Forward Surgical Team Research Articles

Management of gunshot injury to the abdominal aorta and inferior vena cava: a case report of a combat patient wounded in the Russo-Ukrainian war

BackgroundRusso-Ukrainian war is associated with severe traumas, including injuries to the major vessels. Penetrating aortic injury remains one of the most difficult injuries; the mortality rate is 90–100% in case of gunshot wounds, associated with frequent lethal outcomes due to uncontrolled bleeding. Of the three main abdominal veins, the inferior vena cava (IVC) is the most frequently damaged, which is required quick and appropriate surgical decisions to be made. Little is known about the management of gunshot injuries to such major vessels as the aorta and IVC. It is also worth mentioning about the importance to share our practical experience from the ongoing war for better understanding and future considerations by war surgeons of the vascular trauma management. The aim of the study was to demonstrate the specific features of the diagnosis and management of a gunshot shrapnel blind penetrating wound to the abdomen with injury to the aortic bifurcation level and the infrarenal section of the inferior vena cava.Case presentationA 44-year-old male soldier of the Armed Forces of Ukraine received a gunshot injury to the abdomen from a mortars’ explosive shelling. The patient was evacuated to the Forward Surgical Team (Role 1) and received primary surgical treatment within one hour after the injury according to the “golden hour” principle. Then, evacuated was performed to the Role 3 hospital in Kharkiv. At the Role 3 hospital, the patient underwent second-look surgery as well as damage control surgery. At revision, no active bleeding was observed, and the surgical pads (packed previously by the Forward Surgical Team) were removed. Further revision showed a metal projectile within the aortic wall at the level of aortic bifurcation and wall defects were also detected for inferior vena cava. This metal projectile was removed by using the multifunctional surgical magnetic tool followed by suturing of the aortic wall defect as well as defects of the inferior vena cava.ConclusionsApplication of Damage Control Surgery is a useful approach in the management of severe vascular injury as well as useful to stop abdominal contamination by intestinal contents. The application of a surgical magnetic tool for the searching and removal of ferromagnetic foreign bodies reduces operative trauma and reduces the time for identification of foreign bodies.

Training for a mass casualty incident: Conception, development, and implementation of a crew-resource management course for forward surgical teams.

Since 2021, the predeployment training of French FSTs has included a simulation-based curriculum consisting of organizational and human factors. The purpose of this article is to describe the development of a crew-resource management (CRM) training course dedicated for the forward surgical teams (FSTs) of the French Military Health Service. The approach was based on three steps: (1) establishment of a conceptual framework of FSTs deployment; (2) development of an aircrew-like CRM training combining lectures, laboratory exercises, and situational training exercises to consider four fundamental "nontechnical" (cognitive and social) skills for effective and safe combat casualty care: (a) leadership, (b) decision-making, (c) coordination, and (d) situational awareness; (3) Implementation of teamwork evaluation tools. A multidisciplinary team designed a conceptual framework for FST preparedness, 24 French FSTs completed a high-quality training that takes into account both technical and nontechnical skills to maintain quality of combat care during mass-casualty incidents, FSTs' CRM skills were assessed using an audio/video recording of a simulated mass-casualty incident.

A Descriptive Analysis ofBlood Products Utilized by a Forward Deployed Surgical Team inSyria.

