Digital coordination tools have been proposed to improve management during mass casualty incidents (MCIs). In 2021, the IVENA-MANV system was introduced in the Hannover region as an extension of the established IVENA eHealth platform to enable digital patient tracking and hospital capacity management. However, no real-world evaluations have yet quantified their operational impact. This study aimed to provide the first real-world evaluation of the IVENA-MANV digital coordination system and to determine how its implementation affected prehospital distribution processes and time intervals during mass casualty incidents. A retrospective observational study to assess the impact of the IVENA-MANV digital coordination platform on prehospital times during MCIs in Germany was conducted using dispatch records and IVENA-MANV logs from all MCIs between January 2018 and July 2025 in the Hanover-Region in Germany. Primary outcomes were the triage-to-evacuation (TtE) and total prehospital time (TPHT) per patient. Mann-Whitney U tests compared pre- and post-implementation groups, and multiple linear regression models examined associations between IVENA-MANV use, MCI-level, and time intervals. Seventy-three MCIs met inclusion criteria, including 188 documented individual casualty characteristics. 41.1% of incidents used IVENA-MANV. Most MCIs were trauma-related (65.8%) and traffic-associated (64.4%). Mean TtE was 40.2 ± 19.3min, and mean TPHT 83.9 ± 29.5min. No statistically significant differences were found between pre- and post-implementation cohorts (p > 0.05). Regression analysis confirmed MCI-level as the only significant predictor of prolonged intervals (p < 0.001). IVENA-MANV enabled structured hospital allocation and real-time capacity confirmation (mean 1.8min to first confirmation) without extending on-scene times. Implementation of IVENA-MANV did not significantly affect prehospital time intervals but demonstrated qualitative benefits for coordination, documentation, and hospital communication. The value of digital systems in disaster medicine may therefore lie in strengthening coordination and information resilience rather than accelerating evacuation. Prospective multicentre and mixed-methods studies are warranted to assess their broader system-level impact.

BackgroundEmergency health workers encounter critical decision-making challenges during mass-casualty incidents, where psychological factors-including distress tolerance, anxiety, and emotion regulation-may significantly influence triage effectiveness.ObjectiveThe aim of this study was to evaluate the decision-making skills of emergency health workers during triage in mass incidents and to examine the effects of distress tolerance, anxiety levels, and difficulties in emotion regulation on these skills.MethodsA descriptive and comparative study was conducted with 349 paramedics and emergency medical technicians working in pre-hospital emergency health services in Turkey. The Distress Tolerance Scale (SDS), Beck Anxiety Scale (BAS), Difficulties in Emotion Regulation Scale (DAS), and Triage Decision Making Inventory (TDDI) were used for data collection. Shapiro-Wilk test, Chi-square test, Wilcoxon test, and Kruskal-Wallis H test were applied in the study. Correlation analysis was conducted to determine relationships among scales.ResultsThe median values of Triage Decision Making Inventory, Difficulty in Emotion Regulation Scale, Beck Anxiety Scale, and Difficulty withstanding Distress Scale scores were , respectively. According to multiple regression analysis, triage decision-making skills were negatively affected by anxiety, positively affected by distress tolerance, and negatively affected by difficulties in emotion regulation (p < 0.05).ConclusionsIt was found that distress tolerance, emotion regulation, and self-efficacy positively influenced triage decision-making skills, while emotion dysregulation and anxiety negatively affected these skills. Factors such as experience, education level, type of triage training received, gender, marital status, and age also affected triage decision-making skills.

