Battlefield Casualties Research Articles

Losing on the Home Front? Battlefield Casualties, Media, and Public Support for Foreign Interventions

We study the impact of battlefield casualties and media coverage on public demand for war termination. To identify the effect of troop fatalities, we leverage the otherwise exogenous timing of survey collection across 26218 respondents from eight members of the International Security Assistance Force in Afghanistan. Quasi-experimental evidence demonstrates that fatalities increase coverage of the Afghan conflict and public demand for withdrawal. Evidence from a survey experiment replicates the main results. To estimate the media mechanism, we leverage a news pressure design and find that major sporting matches occurring around the time of battlefield casualties drive down subsequent coverage and significantly weaken the effect of casualties on support for war termination. These results highlight the crucial role that media play in shaping public support for foreign military interventions.

Nanoscale Chitosan-Based Hemostasis Membrane

Excessive bleeding or hemorrhage in traumatic injuries is the leading preventable cause of death in the combat and civilian trauma centers. Nearly 50% of military deaths, 90% of military battlefield casualties, and 33-56% mortalities in civilian’s surgical bleeding are associated with severe bleeding and can be prevented

Combat injuries sustained by troops on counter terrorism and counter-insurgency operations in North east Nigeria: Implications for intervention.

BackgroundUnderstanding the epidemiology of battlefield casualties is required for plans and coordinated efforts towards improved combat trauma care (CTC) performance and outcome. The engagement of the Armed Forces of Nigeria (AFN) in containing Boko Haram Terrorism (BHT) and insurgency in Northeast Nigeria has increased the risk of combat injuries to the troops. This study determined the characteristics of combat injuries sustained by soldiers on counter terrorism and counter-insurgency operations to contain BHT.MethodsA retrospective cross-sectional study of combat casualties managed in 7 Division (Field) Hospital, [an equivalent of UN Level 2 facility] Maiduguri, Northeast Nigeria between November 2013 and October 2014. Using data obtained from a designed Operational Casualty Card that contains their sociodemographic characteristics, categorization (as Combat Arm, Combat Support Service, Civ-JTF), nature, mechanism and sites of injury as well as inpatients records. The data were collated and analysed using SPSS version 20.ResultsA total of 209 casualties were treated. The age of the casualties ranged from 18 to 57 years with a mean of 30.6 ± 7.7 years and males constituting 99%. Over two-third (71.3%) casualties had gunshot injuries while 14.3% and 8.1% sustained improvised explosive device (IED) and fragments injuries respectively. Over three-quarter (77.5%) sustained injuries on the upper and lower extremities while 17 (7.7%) and 12 (5.7%) had injuries on thorax/abdomen and head/neck respectively. Nineteen (9.1%) casualties resulted from friendly forces/colleagues.ConclusionThe study revealed that gunshot and IED/blasts on the extremities were the most frequent mechanism and pattern of injuries sustained with less than a tenth of the casualties resulting from friendly forces. Training health personnel on CTC, deployment of combat lifesavers to improve pre-hospital CTC, employment of skilled Orthopaedic Surgeon and other relevant surgical subspecialties and timely air evacuation of critical cases from the Field Hospital to the Base Hospital are recommended.

Initial Assessment and Resuscitation of the Battlefield Casualty—an Overview

This review focuses on the recent evolution of the initial resuscitation of combat-injured personnel. It summarizes the recommendations of TCCC and makes recommendations based on literature review and author experience. Over nearly 20 years, the experience in caring for combat casualties in the global war on terror has led to significant changes within military trauma care. Evolution of pre-hospital care, utilization of tourniquets and TXA for hemorrhage control, and use of whole blood as the preferred resuscitative fluid have significantly reduced mortality. Additionally, the collective wisdom of experienced trauma surgeons serves as an invaluable guide for managing setup and flow within the various levels of the military trauma system. This review article highlights recommended practices for the initial resuscitation of personnel injured in combat along with providing proven methods for trauma team preparation and management that can and should be used by any surgeon preparing to deploy.

Highly realistic cadaveric trauma simulation of the multiply injured battlefield casualty: an international, multidisciplinary exercise in far-forward surgical management.