Traumatically injured combat casualties urgently need both blood and surgery. Forward Surgical Teams (FSTs) or Role 2 (R2) surgical teams were created to minimize the time-space distance from point of injury to damage control surgery. Our goal is to describe the use of blood products from a Split FST deployed to Green Village from July 2018 to April 2019. A retrospective review of a collection of patients treated by a single R2 was conducted following institutional regulatory approval. De-identified data were input into the study database and were then retrospectively reviewed for patients who presented to and received treatment at the R2 facility. Of the 470 total patients treated in 10 months: 226 (48%) received blood products and 132 (28%) underwent operative procedures. The patients were 98% male; 74% Host Nationals (HN), 24% North American Treaty Organization members. Mechanism of injury was 75% explosive and 98% penetrating. Documented Injury Severity Scores (n = 214) were: <9 (n = 57/27%), 9 to 15 (n = 34/16%), 16 to 25 (n = 64/30%), and >25 (n = 59/28%). In total 1,052 units of blood products were administered: whole blood (n = 495), red blood cells (n = 200), fresh frozen plasma (n = 109), and liquid plasma (n = 248). HN whole blood used was 337/495 (68%) units for 78 patients; walking blood bank was mobilized six times for HN patients. Of the patients seen, >99% who arrived with a pulse survived to be discharged to a higher level of care. This analysis describes blood usage associated with one high volume forward deployed operative team and demonstrates the vital importance of the R2 split FST to provide coalition forces with surgical care in proximity to the point of injury. Over time, the supply chain has improved with more component therapy available at R2s; however, the need for walking blood bank and innovative solutions to care for all casualties must be part of small team capabilities. Liquid plasma use should be expanded as soon as it is feasible.

French Military Neurosurgery: At Home and Abroad.

The origins of military neurosurgery are closely linked to those of neurosurgery in France and more particularly in Paris. The history of the field starts with its origins by 2 men, Thierry de Martel and Clovis Vincent. The first note about the creation of military neurosurgery was in 1942, when Marcel David was reassigned from the Sainte Anne Hospital to practice at the Val-de-Grâce Military Hospital. David trained the first military neurosurgeon. The field of military neurosurgery was subsequently developed at the Val-de-Grâce Military Hospital, at Sainte Anne Military Teaching Hospital in Toulon in 1990 and then at Percy Military Teaching Hospital in 1996. Over 29 military neurosurgeons were trained in these institutions. Since 2000, French military neurosurgeons have been deployed from France in the Mobile Neurosurgical Unit. This Mobile Neurosurgical Unit represents 12% of all medical evacuation of casualties categorized as the high dependency level. Neurosurgeons were able to adapt to asymmetrical wars, such as in the Afghanistan campaign where they were deployed in the Role 3 medical treatment facility, and more recently in sub-Saharan conflicts where they were deployed in forward surgical roles. To manage the increasing craniocerebral war casualties in the forward surgical team, the French Military Health Service Academy established a training course referred to as the "Advanced Course for Deployment Surgery" providing neurosurgical damage control skills to general surgeons. Finally, military neurosurgery is reinventing itself to adapt to future conflicts through the enhancement of surgical practices via the addition of head, face, and neck surgeons.

Retrieval of ferromagnetic fragments from the lung using video-assisted thoracoscopic surgery and magnetic tool: a case report of combat patient injured in the war in Ukraine

BackgroundGunshot wounds injury to the thorax is common in armed conflicts or war, including the war of Russia against Ukraine. Injury to the chest is associated with a high mortality or physical disability due to damage to the lungs, heart, and major vessels.The aim of this report is to demonstrate a case of successful management of severe gunshot injury to the lungs using video-assisted thoracoscopic surgery and magnetic tool for a combat patient injured in the war in Ukraine.Case presentationA 51-year-old soldier of the Armed Forces of Ukraine received a gunshot injury due to shelling from artillery strikes in the Donbas battlefield area. After evacuation to Level II, a forward surgical team performed primary surgical debridement. Two hours after the injury, the patient was evacuated to the Level IV of medical care (Kharkiv). At Level IV, a CT scan showed penetrating gunshot wounds to the left part of the chest with injury to the upper lobe of the left lung with the presence of the 2 metal fragments of the artillery projectile with the size of 2.5 × 2.0 cm and 1.0 × 1.0 cm. These two fragments were removed by using video-assisted thoracoscopic surgery (VATS) using the inlet gunshot hole in the left lateral chest area, as well as the assistance of a magnetic tool.ConclusionsVATS and magnetic technologies should be considered for hemodynamically stable combat patients with a gunshot injury to the lungs in the ongoing war. Each combat patient could be treated by individualized approach such as using the wound canal as a scope port after primary surgical debridement of the wound and antibiotic prophylaxis.

