Medical Preparedness Research Articles

Poor Soldier Medical Readiness In The Year Following Return To Unrestricted Duty After Musculoskeletal Injury

Not all Soldiers cleared for full unrestricted duty are without injury just because they do not seek medical attention. Using medical care-seeking as proxy for medical readiness & deployability has limitations. Efficient injury detection & long-term management can improve if surveillance begins before patients make decisions to seek care. PURPOSE: 1) determine proportion of Soldiers reporting new or recurring injuries for which they did not seek medical care, & 2) report perceived ability to perform full military duty when injured & not seeking care. METHODS: This was a secondary analysis of a cohort of Soldiers (n=469) recently cleared to return to full duty (RTFD) without limitations. Monthly adaptive text messages queried about any new or recurrent injuries for 1 yr after clearance to RTFD after spine or lower extremity injury. Presence of MSK pain, care-seeking behavior, & perceived ability to perform military duties were assessed. RESULTS: 424 soldiers had at least 1 response over the 1-yr follow-up & a mean response rate of 45.5% (at least 5 months). 315 participants reported injury-related MSK pain at least once. Of those, 276 (87.6%) reported not seeking care during at least 1 pain episode. When care was not sought, 89 (32.2%) reported it affecting their ability to perform military duties. On at least one occasion, 127 individuals believed they would not pass an annual fitness test due to pain, deconditioning, or fear of injury. CONCLUSIONS: Soldiers do not always seek care for MSK injuries, & thus, many are not confident in their ability to complete military duties. Early indicators & improved surveillance strategies could identify problematic injuries before they reach a threshold of needing to seek care. Equally important is the ability to predict which individuals can self-manage without adversely affecting ability to perform military duties. This research was supported by the Department of Defense Military Operational Medicine Research Program under program number (W81XWH-13-MOMJPC5-IPPEHA). The view(s) expressed herein are those of the author(s) and do not reflect the official policy or position of Brooke Army Medical Center, the U.S. Army Medical Department, the U.S. Army Office of the Surgeon General, the Department of the Army, the Department of the Air Force, the Department of Defense, or the U.S.Government.

Taking Matters into Your Own Hands.

Taking Matters into Your Own Hands.

Delay in Primary Anterior Cruciate Ligament Reconstruction Increases Medical Separation Risk in the U.S. Military