We designed an ultra-high-fidelity military cadaveric surgical simulation course to train military medical teams for specific battlefield injuries. Our aim was to deliver a highly realistic, immersive simulation training experience, teaching both technical and non-technical skills necessary for the management of war-injuries in the austere environment of a far forward surgical facility. We designed an educational cohort study around the course to measure its learning impact. 25 personnel participated in 15 non-continuous hours of simulation that included 12 patient scenarios. Participants were given previously piloted questionnaires pre- and post-simulation to assess their confidence with managing battlefield injuries by body area, their views on the realism of the simulation, and their perceptions of training benefit. All questions were assessed using a Likert scale of 1-10 (10=best). The response rate for complete questionnaires was 95%. Baseline confidence scores were; abdomen (5.5), pelvis (5.7), chest (6.2), airway (6.3), extremity (7.3). Confidence gains following training were; abdomen (+1.7), pelvis (+ 1.6), chest (+1.6), airway (+1.2), extremity (+0.8). The most realistic aspects of the simulation were; injury replication (9.1), the cadaver as a multiply injured casualty (9.1) and the multidisciplinary team (9.2). The mean ratings for technical and non-technical skill acquisition were 9.1 and 9.0 respectively. Cadaveric simulation was reported to be ideal for learning military medical skills (9.3), and participants strongly recommended that provision should be increased (9.7). We have demonstrated an ability to recreate highly realistic injuries in an ultra-high-fidelity simulation of a multiply injured military casualty. There was a measurable increase in confidence for both technical skills in all major body areas, and non-technical skills. Multinational and multidisciplinary working strongly enhanced learning.

HDFx, a Natural Biologic is Associated with Elevated DNA Methylation, Reduced DNA Oxidation and Telomerases Down-regulation in Macrophages and Monocytes Derived from Surviving Animals Subjected to Experimental Shock and Burns: Males vs. Females and Relation to Resistance Against Bacterial & Viral Infections

Circulatory shock and burns are significant and sustained states of hypoperfusion and lead to decreases in circulating blood volume combined with decreased tissue and organ oxygenation. This hypoperfusion state often causes sepsis resulting in a state of “multiple organ failure” [1-3]. Due to severe body burns, battle field casualties are most susceptible to the latter resulting in numerous loss of lives.

HDFx, a Natural Biologic is Associated with Elevated DNA Methylation, Reduced DNA Oxidation and Telomerases Down-regulation in Macrophages and Monocytes Derived from Surviving Animals Subjected to Experimental Shock and Burns: Males vs. Females and Relation to Resistance Against Bacterial & Viral Infections

Circulatory shock and burns are significant and sustained states of hypoperfusion and lead to decreases in circulating blood volume combined with decreased tissue and organ oxygenation. This hypoperfusion state often causes sepsis resulting in a state of “multiple organ failure” [1-3]. Due to severe body burns, battle field casualties are most susceptible to the latter resulting in numerous loss of lives.

Approximate Dynamic Programming for Military Medical Evacuation Dispatching Policies

Military medical planners must consider how aerial medical evacuation (MEDEVAC) assets will be dispatched when preparing for and supporting high-intensity combat operations. The dispatching authority seeks to dispatch MEDEVAC assets to prioritized requests for service, such that battlefield casualties are effectively and efficiently transported to nearby medical-treatment facilities. We formulate and solve a discounted, infinite-horizon Markov decision process (MDP) model of the MEDEVAC dispatching problem. Because the high dimensionality and uncountable state space of our MDP model renders classical dynamic programming solution methods intractable, we instead apply approximate dynamic programming (ADP) solution methods to produce high-quality dispatching policies relative to the currently practiced closest-available dispatching policy. We develop, test, and compare two distinct ADP solution techniques, both of which utilize an approximate policy iteration (API) algorithmic framework. The first algorithm uses least-squares temporal differences (LSTD) learning for policy evaluation, whereas the second algorithm uses neural network (NN) learning. We construct a notional, yet representative planning scenario based on high-intensity combat operations in southern Azerbaijan to demonstrate the applicability of our MDP model and to compare the efficacies of our proposed ADP solution techniques. We generate 30 problem instances via a designed experiment to examine how selected problem features and algorithmic features affect the quality of solutions attained by our ADP policies. Results show that the respective policies determined by the NN-API and LSTD-API algorithms significantly outperform the closest-available benchmark policies in 27 (90%) and 24 (80%) of the problem instances examined. Moreover, the NN-API policies significantly outperform the LSTD-API policies in each of the problem instances examined. Compared with the closest-available policy for the baseline problem instance, the NN-API policy decreases the average response time of important urgent (i.e., life-threatening) requests by 39 minutes. These research models, methodologies, and results inform the implementation and modification of current and future MEDEVAC tactics, techniques, and procedures, as well as the design and purchase of future aerial MEDEVAC assets.