Extremity injuries in the Sahelian conflict: lessons learned from a French Forward Surgical Team deployed in Gao, Mali.

This study aimed to analyse extremity combat-related injuries (CRIs) and non-combat related injuries (NCRIs) treated in the French Forward Surgical Team deployed in Gao, Mali. A retrospective study was conducted using the French surgical database OpEX (French Military Health Service) from January 2013 to August 2022. Patients operated on for an extremity injury less than one month old were included. During this period, 418 patients with a median age of 28years [range 23-31years] were included and totalized 525 extremity injuries. Among them, 190 (45.5%) sustained CRIs and 218 (54.5%) sustained NCRIs. Multiple upper extremity injuries and associated injuries were significantly more common in the CRIs group. The majority of NCRIs involved the hand. Debridement was the most common procedure in both groups. External fixation, primary amputation, debridement, delayed primary closure, vascular repair and fasciotomy were significantly predominant in the CRIs group. Internal fracture fixation and reduction under anaesthesia were statistically more frequent in the NCRIs group. The overall number of procedures and the overall number of surgical episodes were significantly higher in the CRIs group. CRIs were the most severe injuries and did not involve the upper and lower limbs separately. A sequential management was required with application of damage control orthopaedics followed by several procedures for reconstruction. NCRIs were predominant and mostly involved the hand among the French soldiers. This review supports the fact that any deployed orthopaedic surgeon should be trained in basic hand surgery and preferably have microsurgical skills. The management of local patients requires the execution of reconstructive surgery and therefore imposes the presence of adequate equipment.

Entry-Level Forward Surgical Team Training Is Associated with Increased Confidence of Primary Combat Surgeons

Entry-Level Forward Surgical Team Training Is Associated with Increased Confidence of Primary Combat Surgeons

A history of neurosurgical capabilities in the United States Pacific Command: from World War II to present.

Neurosurgery has benefited from innovations as a result of military conflict. The volume and complexity of injuries sustained on the battlefield require medical teams to triage, innovate, and practice beyond their capabilities in order to treat wartime injuries. The neurosurgeons who practiced in the Pacific Command (PACOM) during World War II, the Korean War, and the War in Vietnam built upon field operating room knowledge and influenced the logistics of treating battle-injured patients in far-forward environments. Modern-day battles are held on new terrain, and the military neurosurgeon must adapt. War in the PACOM uniquely presented significant obstacles due to geographic isolation, ultimately accelerating the growth and adaptability of military neurosurgery and medical evacuation. The advancements in infrastructure and resource mobilization made during PACOM conflicts continue to inform modern-day practices and provide insight for future conflicts. In this historical article, the authors review the development and evolution of neurosurgical care, forward surgical teams, and mobile field hospitals with surgical capabilities through US conflicts in the PACOM.

Field tourniquets in an austere military environment: A prospective case series

ObjectiveField tourniquets are often used for battlefield extremity injuries. Their effectiveness has been documented by a large combat theater trauma center. However, their use and effectiveness by an austere forward surgical team has not been reported. Aims of this study were to determine: Whether field tourniquets: (1) Were placed for appropriate indications; (2) significantly reduced hemorrhage as measured by transfusion requirements; (3) influenced vital signs and injury severity scores; and (4) did they cause limb amputation, changed amputation level, or other complications. MethodsTwenty-five patients with 30 involved extremities presenting to a forward surgical team in Iraq met the inclusion criteria. We prospectively collected data regarding the presence, indications for, and effectiveness of field tourniquets based on the need for blood transfusion. We recorded any complications associated with their use. ResultsTourniquets significantly reduced hemorrhage from penetrating injuries as measured by transfusion requirements. Those having major vascular injuries with effective tourniquets, a total of 12 units of blood were transfused (1.7 units/vascular injury; 2 units/patient). However, 19 units were transfused in patients (3.3 units/vascular injury; 3.8 units/patient) who had an ineffective or no tourniquet (p = 0.0006). Transfusion requirements were related the presence of an effective tourniquet regardless of concomitant injuries. The group with effective tourniquets and compressed hemorrhage presented with higher mean systolic (p = 0.003) and diastolic (p = 0.023) blood pressures than the group with no tourniquets or ineffective ones. Complications included one peroneal nerve palsy and no amputations resulted from tourniquet application. ConclusionField tourniquets applied for penetrating injuries with severe bleeding can significantly reduce transfusion requirements and help maintain adequate blood pressure. Tourniquets were not the proximate cause of amputation and did not determine the choice of immediate amputation level.