Chemical warfare agents (CWAs) pose severe global threats due to their historical role in mass casualties and ongoing misuse, particularly blister, nerve, and blood agents. To address the urgent need for field-deployable detection tools, we develop TrioAlert, which, to the best of our knowledge, is the first fluorescent sensor capable of simultaneously detecting the blister agent sulfur mustard, the G-type nerve agent sarin, and the blood agent cyanide. The sensor employs an imidazole moiety for the recognition of sulfur mustard and sarin, while cyanide is detected through a reaction at the 4-position of the coumarin fluorophore. TrioAlert demonstrates a rapid response (within 90 s), high sensitivity (limits of detection: 58.5 nM for sulfur mustard, 46.2 nM for sarin, and 53.4 nM for cyanide), and distinct fluorescence and color changes. The detection performance of TrioAlert for the three chemical warfare agents remains stable in natural environmental matrices and across various temperatures. Furthermore, TrioAlert-loaded test strips enable smartphone-based qualitative and quantitative on-site analysis, with visual detection limits of 0.05 ppm for sulfur mustard, 0.01 ppm for sarin, and 5 ppm for cyanide. The sensor also enables the visualization of all three CWAs in live cells and mouse models. Notably, in vivo fluorescence changes precede pathological damage, with distinct fluorescence triggered at sub-pathological doses. This provides an early visual indication for trace CWA exposure. Furthermore, these fluorescence changes correlate with subsequent alterations in pathological biomarkers (P < 0.01), confirming the sensor's potential for clinical diagnosis. Our study demonstrates the on-site rapid quantitative detection of high-risk chemical warfare agents, thereby advancing the capability to prevent chemical threats and safeguard public health and security.

Following global Phase III trials, a single-arm expanded access program at 23 burn centers in the United States (2019-2024) provided centers with additional experience treating adult and pediatric burn patients with NexoBrid and maintaining burn care preparedness for mass casualty incidents. Eligible patients included children (<18years old) and adults (≥18years old) with deep thermal burns covering up to 30% total body surface area. NexoBrid application was followed by standard care. Patients were monitored weekly until wound closure, and again after 3 and 12months. Outcomes included incidence and time to eschar removal, need for surgical excision or escharotomy, length of hospital stay, wound closure, and Modified Vancouver Scar Scale. A total of 239 patients (215 adult, 24 pediatric) received NexoBrid, with 142 (131 adult, 11 pediatric) completing the 12-month follow-up. Mean ages were 41 and 11years, respectively. Mean treated target wound area was approximately 6% of total body surface area, with 38 circumferential burns. Eschar removal was achieved in 95% of adults and 100% of pediatric patients within 4hours. Surgical excision was performed in 4% of adults, but not in pediatric cases. No escharotomies were needed. Median length of stay was 10days. Wound closure occurred by 22days (adults) and 28days (pediatric). Safety data were consistent with previous trials. NexoBrid demonstrated comparable outcomes versus previous Phase III trials and potential efficacy in preventing burn-induced compartment syndrome.

This study explored the impact of an interprofessional mass casualty simulation on undergraduate nursing students' disaster preparedness. A total of 127 students participated; 50 completed pre- and postsurveys using a validated 14-item tool that assessed knowledge, training, and perceived confidence. Results showed significant improvements in disaster knowledge, preparedness, and confidence. Students' willingness to respond to future mass casualty events did not change, which may be due to their prior experiences living in a hurricane-impacted region. Further research is needed to identify, build, and cultivate resiliency during disaster events.

The Army Trauma Training Course (ATTC) has held the responsibility of training deploying U.S. Army Forward Resuscitative and Surgical Detachments (FRSDs) since September 2001. The program of instruction (POI) consists of didactics and skill stations (Crawl), a mass casualty (MASCAL) situational training exercise (STX) (Walk), and clinical integration into an urban Level I trauma center (Run). Over the program's 25-year existence, there has been no report on the subjective assessment of the rotator's perceived effectiveness of the program as a whole. We hypothesized that a post-course survey would evaluate the POI at the ATTC and that ATTC graduates would subjectively describe improved operational readiness. Post-course surveys were delivered electronically to rotating FRSDs as a graduation requirement. Survey questions were developed on a 5-point Likert scale, and descriptive statistics were calculated. Survey data were analyzed from 25 courses (October 2021 through December 2023), including 485 FRSD members. There were 41 general surgeons, 19 orthopedic surgeons, 48 emergency medicine physicians, 51 CRNAs, 53 critical care nurses, 48 emergency room nurses, 7 other nurses, 57 LPNs, 82 combat medics, 50 surgical technicians, 6 physician assistants, and 23 medical service corps officers. The post-course survey response rate was 441/485 (90.9%), with nearly all respondents answering the entire survey. Among respondents, 402/440 (91.4%) respondents agreed that the MASCAL STX better prepared them to manage a MASCAL scenario; 410/441 (93.0%) respondents agreed that clinical rotations were useful for FRSD team development; 401/440 (90.9%) respondents agreed that their experience at ATTC made them more confident in performing their Individual Critical Task List (ICTL) skills in the deployed setting; 402/424 (94.8%) respondents agreed that their experience at ATTC made them more knowledgeable of the Joint Trauma System (JTS) Clinical Practice Guidelines (CPGs); 398/425 (93.6%) respondents agreed their experience at ATTC contributed favorably to their operational readiness; and 437/441 (99.1%) respondents indicated they would recommend the course to another deploying FRSD. POI at the ATTC subjectively improves FRSD collective and individual preparedness for deployed combat casualty care. Further studies are needed to evaluate the objective effectiveness of the training platform.

