events were obtained from after-action reports, news media, and court proceedings. Time-ordered data were analyzed with control charts with 95% confidence intervals (upper control limit, lower control limit) using QiMacros. Individual gun sales of 9,917,811 occurred in CA with a median monthly rate of 41,324 (range, 20,057-132,903). A median of 263 people lost their lives monthly from firearms (124 homicides, 128 suicides), totaling 53,975 fatalities from 1999 to 2015. Fifteen of 21 current deadliest mass shootings occurred during this study period with 40% from 2012 to 2015. Also, 36 school shootings occurred during the study (mean, 5 deaths; range, 0-33; 6 injuries; range, 0-23) with 31% in 2012 to 2015 at rate of 3 events/year versus 1.4 events/year in the 17 prior years (p < 0.05). Sales were generally consistent from 1996 to 2011 (except post-Columbine, Col). Starting in 2011, sales exceeded the 95% predicted upper control limit every single month. Before October 2011, there was no statistically significant sustained effect of mass shootings on sales (except Col); however, since a statistically significant proportional spike in sales occurred in the months immediately following every single deadliest mass shooting event. Every year since 2012, CA has strengthened gun laws in response to mass shootings yet sales have risen immediately preceding enactment of these laws each January. Gun sales are more frequent since 2012, with an additional increase following both mass shootings and legislative changes enacted in response to these shootings. Epidemiology, level III.

Prehospital trauma experience of the Israel defense forces on the Syrian border 2013-2017.

The Israeli Defense Force Medical Corps (IDF-MC) is routinely collecting prehospital data to establish a prehospital registry. Since February 2013, Israel has been providing medical care to Syrian refugees. This unique humanitarian aid begins in prehospital settings and typically culminates in Israeli civilian hospitals. This report describes the accumulated experience of the IDF-MC to provide Syrian refugees with prehospital treatment. Care provided by IDF-MC medical teams, including prehospital casualty care, is regularly documented and after-action reports are conducted. Records of casualties arriving at the Israeli-Syrian border from February 16, 2013, to December 31, 2017, were prospectively extracted from the IDF Trauma Registry. Patients who did not have a casualty card were excluded. The database included demographic information, injury signature and treatment given. During the study period, 2,785 Syrian casualties were treated, of whom 2,339 were trauma victims. The most common mechanism of injury was penetrating (60.4%). Prehospital lifesaving interventions included 127 endotracheal intubations, 30 cricothyroidotomies, 55 chest decompressions, and 58 tourniquets for extremity hemorrhage control. Remote Damage Control Resuscitation included reconstituted freeze-dried plasma (n = 75) and tranexamic acid (n = 222 casualties) with no adverse effects. The experience of the IDF-MC teams in caring for civilian casualties along a hostile international border is unique. In this capacity, the IDF-MC has demonstrated effectiveness in providing lifesaving and resuscitative interventions including tranexamic acid and freeze-dried plasma. In this experience, tourniquets have been effective in controlling hemorrhage when applied early and endotracheal intubation and cricothyroidotomy have provided effective airway options in select patients. Prehospital combat casualty care presents a significant challenge both in terms of providing adequate care and in terms of data collection and analysis. The experience described in this article is one example of effective, ongoing prehospital data gathering process. Efforts to provide medical relief to victims of the Syrian civil war continue to this day. While we hope for a better future, as long as these lessons continue to accumulate, it is our obligation to use them to support improvement of trauma care and hopefully save more lives. Therapeutic, level III.

Battlefield Analgesia: Adherence to Tactical Combat Casualty Care Guidelines.

Low rates of prehospital analgesia, as recommended by Tactical Combat Casualty Care (TCCC) guidelines, have been demonstrated in the Joint Theaters combat setting. The reasons for this remain unclear. This study expands on previous reports by evaluating a larger prehospital dataset for determinants of analgesia administration. This was part of an approved quality assurance project evaluating adherence to TCCC guidelines across multiple modalities. Data were from the Prehospital Trauma Registry, which existed from January 2013 through September 2014, and comprises data from TCCC cards, Department of Defense 1380 forms, and after-action reports to provide real-time feedback to units on prehospital medical care. Of 705 total patient encounters, there were 501 documented administrations of analgesic medications given to 397 patients. Of these events, 242 (34.3%) were within TCCC guidelines. Special Operations Command had the highest rate of overall adherence, but rates were still low (68.5%). Medical officers had the highest rates of overall administration. The low rates of administration and adherence persisted across all subgroups. Rates of analgesia administration remained low overall and in subgroup analyses. Medical officers appeared to have higher rates of compliance with TCCC guidelines for analgesia administration, but overall adherence to TCCC guidelines was low. Future research will be aimed at finding methods to improve administration and adherence rates.