Optimization of the Casualties' Treatment Process: Blended Military Experiment.

At the battalion level, NATO ROLE1 medical treatment command focuses on the provision of primary health care being the very first physician and higher medical equipment intervention for casualty treatments. ROLE1 has paramount importance in casualty reductions, representing a complex system in current operations. This study deals with an experiment on the optimization of ROLE1 according to the key parameters of the numbers of physicians, the number of ambulances and the distance between ROLE1 and the current battlefield. The very first step in this study is to design and implement a model of current battlefield casualties. The model uses friction data generated from an already executed computer assisted exercise (CAX) while employing a constructive simulation to produce offense and defense scenarios on the flow of casualties. The next step in the study is to design and implement a model representing the transportation to ROLE1, its structure and behavior. The deterministic model of ROLE1, employing a system dynamics simulation paradigm, uses the previously generated casualty flows as the inputs representing human decision-making processes through the recorder CAX events. A factorial experimental design for the ROLE1 model revealed the recommended variants of the ROLE1 structure for both offensive and defensive operations. The overall recommendation is for the internal structure of ROLE1 to have three ambulances and three physicians for any kind of current operation and any distance between ROLE1 and the current battlefield within the limit of 20 min. This study provides novelty in the methodology of casualty estimations involving human decision-making factors as well as the optimization of medical treatment processes through experimentation with the process model.

Postdeployment reintegration attitude of injured Dutch service members: a longitudinal study

ObjectiveAfter deployment, service members can experience difficulties reintegrating. Sustaining injuries on the battlefield can disrupt the reintegration period. The first aim was to follow-up the reintegration attitude towards family, work...

Battlefield Casualties and Ballot-Box Defeat: Did the Bush–Obama Wars Cost Clinton the White House?

ABSTRACTIn the 2016 election, foreign policy may have played a critically important role in swinging an important constituency to Donald Trump: voters in high-casualty communities that had abandoned Republican candidates in the mid-2000s. Trump’s iconoclastic campaign rhetoric promised a foreign policy that would simultaneously be more muscular and restrained. He promised to rebuild and refocus the military while avoiding the “stupid wars” and costly entanglements of his predecessors. At both the state and county levels, we find significant and substantively meaningful relationships between local casualty rates and support for Trump. Trump made significant electoral gains among constituencies that were exhausted and politically alienated by 18 years of fighting. Trump’s foreign policy shows a president beset by competing militaristic and isolationist impulses. Our results suggest that giving into the former may come at a significant electoral cost.