Objectives Large language models (LLMs) using a retrieval-augmented generation (RAG) approach have the ability to respond to user queries with answers grounded in specific sources. We conducted an exploratory evaluation of the accuracy of a RAG-based LLM to provide care recommendations for prehospital scenarios based on the emergency medical services (EMS) policies and treatment protocols (TPs). Methods We conducted a non-human, simulation-based experimental study by uploading all text-based policies/TPs from a single large EMS system into Google’s NotebookLM platform, which uses a RAG-based LLM (Gemini 2.5 Flash) framework to generate grounded responses. We developed six clinical scenario prompts, including adult patient scenarios (i.e., ventricular fibrillation out-of-hospital cardiac arrest [OHCA], blunt head trauma, stroke, hazardous materials exposure mass-casualty incident) and pediatric patient scenarios (i.e., pulseless electrical activity OHCA, traumatic penetrating extremity hemorrhagic shock). For each scenario, we used all relevant policies/TPs to create a specific set of expected patient care actions. We categorized actions as procedures/interventions, medications, and destination guidance. Medication grading included dose/route for all patients and weight-based dosing for pediatrics. After providing the LLM with the prompts, two investigators independently graded the LLM responses and evaluated for LLM “hallucinations.” Missing actions were categorized by investigators based on applicability to the case and potential safety risk (e.g., “non-applicable,” “minor miss,” “major miss”). The primary outcome was model recommendation accuracy, defined as the percentage of all actions correctly provided in the model’s response. We reported descriptive statistics. Results The LLM recommended 127 (75%) of 169 patient care actions across all cases. There were 42 missed actions. Nine of the 169 actions (5%) were categorized as “major misses,” 13 (8%) as “minor misses,” and 20 (12%) as non-applicable to the specific case. Five of nine major misses occurred during the pediatric OHCA case; the majority of these resulted from failure to prompt for evaluation of secondary treatable causes. We identified 12 hallucinations; none were judged to endanger patient safety. Conclusion We found that a RAG-based LLM demonstrated 75% accuracy across various prehospital scenarios when providing responses grounded in the policies/TPs of a single large EMS agency.

Mass casualty incidents (MCIs) continue to pose significant operational challenges for health care facilities, particularly when compounded by electronic health record (EHR) downtime or cyberattacks. Despite advancements in technology, providers may consider using simple, paper-based patient triage and tracking methods during an MCI. This study describes the implementation of a paper-based triage and patient tracking tool, integrated into a broader MCI Toolkit, to support operational continuity. Developed by NYU Langone Hospital-Brooklyn Emergency Department in collaboration with Emergency Management, the tool was deployed in 6 full-scale exercises (2021-2025) and 2 real-world MCIs across trauma and non-trauma ED settings. The tool follows a 3-step process: rapid triage using Simple Triage and Rapid Treatment (START), documentation of acuity and location, and post-triage identity reconciliation. The MCI Toolkit includes operational resources such as contact lists, patient placement maps, and job action sheets. After each event, feedback was gathered from clinical staff and senior leadership. In the feedback sessions, the tool was noted to be intuitive and required minimal training. It enabled rapid triage, patient placement, and real-time situational awareness for Incident Command. During a downtime simulation, it supported a seamless transition from electronic to manual processes. Across incidents, it improved patient throughput, ensured appropriate team assignment, and supported role flexibility when leadership was unavailable. Our experience using the paper-based Triage Tracker showed it reliably maintained patient tracking without electronic systems. Its ease of use and integrated resources supported coordination, patient flow, and operational continuity during MCIs and EHR disruptions.