Social network analysis of Army Public School Shootings: Need for a unified man-made disaster management in Pakistan

This study evaluates the effectiveness of inter-organizational collaboration in response to the Army Public School (APS) Shootings that happened on December 16th, 2014 in the city Peshawar, Pakistan. After reviewing the major changes in terrorism related policies and frameworks before and after September 11, 2002, this article applies a social network analysis to compare the disaster response networks enacted in the formal disaster management plans with the actual response networks formed during the APS attacks. Data were gathered from content analysis of the APS Shootings incident, national and international newspapers, situation reports and after-action reports. The timely response to shootings is attributable to the long term planning efforts of law enforcement agencies. However, for improved results, the response and relief efforts should have been coordinated with the national disaster management framework under the National Disaster Management Authority (NDMA) - the lead authority for disaster management in Pakistan.

Evaluating the frequency of operational research conducted during the 2014–2016 West Africa Ebola epidemic

IntroductionThe West Africa Ebola epidemic of 2014–2016 was the largest Ebola outbreak on record, and thousands of individuals were involved in the response, including local and national governments, as well as numerous philanthropic and other non-governmental organizations. A number of after-action reports and other reviews of the global response to the epidemic routinely pointed out key challenges, including gaps in operational research. MethodsTo determine the extent to which operational research studies were conducted during the 2014–2016 West Africa Ebola epidemic, a quantitative analysis of the literature published during and immediately after the epidemic was conducted. The goal was to identify the proportion of all Ebola-related publications released regarding the epidemic that addressed operational aspects of the response. It was also sought to describe, at a general level, the sorts of studies that were published during the epidemic, with the goal of increasing understanding of whether additional efforts are needed to encourage the conduct and dissemination of operational studies during future public health crises. ResultsAmong the 3681 publications on Ebola published between the World Health Organization announcement of the Ebola outbreak in March 2014 and the end of 2017, 109 (3%) were determined to be operational research publications. Among these, 64 (58%) were published after the World Health Organization initially declared the outbreak over on January 14, 2016, reflecting the time delay of sharing operational lessons with the broader preparedness and response community. DiscussionImproved sharing of firsthand, operational knowledge from practitioners who respond to outbreaks is critical for improving preparedness activities and informing the development of sound, effective policies that support ongoing and future preparedness efforts. Based on the results from this review, we propose several policy and programmatic innovations that could facilitate knowledge sharing during future outbreaks.

Evaluating the Effectiveness of a Full-Scale Exercise of Epidemiologic Capacity for Bioterrorism Response

Abstract Introduction In May 2016, the Texas Department of State Health Services Public Health Region 7, in partnership with the local health departments in their region, designed and conducted a full-scale exercise (FSE) with a real-time epidemiologic phase leading to full-scale medical countermeasures distribution. Methods The exercise was designed to be a plausible scenario with a biologic agent that occurs naturally in Texas, Bacillus anthracis, and align with the Homeland Security Exercise and Evaluation Program (HSEEP) recommendations. After Action Reports (AAR) were reviewed and key informant interviews were conducted and content analyzed for themes through inductive coding. Results Themes identified include: benefits to exercising epidemiology’s role in public health preparedness; identification of gaps in real-time communication between public health and epidemiology; need to incorporate epidemiology into future exercises; importance of exercising realistic epidemiology scenarios in real-time; and identification of strengths and weakness in exercise coordination and logistics. Conclusion There is value in exercising epidemiology capabilities in real-time and in an operational full-scale context. Fully incorporating epidemiology into public health emergency preparedness exercises is one way to strengthen the relationship between these two disciplines and ensure well-coordinated rapid responses to public health threats.