Lest We Forget: World War I and New Mexico by David V. Holtby

Reviewed by: Lest We Forget: World War I and New Mexico by David V. Holtby Joshua E. Kastenberg Lest We Forget: World War I and New Mexico. By David V. Holtby. Norman: University of Oklahoma Press, 2018. xi + 548 pp. Illustrations, maps, notes, bibliography, index. $32.95 cloth. The carnage of the "War to End All Wars," or more aptly, World War I, ended over a century ago. Unlike the Civil War sesquicentennial, which resulted in hundreds of books, the century anniversary of the United States' involvement in the first modern global conflict was rather muted. Nonetheless, quality scholarship resulted in studies on the alteration of laws, science, and medicine, as well as economic and social upheaval. And there were a small number of superb localized histories that studied the war's effects on communities. David V. Holtby's' Lest We Forget: World War I and New Mexico falls into this latter category. Holtby presents a thoroughly researched narrative history that brings several New Mexicans to life, through the haze of a century laden by yet another world war, a depression, and various other political, social, and global conflicts. He notes, in a chapter titled "Sleepwalkers," that "the battlefield's casualties reveal ordinary New Mexicans doing extraordinary things," and then adds that "they deserve to be heard." His book succeeds in doing more than that. New Mexico was one of the two newest states when the US went to war against Imperial Germany and its allies. Its demographics were more than a mirror of the nation. There were citizens who traced their lineage to a period before the Spanish Land Grant of 1692; yet, wide sections of the US would not have viewed them as citizens. Holtby's use of original source material explains the patriotism of, and other reasons for, Hispanic New Mexicans as well as Native Americans joining the armed forces. One only need look at the bibliography to learn of Holtby's use of the personal correspondences and governmental records of the state's participants in the war. He brings to life their experience of basic training, journey to the Western Front, and life (and death) in the trenches. This includes the fact that some of the Nuevomexicano soldiers did not read or write [End Page 245] English and had to rely on fellow soldiers to make it through military life. Holtby also provides insight into the role of women during the war, including the importance of their efforts in promoting the war and gaining employment. Women, it has been written, achieved a foothold in the nation's economy and political life as a result of the war, and Holtby provides evidence that this occurred in New Mexico. Yet he also shows how in a population divided by race, ethnicity, and economy, the roles and advances of each group were hardly uniform, and that Anglos socially benefited more than any other group. If there is one shortcoming in the book, and this shortcoming is minimal, it is that he does not spend enough time on how the military's unique disciplinary system or how the Espionage and Sedition Acts of 1917 and 1918 affected the state population. New Mexico was, and is, not New York. Its population in 1917 placed it at the bottom of the list of state populations. And its demographics, though hardly homogenous, were unique to it. Yet any scholar who seeks insight into how a global conflict affects a state population should read this book, for it contributes superbly not only to New Mexico history but also to the history of the nation. Joshua E. Kastenberg School of Law University of New Mexico Copyright © 2020 Center for Great Plains Studies, University of Nebraska–Lincoln

Management of Hypothermia in Tactical Combat Casualty Care: TCCC Guideline Proposed Change 20-01 (June 2020)

As an outcome of combat injury and hemorrhagic shock, trauma-induced hypothermia (TIH) and the associated coagulopathy and acidosis result in significantly increased risk for death. In an effort to manage TIH, the Hypothermia Prevention and Management Kit™ (HPMK) was implemented in 2006 for battlefield casualties. Recent feedback from operational forces indicates that limitations exist in the HPMK to maintain thermal balance in cold environments, due to the lack of insulation. Consequently, based on lessons learned, some US Special Operations Forces are now upgrading the HPMK after short-term use (60 minutes) by adding insulation around the casualty during training in cold environments. Furthermore, new research indicates that the current HPMK, although better than no hypothermia protection, was ranked last in objective and subjective measures in volunteers when compared with commercial and user-assembled external warming enclosure systems. On the basis of these observations and research findings, the Committee on Tactical Combat Casualty Care decided to review the hypothermia prevention and management guidelines in 2018 and to update them on the basis of these facts and that no update has occurred in 14 years. Recommendations are made for minimal costs, low cube and weight solutions to create an insulated HPMK, or when the HPMK is not readily available, to create an improvised hypothermia (insulated) enclosure system.

Forward Surgical Team Procedural Burden and Non-operative Interventions by the U.S. Military Trauma System in Afghanistan, 2008-2014.

No published study has reported non-surgical interventions performed by forward surgical teams, and there are no current surgical benchmarks for forward surgical teams. The objective of the study was to describe operative procedures and non-operative interventions received by battlefield casualties and determine the operative procedural burden on the trauma system. This was a retrospective analysis of data from the Joint Trauma System Forward Surgical Team Database using battle and non-battle injured casualties treated in Afghanistan from 2008-2014. Overall procedure frequency, mortality outcome, and survivor morbidity outcome were calculated using operating room procedure codes grouped by the Healthcare Cost and Utilization Project classification. Cumulative attributable burden of procedures was calculated by frequency, mortality, and morbidity. Morbidity and mortality burden were used to rank procedures. The study population was comprised of 10,992 casualties, primarily male (97.8%), with a median age interquartile range of 25.0 (22.0-30.0). Affiliations were non-U.S. military (40.0%), U.S. military (35.1%), and others (25.0%). Injuries were penetrating (65.2%), blunt (32.8), and burns (2.0%). Casualties included 4.4% who died and 14.9% who lived but had notable morbidity findings. After ranking by contribution to trauma system morbidity and mortality burden, the top 10 of 32 procedure groups accounted for 74.4% of operative care, 77.9% of mortality, and 73.1% of unexpected morbidity findings. These procedure groups included laparotomy, vascular procedures, thoracotomy, debridement, lower and upper gastrointestinal procedures, amputation, and therapeutic procedures on muscles and upper and lower extremity bones. Most common non-operative interventions included X-ray, ultrasound, wound care, catheterization, and intubation. Forward surgical team training and performance improvement metrics should focus on optimizing commonly performed operative procedures and non-operative interventions. Operative procedures that were commonly performed, and those associated with higher rates of morbidity and mortality, can set surgical benchmarks and outline training and skillsets needed by forward surgical teams.