Application of Hemostatic Tourniquet on Wounded Extremities in Modern "Trench" Warfare: The View of a Vascular Surgeon.

Blood vessel injuries in modern military conflicts account for 12% of all wounds (1), and 50%-95% of these involve arterial damage in extremities (3, 5). Furthermore, 10%-15% of all deaths on the battlefield occur due to extremity hemorrhage (2). Therefore, tourniquets and compression dressings continue to be the main methods of controlling extremity hemorrhage (4). The article analyzes the use of hemostatic tourniquets on wounded extremities for personnel that were provided second-level medical care by a Forward Surgical Team (FST) of one of the field hospitals of the Armed Forces of Ukraine.In these clinical cases, care was provided at the FST base in one of the district hospitals and during visits to civilian frontline hospitals by a vascular surgeon. This FST provided medical care to all severely and moderately injured or wounded in the area.The analysis included both military and civilians delivered with hemostatic tourniquets on their extremities. Assistance was provided to 69 wounded or injured, including 5 civilians. In all, 102 tourniquets were applied on 95 extremities. Tourniquets were applied on all 95 (100%) extremities including 21 (22.1%) upper extremities and 74 (77.9%) lower extremities. In 5 cases, tourniquets were applied on 3 extremities, in 16 cases on 2 extremities, and in 48 cases on 1 extremity. Combat Application Tourniquets (CAT) were used in 81 (85.3%) cases, Esmarch type in 10 (10.5%) cases, and improvised tourniquets in 4 (4.2%) cases. Duration of tourniquet application was less than 1 hour in 27 cases, 1-2 hours in 18 cases, 2-3 hours in 15 cases, and over 3 hours in 9 cases.The level of primary blood loss at the time of admission was categorized as <1 L in 44 (63.7%) cases, 1.0-1.5 L in 11 (11.5%) cases, 1.5-2.0 L in 7 (7.2%) cases, 2.0-2.5 L in 3 (3.1%) cases, and >2.5 L in 4 (4.2%) cases. Main arteries were damaged in 14 extremities in 12 (17.4%) wounded. Main veins were damaged in 4 (5.8%) cases without the involvement of the main arteries. Damage to the branches of arteries and veins was seen in 53 (76.8%) of the wounded. Surgical procedures performed included main artery reconstruction in 6, ligation of main arteries in 2, main vein ligation in 4, primary amputations of extremities in 9, and surgical debridement with ligation of arterial and/or venous branches in 37 cases. Reasons for excessive blood loss (>1.0 L) included delayed tourniquet application in 8 cases, inadequate tourniquet application in 12 cases, and bleeding secondary to injuries of the chest/abdominal cavity or head in 5 cases. (1) Tourniquet application was appropriate in 24.6% of the wounded with tourniquets.(2) The success of hemostatic tourniquet use is dependent upon the experience of staff rather than the type of tourniquet used.(3) In patients with significant blood loss, the duration of ischemia should be calculated from the time of injury and not from the time tourniquet was applied.(4) During the reconstruction of the main arteries in extremities after the prolonged use of the tourniquet, a longer than usual anastomosis line is advised.(5) Injuries to upper extremities will be more common during active combat, compared to positional warfare in fortified positions.