Objectives:Anterior cruciate ligament reconstruction (ACLR) remains one of the most readiness-impairing surgical conditions treated in the US Military. Greater time from the index injury to surgical management (ACLR) unnecessarily prolongs the total time of limited duty. Additionally, prolonged wait times from the index injury to ACLR may increase the patient’s likelihood of sustaining concomitant or secondary intraarticular pathologies (e.g., cartilage and meniscus damage). The optimal timing for surgical reconstruction following ACL injury is debated. The purpose of this study was to determine the impact of prolonged time from injury to surgery on medical separation within five years of primary ACLR. We hypothesized that longer durations from injury to primary ACLR would be associated with greater medical separation risk within five years following surgery.Methods:We conducted a retrospective database review using data from the Military Health System Data Repository (MDR) of primary ACLR without and with concomitant procedures (meniscus [M] and/or cartilage [C]) performed within Military Treatment Facilities (MTF) from fiscal year 2009 to and/or cartilage [C]) performed within Military Treatment Facilities (MTF) from fiscal year 2009 to 2011. At the time of the ACLR, ADSMs had to be continuously enrolled for two years prior to the surgery with no history of knee surgeries in direct care (i.e., MTFs) or purchased care to ensure a higher likelihood of the index event being a primary ACLR and not an ACLR revision. A total 2,809 active duty service members were included with primary ACLR. The MDR was queried for baseline demographic, military service, and surgical information at the time of ACLR. Duty status at the time of the ACLR and cause of separation up to five years after primary ACLR were abstracted. The time from the index injury diagnosis to the primary ACLR was calculated and grouped as follows: Acute = 0-42 days, Subacute = 43-91 days, Delayed = 92-179 days, Chronic ≥ 180 days. Kaplan-Meier survivability curves were estimated and evaluated with Log-rank. Cox Proportional Hazard Models calculated Hazard Ratios (HR) with 95% confidence intervals (95% CI) to identify time from injury to surgery, demographic, and military status factors that influenced medical separation risk for patients with primary ACLR (ACLR, ACLR+M, ACLR+C, ACLR+M+C).Results:The index surgical events were categorized by isolated ACLR (48%), ACLR+M (42%), ACLR+C (5%), and ACLR+M+C (4%). Overall, the time from diagnosis to ACLR was approximately equivalent across all time categories: Acute (19%), Subacute (31%), Delayed (23%), and Chronic (25%). The probability of medical separation 5 years following primary ACLR (ACLR, ACLR+M, ACLR+C, ACLR+M+C) was highest for the delayed [92-179 days] group (17%) and lowest for the acute [0-42 days] group (12%). Patients in the delayed group were over 51% more likely to medically separate in the 5 years following the primary ACLR than those who were treated within 42 days from injury (acute group). The difference between the acute group and subacute or chronic was not statistically significant. Those in infantry and combat support related military occupation classifications were 27% more likely to medically separate. Service members in the Army were more than 4.5 times more likely to medically separate compared to those in the Air Force. Smoking and BMI over 29 also increased the risk of medical separation within 5 years by 42% and 91%, respectively. The type of injury at the index event (ACLR, ACLR+M, ACLR+C, ACLR+M+C) did not significantly influence the likelihood of medical separation risk.Conclusion:Delay in treatment from injury to primary ACLR increases the number of limited duty days, effects medical readiness of ADSM, and military retention rates post ACLR. Specifically, when primary ACLR is delayed 3 to 6 months from injury, ADSM have a 51% increased likelihood of military medical separation risk in the 5 years following the ACLR than if they would have been treated within 41 days of injury. Early recognition of ACL tears as well as availability of surgeons and Operative Rooms (ORs) should be evaluated to determine their contribution to the delay in ACLR in the MHS.

A data driven epidemic model to analyse the lockdown effect and predict the course of COVID-19 progress in India.

We propose a data driven epidemic model using the real data on the infection, recovery and death cases for the analysis of COVID-19 progression in India. The model assumes continuation of existing control measures such as lockdown and quarantines, the suspected and confirmed cases and does not consider the scenario of 2nd surge of the epidemic due to any reason. The model is arrived after least square fitting of epidemic behaviour model based on theoretical formulation to the real data of cumulative infection cases reported between 24 March 2020 and 30May 2020. The predictive capability of the model has been validated with real data of infection cases reported during June 1–10, 2020. A detailed analysis of model predictions in terms of future trend of COVID-19 progress individually in 18 states of India and India as a whole has been attempted. Infection rate in India, as a whole, is continuously decreasing with time and has reached 3 times lower than the initial infection rate after 6 weeks of lock down suggesting the effectiveness of the lockdown in containing the epidemic. Results suggest that India, as a whole, could see the peak and end of the epidemic in the month of July 2020 and March 2021 respectively as per the current trend in the data. Active infected cases in India may touch 2 lakhs or little above at the peak time and total infected cases may reach over 19 lakhs as per current trend. State-wise results have been discussed in the manuscript. However, the prediction may deviate particularly for longer dates, as assumptions of model cannot be met always in a real scenario. In view of this, a real time application (COV-IND Predictor) has been developed which automatically syncs the latest data from the national COVID19 dash board on daily basis and updates the model input parameters and predictions instantaneously. This real time application can be accessed from the link: https://docs.google.com/spreadsheets/d/1fCwgnQ-dz4J0YWVDHUcbEW1423wOJjdEXm8TqJDWNAk/edit?usp=sharing and can serve as a practical tool for policy makers to track peak time and maximum active infected cases based on latest trend in data for medical readiness and taking epidemic management decisions.