An analysis of the incidence of hypothermia in casualties presenting to emergency departments in Iraq and Afghanistan

IntroductionHypothermia on the battlefield has been shown to be associated with severe injury and higher mortality. The incidence of battlefield casualties presenting with hypothermia are described. MethodsThe Department of Defense Trauma Registry (DoDTR) was queried from January 2007 to August 2016. We identified casualties with a documented temperature of <32°Celsius (C) (severe), 32–33.9 °C (moderate), 34–36 °C (mild). We defined serious injuries as those resulting in an AIS of ≥3 by body region. ResultsThere were 25,484 records with at least one documented temperature and 2501 (9.8%) casualties with hypothermia within our range. Nineteen (0.75%) casualties presented with severe hypothermia, 225 (9%) with moderate, and 2257 (90%) with mild. The mean injury severity score (ISS) for non-hypothermic, mild, moderate, and severe hypothermic casualties was 8 [4–14], 14 [6–24], 21 [13–29], and 21 [9–25], (p <0.001), respectively. Survival for casualties with severe hypothermia was 57.8%, moderate 80.9%, mild hypothermia 90.9%, and non-hypothermic group 97.6%, p<0.001. When adjusting for composite injury score, patient category, mechanism of injury, and location, this finding remained significant (OR 0.27, 0.21–0.34, p<0.001). Massive transfusion was more common in hypothermia casualties n = 566 (19%) versus non-hypothermic recipients n = 1734 (6.9%), p <0.001. ConclusionsThough the number of casualties that presented hypothermic was small, their injuries were more severe, and were more likely to receive massive blood transfusions. This cohort also had a higher mortality rate, a finding which held when adjusting for confounders. There appears to be an opportunity to improve hypothermia prevention for combat.

Coping strategies of Dutch servicemembers after deployment

BackgroundThis study examines the relationship between coping strategies and symptoms of anxiety or depression among Dutch servicemembers deployed to Afghanistan.MethodsCoping strategies were assessed in 33 battlefield casualties (BCs) and the control group (CTRLs) of 33 uninjured servicemembers from the same combat units using the Cognitive Emotion Regulation Questionnaire. A factor analysis was performed, and two clusters of coping strategies were derived, namely, adaptive and maladaptive coping. Symptoms of anxiety and depression were evaluated using the depression and anxiety subscales of the Symptom Checklist-90-Revised. Correlations between coping and symptoms of anxiety and between coping and symptoms of depression were calculated, and a logistic regression was performed.ResultsA moderate correlation was observed between maladaptive coping and symptoms of anxiety in the BC group (r = 0.42) and among the CTRLs (r = 0.56). A moderate correlation was observed between maladaptive coping and symptoms of depression in both groups (r = 0.55). The statistical analysis for the total sample (BCs and CTRLs) demonstrated no association between coping and symptoms of anxiety or depression.ConclusionsA correlation but no association was observed between maladaptive coping and mental health disorders in deployed Dutch servicemembers. Further research should focus on constructing cluster profiles of coping strategies and associating them with mental health outcomes and reintegration into society.

Rubrum Coelis: The Contribution of Real-Time Telementoring in Acute Trauma Scenarios-A Randomized Controlled Trial.