Effective and standardized prehospital triage is crucial in mass casualty incidents (MCIs) to optimize patient outcomes. Existing triage systems often vary by region, creating challenges for multinational disaster response. A "translational" tool, intended to support interoperability and potentially bridge routine and MCI contexts, has been proposed. As a preliminary step, this study evaluates the concordance, defined here as the post-hoc categorical agreement) of the translational triage tool (TTT) with established, routine triage systems across diverse international settings. This multinational observational study included 301 patients from Poland, Saudi Arabia, and Thailand. Agreement between the routine triage outcome and TTT categorization applied by the observer was assessed within each country using Cohen's kappa (linear and quadratic weights). For sites using five-level routine systems (CTAS / ESI), categories were pre-specified and collapsed into a three-level framework for comparison (CTAS 1 = Red; CTAS 2 = Yellow; CTAS 3-5 = Green; ESI 1 = Red; ESI 2 = Yellow; ESI 3-5 = Green). Cross-tabulations were used to describe patterns of discordance (over- and under-triage relative to the local routine triage system). No inferential comparisons between the tools were performed beyond agreement estimates because the data were categorical/ordinal and pooled analyses were not defensible given heterogeneity across sites. Agreement levels varied across countries: complete categorical concordance in Poland (kappa = 1.000), substantial in Saudi Arabia (kappa = 0.810), and good in Thailand (kappa = 0.701). Discordant cases in Saudi Arabia and Thailand suggested that the physiologically focused TTT-more often assigned lower urgency to patients with stable physiology but high-risk presentations or medical histories, while sometimes assigning higher urgency when respiratory signs appeared abnormal. The TTT shows strong alignment with the physiologically oriented START approach but diverges from complaint- and risk-modifier-driven systems such as CTAS and ESI, particularly when assigning of lower urgency to some high-risk presentations without overt physiological compromise. This study assesses post-hoc concordance rather than clinical accuracy or patient outcomes; therefore, the findings should not be interpreted as validation of TTT for routine clinical use. The pattern of agreement with START and discordance with CTAS/ESI systems is consistent with a physiologically driven disaster triage approach, and future studies should evaluate the TTT specifically in surge / MCI contexts, including operational feasibility and outcome-based safety.

Objectives Emergency medicine (EM) residency curricula are designed to prepare future physicians for independent practice. Although the Accreditation Council for Graduate Medical Education requires that EM residents have prehospital experiences, very few programs augment this experience with a dedicated resident response vehicle. There are minimal data demonstrating the utility of such an approach. Our residency program staffs a dedicated response vehicle with a PGY-2/3 resident 24/7/365 to respond to high-acuity emergency medical services (EMS) calls. Additionally, from 0800 to 2300, the on-duty resident provides on-line medical control (OLMC) for the county. Each resident averages one 24-h shift per 4-week EM block. The purpose of this study is to describe the prehospital educational experiences and curricular contributions that this program provides. Methods We used a retrospective observational study design of administrative patient care records over a 5-year period. The primary outcomes were the number of unique encounters and patient experiences per resident per cohort year. The secondary outcomes included characterization of the prehospital experiences among all residents: physician role, patient age-group and sex, problem type, scene location, and procedures. Descriptive statistics were computed to quantify the number, type, and characteristics of the prehospital encounters. Results Ninety unique resident users were identified in the charting system. The mean number of encounters per resident was grouped by graduation year and spanned from 28.7 (SD 15) for 2018 to 79.2 (SD 49.2) for 2022, with a range of 2–222 encounters per resident documented. Over the study period, our residents managed 1313 out-of-hospital cardiac arrests (34 pediatric), 1048 refusals, 596 death pronouncements, 172 critical trauma patients, and answered 2053 complex OLMC consults. Conclusions This study quantified the prehospital experiences of our senior EM residents with the addition of a physician response vehicle to our longitudinal EMS curriculum. This has allowed our residents to gain valuable first-hand exposure to out-of-hospital adult and pediatric cardiac arrests, refusals of care, altered mental status, and respiratory emergencies, in addition to prehospital scenarios not likely to be seen within the hospital walls, including motor vehicle collisions with entrapment and mass casualty incidents.