Using root cause analysis (RCA) to facilitate corrective actions, after action reports (AARs), and improvement plans

Root cause analysis (RCA) is methodology recommended by the Homeland Security Exercise and Evaluation Program (HSEEP) for examining why exercise objectives were not met and providing specific recommendations for corrective action. The consequence of not completing the RCA as required by HSEEP is significant. In the absence of a RCA arriving at the best corrective action is less likely. Despite its importance, there is research evidence from a Centers for Disease Control and Prevention study that the RCA is seldom completed. Several reasons are presented as to why the RCA is not completed including a lack of guidance as to how to conduct a RCA. An example of how to complete a RCA is provided followed by a discussion of the benefits of using the approach over traditional exercise debriefing methods. Reasons why there may be continued resistance to using RCA despite having the necessary facilitation skills and dedicated time are also discussed.

Emergency Response to Radiological Releases: Have We Communicated Effectively to the First Responder Communities to Prepare Them to Safely Manage These Incidents?

Emergency Response to Radiological Releases: Have We Communicated Effectively to the First Responder Communities to Prepare Them to Safely Manage These Incidents?

Reducing Risk Through Academic Community Engagement in Homeland Security and Emergency Management

This inquiry engaged graduate students in the Homeland Security and Emergency Management program course designated as Academic Community Engagement (ACE) at an Institution of Higher Education (IHE) in rural Texas. The purpose was to evaluate an American Red Cross (ARC) risk-reduction Home Fire Campaign initiative and to implement new strategies designed by students and grounded in after action reports (AARs) and principles of emergency management (EM). Vygotsky's model of social learning and Cultural Historical Activity Theory (CHAT) framed the study. Students partnered with the ARC, emergency responders, and civil society organizations to (a) assess the effectiveness of the ARC-led campaign; (b) apply EM principles in designing the student-led campaign; (c) implement EM principles to new capability-building strategies; and (d) offer recommendations. Comparative analyses of separate campaign events in the community revealed reciprocal benefits; solutions devised by students enhanced program effectiveness and expanded social capital; students reported deep contextualized learning.

Prehospital Administration of Antibiotic Prophylaxis for Open Combat Wounds in Afghanistan: 2013-2014.

Military operations place injured Servicemembers at high risk for open wounds. Austere environments and initial wound contamination increase the risk for infection. Wound infections continue to cause significant morbidity among injured Servicemembers. Limited evidence suggests that early antibiotic therapy for open wounds reduces infection rates. We obtained data from the Prehospital Trauma Registry (PHTR) from January 2013 through September 2014. This database includes data from Tactical Combat Casualty Care (TCCC) cards, Department of Defense 1380 forms, and after-action reports to provide near-real-time feedback to units on prehospital medical care. We evaluated whether patients with open wounds received antibiotics in accordance with TCCC guidelines. Low adherence was defined at less than 80%. In this data set, overall, prefixed facility providers administered antibiotics to 54.0% of patients with an open combat wound. Of the antibiotics given, 11.1% were within TCCC guidelines. The relatively low administration and adherence rates persisted across subgroup analyses. Overall, relatively few patients with open combat wounds receive antibiotic administration as recommended by TCCC guidelines. In the group that received antibiotics, few received the specific antibiotics recommended by TCCC guidelines. The development of strategies to improve adherence to these TCCC recommendations is a research priority.

Using "Mystery Patient" Drills to Assess Hospital Ebola Preparedness in New York City, 2014-2015.

In response to the Ebola virus disease (EVD) outbreak in West Africa, rapid measures were taken to ensure readiness at frontline New York City (NYC) healthcare facilities, including mandating monthly EVD mystery patient drills to test screening protocols. This study analyzed after-action reports to describe the use of mystery patient drills to test rapid identification and isolation of potential EVD cases in NYC emergency departments. NYC hospitals were required to develop protocols for EVD screening and isolation, and to conduct drills with an actor presenting to the emergency department with symptoms suggestive of EVD. Fifty-five hospitals that participate in NYC's hospital preparedness program were invited to submit after-action reports summarizing at least 1 drill conducted between October 2014 and April 2015. Summary statistics were generated from reported quantitative measures. Report narratives were reviewed, coded, extracted, and analyzed to identify strengths and challenges experienced. Forty-five hospitals submitted after-action reports (82%). The median time from patient entry to isolation was 9 minutes and from isolation to evaluation was 14 minutes. Recurrent strengths included consistent travel history screening and compliance with infection control protocols. Themes for improvement included ensuring timely screening, staff competency with personal protective equipment (PPE), and clarifying notification procedures and staff roles. Mystery patient drills gave hospitals the means to test screening and isolation protocols and identify key gaps, such as competency-based training in PPE, to improve their capacity to respond to highly communicable diseases. Findings from this study will inform the development of a standardized mystery patient drill program.