Background: Most deaths in military trauma occur soon after wounding, and demand immediate on scene interventions. Although hemorrhage predominates as the cause of potentially preventable death, airway obstruction and tension pneumothorax are also frequent. First responders caring for casualties in operational settings often have limited clinical experience.Introduction: We hypothesized that communications technologies allowing for real-time communications with a senior medically experienced provider might assist in the efficacy of first responding to catastrophic trauma.Methods: Thirty-three basic life saving (BLS) medics were randomized into two groups: either receiving telementoring support (TMS, n = 17) or no telementoring support (NTMS, n = 16) during the diagnosis and resuscitation of a simulated critical battlefield casualty. In addition to basic life support, all medics were required to perform a procedure needle thoracentesis (not performed by BLS medics in Israel) for the first time. TMS was performed by physicians through an internet link. Performance was assessed during the simulation and later on review of videos.Results: The TMS group was significantly more successful in diagnosing (82.35% vs. 56.25%, p = 0.003) and treating pneumothorax (52.94% vs. 37.5%, p = 0.035). However, needle thoracentesis time was slightly longer for the TMS group versus the NTMS group (1:24 ± 1:00 vs. 0:49 ± 0:21 minu, respectively (p = 0.016). Complete treatment time was 12:56 ± 2:58 min for the TMS group, versus 9:33 ± 3:17 min for the NTMS group (p = 0.003).Conclusions: Remote telementoring of basic life support performed by military medics significantly improved the medics' ability to perform an unfamiliar lifesaving procedure at the cost of prolonging time needed to provide care. Future studies must refine the indications and contraindications for using telemedical support.

Handling of surgical cases in a forward military location: Experience during the corona times

COVID-19 has changed the way we practice modern medicine forever, altering the basic tenets of touch, feel, and bond with patients. The practices of surgical specialties had to be changed like never before and triage has shifted from the battlefield and mass casualties practices to daily practice. Despite the primary responsibility of our hospital being to cater for the needs of operationally committed soldiers, we had to play a significant role in once in a lifetime crisis. A modus operandi to handle surgical cases was formulated. Core team: A core team was formulated to remain abreast of the abundant literature on COVID-19, which was shared with others on a daily basis Augmentation of infrastructure: Operational commitments remained unrelenting. Major changes in infrastructure were made to segregate routine cases from those suspected or confirmed of COVID-19 COVID surgical ward: All new surgical patients were admitted in a separate earmarked ward with mandatory physical distancing. With proper facilities for food distribution and linen collection Augmentation and training of workforce: workforce was augmented. Regular and periodic training of all available workforce was done Surgical grouping: Surgeons are precious commodities, and it can be catastrophic if the presence of one infected case leads to isolation/quarantine of the whole surgical setup of the hospital. Surgical teams were grouped and were forbidden to interact with each other or the same set of patients to form a barrier Common tenets for surgery: Surgeries were rationalized and limited All urgent surgeries were assessed to combat postoperative COVID19 infection Nonsurgical modalities where feasible were encouraged The hospital stay was reduced to the minimum possible Use of electronic media to reduce hospital visits Surgical triage:[1] Urgent surgeries: Only life and limb saving surgeries with complete personal protective equipment (PPE) were performed. The operation theater was thoroughly sanitized after the surgery as per the existing guidelines Nonurgent surgeries: Surgery was deferred till the time COVID status was ascertained. Preferably up to 7 days after hospitalization, these patients were closely watched for any change in condition Nonoperative treatments: Nonsurgical options were advised Elective surgeries: After evaluation of the risks of deferring these surgeries, they were delayed by a period of 3–6 months. Patients were properly counseled and procedures to return if need arises were established General instructions for surgery: Numerous guidelines have been offered for the performance of surgery with precautions for COVID-19.[1] Although each specialty has its own challenges but generally undermentioned are the important ones PPE was used suitably for both patients and doctors Patients were selected carefully Aerosol dispersal was minimized Use of low intra-abdominal pressures Using low-level electro-cautery was used with low burst time Pneumo-peritoneum was completely disinflated before trocar removal Bowel handling was minimized. For neurotrauma patients, guidelines issued by National Health Services (NHS) were adhered[2] Separation of these patients from other patients was ensured. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Prehospital Whole Blood in SOF: Current Use and Future Directions.