BackgroundThe ongoing genocide (as declared on September 16, 2025 by the UN Independent International Commission of Inquiry on the Occupied Palestinian Territory, including East Jerusalem, and Israel) and militarized siege in Gaza has led to the systematic collapse of the health system, with hospitals overwhelmed by targeted bombings, mass casualties, infrastructural annihilation, and profound psychological suffering. Nurses have been subjected not only to extreme occupational stress but to deliberate conditions of deprivation and moral violation.Research aimTo explore the lived experiences of nurses in Gaza's hospitals, documenting compassion fatigue, burnout, and moral injury within a genocidal context of healthcare destruction.Research designA qualitative design was employed using thematic analysis of in-depth testimonies.Participants and Research ContextTestimonies were collected from nurses working in Gaza's remaining hospitals between late 2023 and mid2025. Participants served as frontline caregivers while enduring forced displacement, starvation, and personal bereavement.Ethical considerationsEthical approval was obtained from local review boards. Informed consent, confidentiality, and emotional safety were ensured under exceptionally high-risk conditions.FindingsSix themes were identified: (1) collapse of hospital care; (2) nurses' bodies and minds under siege; (3) maternal starvation and neonatal death; (4) burden of infection and decay; (5) solitary mourning and improvised funerary practices; and (6) the struggle to endure and find meaning. Nurses reported compassion fatigue, moral injury, somaticexhaustion, and cognitive impairment, all intensified by the genocide's material and emotional toll.DiscussionCaregiving persisted despite repeated targeting of medical personnel and infrastructure. Findings extend conventional models ofburnout and secondary trauma by situating experiences within the concept of 'medicide,' defined as the systematic destruction of health systems.ConclusionsThis study provides an empirically grounded account of nursing labor under conditions described by international bodies as genocidal. Insights have urgent implications for nursing ethics, international humanitarian law, and interventions to support health workers in colonized and militarized settings.

Mass casualty incidents (MASCAL) in modern naval large-scale combat operations (LSCO) present unique triage challenges due to the confined environments, operational constraints, and saturation of medical resources. Combat Medical Early Warning Systems (CMEWS)-integrating wearable biosensors with automated early warning scores (EWS)-may support dynamic triage, but their use in a naval military setting has not been previously studied. This prospective observational pilot study was conducted aboard a French Navy amphibious helicopter carrier during the POLARIS 25 naval LSCO simulation (May-June 2025). The tested CMEWS combined new-generation autonomous OXYFLEX® biosensors with a trauma-adapted EWS, displayed via color-coded LEDs. Biosensors collected heart rate (HR), respiratory rate (RR), oxygen saturation (SpO₂), and transcutaneous hemoglobin (SpHb) every 10s. Simulated scenarios included onboard and task force-level MASCAL events with aeromedical evacuation. Primary endpoints were data quality-defined by the proportion of valid physiological data points-and usability, evaluated using the System Usability Scale (SUS), Computer System Usability Questionnaire (CSUQ), and After Scenario Questionnaire (ASQ). Data quality assessment focused on technical feasibility and signal robustness under operational conditions rather than measurement accuracy against a reference standard. Twenty-two simulated combat casualties were monitored, including 10 during helicopter evacuation. Over 34h of monitoring yielded 12,476 data points per variable. New-generation biosensors provided 79% valid data-indicating technically feasible physiological signal acquisition under operational conditions. HR showed the highest proportion of valid data (91.2%) and RR the lowest (59.6%). Lower proportions of valid data were observed during helicopter evacuation. Usability feedback was favorable (N=21): SUS 86 (SD 7.6) (Grade A), CSUQ 1.9 (0.9), ASQ 1.6 (0.6). Participants reported ease of use, improved situational awareness, and enhanced triage efficiency. Reported limitations included absence of blood pressure monitoring and a basic interface. CMEWS deployment in a naval MASCAL setting proved technically feasible, logistically achievable, and well-accepted by users. While biosensor performance was robust in static conditions, further technical optimization and clinical validation in real operational and clinical settings are needed for broader operational use.