Committee on Surgical Combat Casualty Care position statement on the use of single surgeon teams and invited commentaries.

Over the last 20 years of war, there has been an operational need for far forward surgical teams near the point of injury. Over time, the medical footprint of these teams has decreased and the utilization of mobile single surgeon teams (SSTs) by the Services has increased. The increased use of SSTs is because of a tactical mobility requirement and not because of proven noninferiority of clinical outcomes. Through an iterative process, the Committee on Surgical Combat Casualty Care (CoSCCC) reviewed the utilization of SSTs and developed an expert-opinion consensus statement addressing the risks of SST utilization and proposed mitigation strategies. A small triservice working group of surgeons with deployment experience, to include SST deployments, developed a statement regarding the risks and benefits of SST utilization. The draft statement was reviewed by a working group at the CoSCCC meeting November 2021 and further refined. This was followed by an extensive iterative review process, which was conducted to ensure that the intended messaging was clear to senior medical leaders and operational commanders. The final draft was voted on by the entire CoSCCC membership. To inform the civilian trauma community, commentaries were solicited from civilian trauma leaders to help put this practice into context and to further the discussion in both military and civilian trauma communities. After multiple revisions, the SST statement was finalized in January 2022 and distributed to the CoSCCC membership for a vote. Of 42 voting members, there were three nonconcur votes. The SST statement underwent further revisions to address CoSCCC voting membership comments. Statement commentaries from the President of the American Association for the Surgery for Trauma, the chair of the Committee on Trauma, the Medical Director of the Military Health System Strategic Partnership with the American College of Surgeons and a recently retired military surgeon we included to put this military relevant statement into a civilian context and further delineate the risks and benefits of including the trauma care paradigm in the Department of Defense (DoD) deployed trauma system. The use of SSTs has a role in the operational environment; however, operational commanders must understand the tradeoff between tactical mobility and clinical capabilities. As SST tactical mobility increases, the ability of teams to care for multiple casualty incidents or provide sustained clinical operations decreases. The SST position statement is a communication tool to inform operational commanders and military medical leaders on the use of these teams on current and future battlefields.

Wartime upper-extremity injuries in the Sahelian strip: Experience from a French Forward Surgical Team deployed in Mali

This study aimed to analyze upper-extremity combat-related injuries (CRIs) and non-combat-related injuries (NCRIs) treated in the French Forward Surgical Team currently deployed in Gao, Mali. A retrospective study was conducted using the French Military Health Service OpEX surgical database from February 2013 to March 2020. All patients operated on for upper-extremity injury were included: 224 patients, with a mean age of 28.15 years, for 249 upper-extremity injuries. Seventy-six (33.9%) sustained CRIs and 148 (66.1%) NCRIs. Multiple upper-extremity injuries and associated injuries were significantly more common in the CRI group. The majority of NCRIs involved the hand. Debridement and wound care was the most common procedure in both groups. External fixation and fasciotomy were significantly more frequent in the CRI group, and internal fracture fixation in the NCRI group. The overall number of procedures was significantly higher in the CRI group. Due to the high frequency of upper-extremity injury in current theaters of operations, deployed orthopedic surgeons should be trained in basic hand surgery so as to optimally manage both CRIs and NCRIs.

Lessons Learned During Prolonged Care of Combat Casualties by a Minimally Manned Surgical Team.

In the current deployed environment, small teams are dispersed to provide damage control surgical capabilities within an hour of injury. Given the well-developed evacuation system, these teams do not typically have a significant patient hold capability. Improved understanding of the shortfalls and problems encountered when caring for combat casualties in prolonged care situations will facilitate improved manning, training, and equipping of these resource-limited teams. We present the case of two critically injured soldiers who were evacuated to a 10-person split Forward Surgical Team (FST) during a weather system that precluded further evacuation. The casualties underwent damage control procedures necessitating temporary abdominal closures. The FST had to organize itself to provide intensive care significantly longer than traditional timelines for this role of care. Additionally, most team members had scarce critical care experience. An after-action review confirmed that most team members felt that they had not received adequate pre-mission training in postoperative intensive care and were not comfortable managing ventilated patients. In the current mature theaters of operations, there are robust evacuation capabilities, and presentations of scenarios like that are rare. However, as combat casualty care becomes increasingly austere and remote, small surgical teams need to train and be equipped to provide care outside of normal operation and doctrinal limits, including robust team cross-training. Incorporating principles of the prolonged care of combat casualties into the training of military surgeons will improve preparedness for these challenging situations.