The US Joint Trauma System (JTS) recommends stored whole blood (SWB) as the preferred product for prehospital resuscitation of battlefield casualties in both their Tactical Combat Casualty Care (TCCC) guidelines and their clinical practice guidelines (CPGs). Clinical data from nearly 2 decades of war during Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF) suggest that whole blood (WB) is safe, effective, and far superior to crystalloid and colloid resuscitation fluids. The JTS CPG for whole blood transfusion reflects the most recent clinical evidence but poses unique challenges for execution by Special Operations Forces (SOF) operating in austere environments. Given the limited shelf-life of 35 days, WB requires a constant steady pool of donors. Additionally, the cold-chain requirement for storage poses challenges for SOF on long missions without access to blood refrigerators. SOF operating in less-developed theaters face additional logistical challenges. To mitigate the challenges of WB delivery, US SOF have implemented various protocols to ensure optimal donor pool, awareness/education among medics and specialized equipment for tactical methods of blood-carry and delivery. In general, steps taken include the following: (1) Prior to deployment, soldiers are screened for blood type and titers in order to establish a large donor pool. Support soldiers have been found to be particularly beneficial donors as they typically are in closer proximity to the blood support detachment. (2) In units that operate in smaller teams, such as ODAs, medics are outfitted with "blood kits" to carry blood on missions for point of injury transfusion. In units with larger teams, LTOWB donors are identified on missions and deliver fresh WB in the event of casualties. (3) Medics receive a WB transfusion refresher tabletop exercise and review after action reviews from previous rotations. Additionally, prehospital WB delivery is a required component of scenario-based premission training. The expectation is that medics will administer WB on missions when tactically feasible. Using the prolonged field care framework (ruck, truck, house) as a template, medics now use different methods to store and transport the SWB depending on phase. Medic "truck" and "house" kits include the Dometic CFX™ powered coolers that run on AC, DC, or solar power and allow for constant temperature monitoring. When on foot, medics have been outfitted with tactical blood coolers including the Pelican Biomedical Medic 4™ or Combat Medical Blood Box™ along with a Belmont Buddy-Lite™ intravenous (IV) infusion warmer and IV administration kit with standard micron filter. Presently, SOF medics have the donor support, logistical framework, training, and equipment to deliver WB at the point of injury. However, widespread implementation will require expanded distribution and standardization of "blood kits." Additionally, SOF medical planners must put greater emphasis on education and the importance of WB over crystalloids or colloids-as many medics continue to carry only these products out of convenience. As SOF strive to establish tactics, techniques, and procedures (TTPs) and streamline prehospital WB delivery, we must constantly reassess and refine our procedures, incorporate the latest evidence and technology, and adapt to an evolving battlefield.

Improvised Ground Evacuation Platforms for Austere Special Operations Casualty Transport.

There are no established ground medical-evacuation systems within Special Operations Command Africa (SOCAFRICA), given the austere and varied environments. Transporting the injured casualty requires ingenuity and modification of existing vehicles. The Expeditionary Resuscitative Surgical Team (ERST) assigned to SOCAFRICA used four unconventional means for ground evacuation. This is a retrospective review of the various modes of ground transportation used by the ERST-3 during deployment with SOCAFRICA. All handcarried litter and air evacuation platforms were excluded. Over 9 months, four different ground casualty platforms were used after they were modified: (1) Mine-Resistant Ambush-Protected All-Terrain Vehicle (MAT-V; Oshkosh Defense); (2) MRZR-4 ("Razor"; Polaris Industries); (3) nonstandard tactical vehicles, (NSTVs; Toyota HiLux); and (4) John Deere TH 6x4 ("Gator"). Use of all vehicle platforms was initially rehearsed and then they were used on missions for transport of casualties. Each of the four methods of ground evacuation includes a description of the talon litter setup, the necessary modifications, the litter capacity, the strengths and weaknesses, and any summary recommendations for that platform. Understanding and planning for ground casualty evacuation is necessary in the austere environment. Although each modified vehicle was used successfully to transfer the combat casualty with an ERST team member, consideration should be given to acquisition of the MAT-V medical-specific vehicle. Understanding the currently available modes of ground casualty evacuation transport promotes successful transfer of the battlefield casualty to the next echelon of care.