This study evaluates the evolution of surgical activities aboard a French aircraft carrier over the past decade. Historically focused on routine surgical care, the carrier has recently upgraded its facilities to address emerging challenges posed by high-intensity conflicts. Data were collected from surgical reports between 2013 and 2023. Key advancements, including the implementation of a Navalized Antenna of Resuscitation and Emergency Surgery (ARCS), were analyzed. The study also reviews the carrier's enhanced capabilities in trauma and mass casualty management. From 2013 to 2023, 220 surgical procedures were performed, including 143 orthopedic (64%) and 80 visceral surgeries (36%). Local anesthesia was used in 44% of cases, regional anesthesia in 20%, general anesthesia with spontaneous ventilation in 27%, and general anesthesia with endotracheal intubation in 9%. The introduction of the ARCS system in 2024 significantly improved the carrier's ability to handle combat-related injuries, with new facilities enabling 2 simultaneous surgeries, enhanced imaging, and tele-assisted procedures. The French aircraft carrier's surgical capabilities have evolved from routine care to readiness for high-intensity conflicts and mass casualty events. These advancements ensure hospital-standard care onboard and position the carrier to meet the demands of modern warfare.

Field transfusion of whole blood is vital for patients in hemorrhagic shock, particularly in austere or resource-limited environments. Military use of warm fresh whole blood (WFWB) has inspired civilian interest in walking blood banks (WBBs) for rural, prehospital, and mass casualty settings where blood product access is limited. However, standardized training and proficiency benchmarks are lacking. This project developed a checklist and established validity evidence to assess provider proficiency in WFWB collection and transfusion. A multidisciplinary panel created a checklist and modified an existing training video for WFWB collection and transfusion. Using simulation, medical students, nurses, nurse practitioners, physicians, and emergency medical service providers were evaluated to validate the checklist and define proficiency thresholds. Participants (n = 41) were categorized as novice (n = 12), intermediate (n = 13), or expert (n = 16) based on experience. After reviewing the video, participants performed simulated procedures graded by independent evaluators. The maximum score was 47 points, with competency defined by expert performance. Analyses of variance revealed significant differences between novice and intermediate (p <.01) and novice and expert (p<.01) groups, but not between intermediate and expert (p = .09). Mean rubric scores and completion times were: novice (31/47; 41 min 17 s), intermediate (38/47; 33 min 7 s), expert (41/47; 29 min 19 s). The competency threshold was set at 41/47 and 33 min 27 s. The validated checklist and training video provide a foundation for standardized WFWB education and proficiency assessment, supporting safe WBB implementation in military and civilian settings.

Evidence-based AI clinical decision support system for acute burn care and complex reconstruction.

Strengthening emergency care systems could reduce death and disability in low- and middle-income countries (LMICs), yet many struggle to provide timely, high-quality care. LMICs also face growing risks from climate-related shocks and mass casualty events. This study identifies unmet emergency care needs in Nepal-one of the world's most climate-vulnerable countries-using high-resolution geospatial data to estimate socioeconomic and climate-related inequalities. We conducted a cross-sectional geospatial analysis using data from the 2022 Nepal Demographic and Health Survey (DHS), the 2021 DHS Service Provision Assessment and publicly available climate vulnerability data. Government hospitals were classified into three emergency care levels using World Health Organzation criteria: A (basic 24-hour services), B (A plus resuscitative capabilities) and C (B plus ≥50 beds and a surgeon). Household location and injury data were obtained from the DHS. Accessibility was defined as the proportion of the population within 1-hour and 2-hour travel times, estimated using AccessMod 5.8, incorporating road networks, rivers, land cover and elevation. Most public hospitals (77.7%) met Level A criteria but only 49.3% met Level B and 10.8% met Level C. Nationally, 78.7% of households had 1-hour access to Level A care, 71.8% to Level B and 44.6% to Level C. Adjusted logistic regression showed rural, poorer and climate-vulnerable households had significantly lower 1-hour access compared with urban households, rural households had lower odds of access: Level A OR: 0.33 (95%CI 0.30 to 0.37), Level B OR: 0.33 (95%CI 0.30 to 0.36), Level C OR: 0.56 (95%CI 0.51 to 0.61). Households in high climate vulnerability areas had reduced access across all levels. Substantial gaps and inequities in timely access to high-quality emergency care exist in Nepal. Rural, poorer and climate-vulnerable populations experience markedly lower access. Targeted, decentralised strengthening of emergency care capacity is essential both in Nepal and in other LMICs facing similar constraints.