Trauma, Teams, and Telemedicine: Evaluating Telemedicine and Teamwork in a Mass Casualty Simulation.

Mass casualty events (MASCAL) are on the rise globally. Although natural disasters are often unavoidable, the preparation to respond to unique patient demands in MASCAL can be improved. Utilizing telemedicine can allow for a better response to such disasters by providing access to a virtual team member with necessary specialized expertise. The purpose of this study was to examine the positive and/or negative impacts of telemedicine on teamwork in teams responding to MASCAL events. We introduced a telemedical device (DiMobile Care) to Forward Surgical Teams during a MASCAL simulated training event. We assessed teamwork-related attitudes, behaviors, and cognitions during the MASCAL scenario through pre-post surveys and observations of use. Analyses compare users and nonusers of telemedicine and pre-post training differences in teamwork. We received 50 complete responses to our surveys. Overall, clinicians have positive reactions toward the potential benefits of telemedicine; further, participants report a significant decrease in psychological safety after training, with users rating psychological safety as significantly higher than non-telemedicine users. Neither training nor telemedicine use produced significant changes in cognitive and behavioral-based teamwork. Nonetheless, participants reported perceiving that telemedicine improved leadership and adaptive care plans. Telemedicine shows promise in connecting Forward Surgical Teams with nuanced surgical expertise without harming quality of care metrics (i.e., teamwork). However, we advise future iterations of DiMobile Care and other telemedical devices to consider contextual features of information flow to ensure favorable use by teams in time-intensive, high-stakes environments, such as MASCAL.

The place of forward surgical teams in the system of medical support of the Defense Forces of Ukraine

The article highlights the authors' view on the peculiarities of providing surgical care in the system of medical support of the Defense Forces of Ukraine and identifies problems that need to be addressed at the organizational level. The existence of the armed conflict in eastern Ukraine, which has been going on since 2014, and the experience of the medical service gained over the years, encourages the creation of new structures that bring medical care closer to the wounded. This, in turn, allows you to keep the rule of the "golden hour", because the lack of medical care for 1 hour increases mortality by 10-15 %. The purpose of the work is to develop new structures of the medical forces of the Armed Forces of Ukraine to improve the efficiency of medical care at the second level of medical care. Tactical-special training was conducted, which worked out the main issues of deployment and operation of the advanced surgical team, as a separate stage of medical care. During the practical part, the scope of medical care was analyzed and standardized depending on the operational situation. The issues of terminology are considered in the work, definitions of separate terms are given and their semantic loading is specified. The authors considered the structure and organization of the work of advanced surgical support groups, qualitative characteristics of medical care at the stages of medical evacuation of the second level of medical care, its scope and content, options for strengthening medical care. Variants of application of advanced surgical groups in the conditions of the armed conflict of low intensity and local war – the conflict of high intensity are covered. The obtained results indicate that the creation of an advanced surgical team allows to bring medical care closer to the line of combat. The mobility of the group provides the opportunity to be directly near the center of sanitary losses.

Forward Surgical Teams as a Model for Humanitarian Orthopedic Surgical Care: A Review of Current Literature.