Meeting the Changing National Preparedness and Response Needs for the Public in a Crisis

ABSTRACT Today, 24/7 news and social media herald, “Another Disaster!” The gap widens between public expectations – what is wanted – and what government emergency responders can deliver. Further, public trust in government evaporates when individual stakeholders fan anger, fear and frustration, through social media blogs and other media. The authors analyze current U.S. policy guidance, IOSC papers, after-action reports, and practitioner experience to identify gaps where stronger guidance, connectivity, and effort could improve emergency response and preparedness. US efforts will be contrasted with international standards published and implemented in Europe. US Coast Guard incident management doctrine now requires engagement and coordination with the broad range of community and leadership stakeholders. Meeting the concerns of that broader set of stakeholders requires: 1) a significant commitment of resources by industry and government to address the needs of stakeholders, and 2) the development of skills in crisis responders, and their leaders, that can assure the confidence (trust) of their community. The authors' recommendations focus on improving shared responsibilities for successful collaboration in the following general areas: 1) the role of government, policy and regulation, to insure proper early actions during large incidents and spills of national significance; 2) the roles of leaders, their preparedness and capabilities to manage the incident in the role of the Incident Commander; 3) plans needed to meet information management demands of large complex organizations stood up during a catastrophic incident; and 4) the development of collaborative and coordination approaches to meet the needs of stakeholders both inside and outside of the response organization.

Experience With Prehospital Damage Control Capability in Modern Conflict: Results From Surgical Resuscitation Team Use.

Early resuscitation and damage control surgery (DCS) are critical components of modern combat casualty care. Early and effective DCS capabilities can be delivered in a variety of settings through the use of a mobile surgical resuscitation team (SRT). Twelve years of after-action reports from SRTs were reviewed. Demographics, interventions, and outcomes were analyzed. Data from 190 casualties (185 human, five canine) were reviewed. Among human casualties, 12 had no signs of life at intercept and did not survive. Of the remaining 173 human casualties, 96.0% were male and 90.8% sustained penetrating injuries. Interventions by the SRT included intravascular access (50.9%) and advanced airway establishment (29.5%). Resuscitation included whole blood (3.5%), packed red blood cells (20.8%), and thawed plasma (11.0%). Surgery was provided for 63 of the 173 human casualties (36.4%), including damage control laparotomy (23.8%) and arterial injury shunting or repair (19.0%). SRTs were effectively used to augment an existing medical treatment facility (70.5%), to facilitate casualty transport (13.3%), as an independent surgical entity at a forward ground structure (9.2%), and in mobile response directly to the point of injury (6.9%). Overall survival was 97.1%. An SRT provides a unique DCS capability that can be successfully used in a variety of flexible roles.

Strengthening Health Systems While Responding to a Health Crisis: Lessons Learned by a Nongovernmental Organization During the Ebola Virus Disease Epidemic in Sierra Leone

An epidemic of Ebola virus disease (EVD) beginning in 2013 has claimed an estimated 11 310 lives in West Africa. As the EVD epidemic subsides, it is important for all who participated in the emergency Ebola response to reflect on strengths and weaknesses of the response. Such reflections should take into account perspectives not usually included in peer-reviewed publications and after-action reports, including those from the public sector, nongovernmental organizations (NGOs), survivors of Ebola, and Ebola-affected households and communities. In this article, we first describe how the international NGO Partners In Health (PIH) partnered with the Government of Sierra Leone and Wellbody Alliance (a local NGO) to respond to the EVD epidemic in 4 of the country's most Ebola-affected districts. We then describe how, in the aftermath of the epidemic, PIH is partnering with the public sector to strengthen the health system and resume delivery of regular health services. PIH's experience in Sierra Leone is one of multiple partnerships with different stakeholders. It is also one of rapid deployment of expatriate clinicians and logistics personnel in health facilities largely deprived of health professionals, medical supplies, and physical infrastructure required to deliver health services effectively and safely. Lessons learned by PIH and its partners in Sierra Leone can contribute to the ongoing discussion within the international community on how to ensure emergency preparedness and build resilient health systems in settings without either.