Effective preparedness and response to mass casualty incidents (MCI) are essential for hospital safety, operational efficiency, and the delivery of timely, high-quality patient care during emergencies. This study assessed a tertiary government hospital in Lebanon's Code Orange plan by reviewing documentation for alignment with international guidelines and evaluating staff knowledge, attitudes, and practices (KAP) regarding MCI preparedness. Documents reviewed at Rafik Hariri University Hospital (RHUH) included the current Code Orange plan, relevant policies, and international guidelines. A comprehensive evaluation framework was used, focusing on preparedness, incident command systems, communication, and management. A comparison with established standards was conducted to identify gaps. Complementing this, a cross-sectional study was conducted using a convenient sample of medical and non-medical healthcare workers to evaluate their KAP regarding MCI preparedness. The desk review of the RHUH Code Orange plan identified both strengths and significant gaps in MCI preparedness. While the plan defines staff roles and resources for emergency response, it lacks detailed procedures for activation strategies, surge capacity, continuity of essential services, and triage processes. Additionally, post-event recovery protocols are insufficient or absent, and the importance of regular drills is not adequately emphasized. The KAP study revealed significant differences between medical and non-medical staff in terms of MCI knowledge, involvement, and training engagement, with medical staff reporting higher levels of familiarity and desire for participation. The findings underscore the need to bridge knowledge and engagement gaps between medical and non-medical staff to enhance MCI response. Key actions include interdisciplinary training to build coordination, clear communication protocols to streamline information flow, and routine drills with defined roles to strengthen preparedness. Additionally, implementing performance monitoring during drills and real MCIs, along with conducting regular evaluations, will allow for continuous refinement of response strategies.

Future United States military conflicts may involve near-peer adversaries and large-scale combat operations resulting in mass casualties with delayed evacuation. Health service support planning for such conflicts will require data informing patterns of survival among injured combatants. We determined the probability of survival to 24 hours post injury for trauma patients with blunt or penetrating non-compressible torso hemorrhage (NCTH) in a relatively resource-constrained environment. We hypothesized that the conditional probability of 24-hour survival would rise with survival to intermediary timepoints of progressively increasing duration. This secondary analysis of trauma patients treated in South Africa's Western Cape leveraged data collected during the Epidemiology and Outcomes of Prolonged Trauma Care (EpiC) study. EpiC captures data from point-of-injury through either hospital discharge or patient death. Patients must survive to reach ambulance or facility care to be included in EpiC. Inclusion criteria for this analysis included patients with NCTH, defined as an abbreviated injury scale (AIS) severity score of 2+ in the chest, abdomen, and/or pelvis body regions without AIS 3+ in any other body region. The primary outcome was survival at 24 hours post injury. We considered intermediary timepoints at: 1, 2, 3, 6, 12, and 18 hours post injury. We calculated unadjusted conditional Kaplan-Meier curves, visually describing crude overall 24-hour survival trajectories conditional on survival to the prespecified set of intermediary timepoints. To adjust for potential confounding, we generated an adjusted 24-hour survival curve using a Cox proportional hazards model adjusting for age, sex, new injury severity score (NISS), and triage early warning score (TEWS). Using the adjusted survival curve, we estimated conditional probabilities of 24-hour survival given survival to each of the intermediary timepoints individually. We plotted the linear trend line of conditional 24-hour survival probability versus intermediary timepoints, using segmented regression trendlines to account for changes in the relationship. We included 2,685 patients: 111 (4.1%) died within 24 hours. Survival probability estimates consistently demonstrated that survival to intermediary timepoints of increasing duration was associated with higher probability of 24-hour survival. An inflection point in 24-hour survival trajectory occurred at 3.6 (95% CI: 2.8-4.3) hours. For every hour that a patient survived up to the first 3.6 hours after injury, the probability of 24-hour survival increased by 0.53% (95% CI: 0.38%-0.69%). For every additional hour of survival after 3.6 hours and before 24 hours post injury, the probability of 24-hour survival increased by 0.07% (95% CI: 0.05%-0.10%). Among civilian patients with blunt force injury or penetrating NCTH injuries who survived to ambulance retrieval (role 1 equivalent) or health facility (role 2 equivalent), the overall 24-hour mortality was 4.1%. Conditional survival probability estimates consistently demonstrated that survival to intermediary timepoints of increasing duration was associated with higher probability of 24-hour survival. We identified 3.6 hours from time of injury as a threshold beyond which patients derive relatively less additional 24-hour survival benefit progression to subsequent intermediate time points. Military medical doctrine should acknowledge increased risk of casualty deaths when evacuation timelines exceed three and a half hours.