Orthopedic trauma is a significant portion of global burden of disease in low- and middle-income countries (LMICs). This has led the World Health Organization to advocate for increased surgical intervention in LMICs. The two largest barriers to orthopedic surgical care for LMICs are cost of procedure and geographic access to centers with appropriate surgical capabilities. There is no current consensus on how to structure surgical interventional teams. The overall objective of this study is to describe the composition of a forward surgical team (FST), including its abilities and limitations. It is hypothesized that an FST is an effective model for orthopedic surgical relief efforts in LMICs. A narrative literature review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analysis standards published by the National Academies of Medicine. Studies were evaluated by structured review procedures to identify an FST's capacity for orthopedic surgery, as well as applicability for humanitarian care. Articles detailing FST logistics, types of orthopedic treatment provided, and instances of humanitarian care while deployed in austere environments were included for review. The FST is a military surgical unit operating with a small crew of surgeons and supporting staff who use tents or trailers that can be positioned near points of conflict, often in remote or austere environments. FSTs were designed to treat traumatic injuries, including orthopedic trauma from RTIs. If used as a sponsored humanitarian aid mission, FSTs can provide surgical care at free or greatly reduced costs. Because FSTs carry limited supplies and personnel, they are highly mobile surgical units that can be transported via truck. FSTs are effective models for humanitarian orthopedic surgery in LMICs. FSTs were designed to treat orthopedic trauma, the largest burden of orthopedic care in LMICs. Efficient use of limited equipment allows FSTs to be cost effective for funding sources and highly mobile to reduce the geographic barrier to care. Further research is needed to determine the cost to operate an FST and ethical consideration for military intervention for foreign humanitarian aid.

The French Pre-Deployment Advanced Course in Anesthesia and Resuscitation: Development and Future Prospects.

Military anesthesiologists from the French Military Medical Service (FMMS) are part of the Forward Surgical Teams deployed in overseas military operations. The practice of anesthesia in combat zones requires specific skills that are not taught during the initial curriculum for French civilian anesthesiologist. The Pre-Deployment Advanced Course in Anesthesia and Resuscitation (DACAR) program was developed to prepare military anesthesiologist from the FMMS before their deployment in overseas military operations. Created in 2013 by the French Military Medical Academy, the DACAR program is divided into two modules and carried out once a year. The DACAR program trains all military anesthesiologist residents at the end of their curricula. Since 2019, a number of Certified Registered Nurse Anesthetists have completed the DACAR program. The DACAR program is organized around the main axes of experience feedback from previous deployments in combat zones as well as didactic learning and practical training using high-fidelity simulation. Since 2013, a total of 99 trainees completed the DACAR program during six complete cycles of two modules. The DACAR program has gradually been enriched from 14 courses in 2013 to 28 in 2019. Participants' reported satisfaction rates have increased steadily since 2016, when 88% of courses were rated as "interesting" or "very interesting," and only 4% as "not very interesting." By 2019, those figures had improved to 96% and 2%, respectively. The DACAR program is a structured and adapted military medical course aimed at completing the curriculum of military anesthesiologists from the FMMS before deployment in overseas military operations. Regular audits and updates ensure that the DACAR training program maintains the highest standards of quality and rigor.

Adding the Capacity for an Intensive Care Unit Dedicated to COVID 19, Preserving the Operational Capability of a French Golden Hour Offset Surgical Team in Sahel.

IntroductionIn April 2020, the military medical planning needs to be recalibrated to support the COVID-19 crisis during a large-scale combat operation carried out by the French army in Sahel.Material and MethodsSince 2019, proper positioning of Forward Surgical Teams (FSTs) has been imperative in peer-to-near-peer conflict and led to the development of a far-forward surgical asset: The Golden Hour Offset Surgical Team (GHOST). Dedicated to damage control surgery close to combat, GHOST made the FST aero-mobile again, with a light logistical footprint and a fast setting. On 19 and 25 March 2020, Niger and Mali confirmed their first COVID-19 cases, respectively. The pandemic was ongoing in Sahel, where 5,100 French soldiers were deployed in the Barkhane Operation.ResultsFor the first time, the FST had to provide, continuously, both COVID critical care and surgical support to the ongoing operation in Liptako. Its deployment on a Main Operating Base had to be rethought on Niamey, to face the COVID crisis and support ongoing operations. This far-forward surgical asset, embedded with a doctrinal Role-1, sat up a 4-bed COVID intensive care unit while maintaining a casualty surgical care capacity. A COVID training package has been developed to prepare the FST for this innovative employment. This far-forward surgical asset was designed to support a COVID-19 intensive care unit before evacuation, preserving forward surgical capability for battalion combat teams.ConclusionFar-forward surgical assets like GHOST have demonstrated their mobility and effectiveness in a casualty care system and could be adapted as critical care facilities to respond to the COVID crisis in wartime.

Hypocalcemia in Military Casualties From Point of Injury to Surgical Teams in Afghanistan.

Hypocalcemia is a known sequela of citrated blood product transfusion. Civilian data suggest hypocalcemia on hospital admission is associated with worse outcomes. Initial calcium levels in military casualties have not previously been analyzed. The objective of this retrospective review aimed to assess the initial calcium levels in military trauma casualties at different Forward Surgical Teams (FST) locations in Afghanistan and describe the effects of prehospital blood product administration on arrival calcium levels. This is a retrospective cohort analysis of military casualties arriving from point of injury to one of two FSTs in Afghanistan from August 2018 to February 2019 split into four locations. The primary outcome was incidence of hypocalcemia (ionized calcium < 1.20 mmol/L). There were 101 patients included; 55 (54.5%) experienced hypocalcemia on arrival to the FST with a mean calcium of 1.16 mmol/L (95% confidence interval [CI], 1.14 to 1.18). The predominant mechanism of injury consisted of blast patterns, 46 (45.5%), which conferred an increased risk of hypocalcemia compared to all other patterns of injury (odds ratio = 2.42, P = .042). Thirty-eight (37.6%) patients required blood product transfusion. Thirty-three (86.8%) of the patients requiring blood product transfusion were hypocalcemic on arrival. Mean initial calcium of patients receiving blood product was 1.13 mmol/L (95% CI, 1.08 to 1.18), which was significantly lower than those who did not require transfusion (P = .01). Eight (7.9%) of the patients received blood products before arrival, with 6/8 (75%) presenting with hypocalcemia. Hypocalcemia develops rapidly in military casualties and is prevalent on admission even before transfusion of citrated blood products. Blast injuries may confer an increased risk of developing hypocalcemia. This data support earlier use of calcium supplementation during resuscitation.

There Is No Role for Damage Control Orthopedics Within the Golden Hour.

Trauma systems within the United States have adapted the "golden hour" principle to guide prehospital planning with the goal to deliver the injured to the trauma facility in under 60 minutes. In an effort to reduce preventable prehospital death, in 2009, Secretary of Defense Robert M. Gates mandated that prehospital transport of injured combat casualties must be less than 60 minutes. The U.S. Military has implemented a 60-minute timeline for the transport of battlefield causalities to medical teams to include Forward Surgical Teams and Forward Resuscitative Surgical Teams. The inclusion of orthopedic surgeons on Forward Surgical Teams has been extrapolated from the concept of damage control orthopedics (DCO). However, it is not clear if orthopedic surgeons have yielded a demonstrable benefit in morbidity or mortality reduction. The purpose of this article is to investigate the function of orthopedic surgeons during the military "golden hour." The English literature was reviewed for evidence supporting the use of orthopedic surgeons within the golden hour. Literature was reviewed in light of the 2009 golden hour mandate by Secretary Gates as well as those papers which highlighted the utility of DCO within the golden hour. Evidence for orthopedic surgery within the "golden hour" or in the current conflicts when the United States enjoys air superiority was not identified. Within the military context, DCO, specifically pertaining to fracture fixation, should not be considered an element of golden hour planning and thus orthopedic surgeons are best utilized at more centralized Role 3 facility locations. The focus within the first hour after injury on the battlefield should be maintained on rapid and effective prehospital care combined with timely evacuation, as these are the most critical factors to reducing mortality.