The Military Health System faces increasing readiness strain as global peer competition, sustained operational demands and post COVID-19 workforce and budget constraints reduce military treatment facility (MTF) capability and shift care to civilian networks. This trend erodes readiness-relevant clinical experience across undergraduate and graduate medical education, threatening the ability to generate and sustain a ready medical force capable of delivering combat casualty care at the scale anticipated in large-scale combat operations, humanitarian crises, and mass casualty events. High-performing civilian Academic Health Systems (AHS) provide a proven framework to integrate clinical care, education and research into a single learning enterprise that improves outcomes, enables rapid adaptation during crisis, and accelerates innovation. The National Capital Region (NCR) already contains the core components of such a system, including the Uniformed Services University, the National Capital Consortium, and multiple major MTFs, yet remains limited by service parochialism, soloed governance, and misaligned referral management. Multiple National Defense Authorization Acts provide legal precedent supporting modernization and explicitly authorize the creation of an AHS in the NCR. We propose an NCR pilot integrated military AHS centered on physician-led clinical departments and a unified practice plan to align clinical volume, education, and research with readiness requirements, streamline referrals across the enterprise, and accelerate military-relevant innovation. Timely implementation would strengthen trauma readiness, improve medical force generation, and provide a scalable model for other Defense Health Networks. (J Trauma Acute Care Surg. 2026;00: 00-00. Copyright © 2026 Wolters Kluwer Health, Inc. All rights reserved.).

Aldicarb is a carbamate pesticide used for pest control in agriculture. As a fast-acting acetylcholinesterase inhibitor, aldicarb interferes with the nervous system by preventing the breakdown of acetylcholine. Aldicarb could be used as a chemical-warfare agent to cause mass casualty incidents. There is no specific FDA-approved medication for aldicarb detoxification. Our previous study revealed that an Fc-fused butyrylcholinesterase (BChE) mutant, known as CocH3-Fc(M3), can be inhibited rapidly by aldicarb and that the aldicarb-inhibited enzyme CocH3-Fc(M3) can be reactivated spontaneously, suggesting that CocH3-Fc(M3) may hydrolyze aldicarb. However, the suggested CocH3-Fc(M3)-catalyzed hydrolysis of aldicarb was not confirmed experimentally in the previous study. In the present study, by developing an LC-MS/MS method to detect and quantify aldicarb and aldicarb oxime concentrations, we were able to directly observe the CocH3-Fc(M3)-catalyzed aldicarb hydrolysis for the first time, confirming that CocH3-Fc(M3) indeed has the desirable catalytic activity for aldicarb hydrolysis and may be considered as the first aldicarb hydrolase identified so far. Further, we carried out Michaelis-Menten kinetic analysis on the CocH3-Fc(M3)-catalyzed aldicarb hydrolysis and determined the catalytic parameters (kcat=0.060min-1, KM=2.5μM, and kcat/KM=2.4×104 min-1 M-1) at 37°C. The obtained kinetic parameters at 37°C will be valuable for further in vivo studies and translational research using CocH3-Fc(M3) and for designing more potent enzymes to hydrolyze aldicarb in the future. Additionally, the LC-MS/MS method developed in this study may serve as a valuable tool to accurately detect aldicarb and its reaction products in future food and environmental safety control efforts and aldicarb-related toxicology studies.