Injury Patterns and Wilderness Medical Preparedness in BASE Jumping

Injury Patterns and Wilderness Medical Preparedness in BASE Jumping

0385 Risk Assessment of Sleep Disorder Comorbidity Across Active Duty Army Installations from Military Medical Databases

Abstract Introduction The impact of sleep disorders on active duty Soldiers’ medical readiness is clinically significant. Sleep disorders present high comorbidity with disease states directly impacting medical readiness, ranging from musculoskeletal injury (MSK-I), obesity, and drug dependence. The current study performed a risk assessment of sleep disorder comorbidity with MSK-I, obesity, and drug dependence across active duty United States Army installations. Methods Health incidences (percent active duty per installation) were queried from the Office of the Surgeon General Health of the Force (HoF) report, specifically for Fiscal Year (FY) 2017 (n = 471,000; 85.5% male, > 70% between 18 -34). Nonparametric ranked tests identified active duty Army installations at low risk (green; < 25% percentile relative to mean rank), moderate risk (amber; 25% - 50%), and high risk (red; > 75% percentile). Linear regressions determined extent of comorbidity of sleep disorders with MSK-I, obesity, and drug dependence (tobacco use and substance abuse). Results Mean rank comparisons for sleep disorders vs. injury index (p=0.499), obesity (p=0.306), tobacco use (p=0.378), and substance abuse (p=0.591) did not differ for each installation. Further, there was a high degree of co-morbidity for mean percentage of diagnosed sleep disorder with injury index (p<0.001; r2 = 0.517), obesity (p<0.001; r2 = 0.963), tobacco use (p<0.001; r2 = 0.928), and substance abuse (p<0.001; r2 = 0.968). Conclusion In general, large infantry and artillery training units located in the Southeastern United States were “in the red” for not meeting medical readiness standards. A few exceptions include Virginia-Maryland triangle, a heavily populated area. These data demonstrate strong geographical influences on health risk comorbidity in active duty Soldiers comparable to civilian sectors. Support Military Operational Medicine Research Program

Simulation-based training programme and preparedness testing for COVID-19 using system integration methodology

BackgroundCOVID-19 pandemic is presenting serious challenges to the world’s healthcare systems. The high communicability of the COVID-19 necessitates robust medical preparedness and vigilance.ObjectiveTo report on the simulation-based training and test...

Army Physician Career Satisfaction Based on a Medical Corps Survey.

It is critical the U.S. Army retains skilled physicians in the Medical Corps (MC) to ensure direct support to military operations and medical readiness. The purpose of this study was to examine U.S. Army physicians' opinions concerning: readiness to perform required duties, work environment, support and recognition they receive, military career intentions, and how these factors may relate to Army physician job satisfaction. A cross-sectional study of Army physicians was conducted using a 45-item web-based survey tool, "Army Medicine Medical Corps (MC) Engagement/Satisfaction Survey 2018." The survey used a combination of multiple choice (Likert-scaled and categorical) and open text statements and questions. Satisfaction with their Army physician career was measured using a 5-point unipolar Likert scale response on level of satisfaction. Chi-square tests of independence were conducted on all demographic characteristics to examine if levels of satisfaction with Army physician career were associated with a particular demographic profile. Agreement opinions expressed on 20 statements about professional readiness, work environment, and job recognition were summarized and rank-ordered by percentage of "strongly agree" responses. Categorical responses to several questions related to career intentions were summarized overall and by career satisfaction level. Multivariate logistic regression was performed to identify demographic factors, which may influence career satisfaction as an Army physician. Approximately 47% (2,050/4,334) of U.S. Army physicians participated in the MC 2018 survey. Career satisfaction percentages overall were: "extremely satisfied" (10.0%), "quite satisfied" (24.8%), "moderately satisfied" (33.9%), "slightly satisfied" (22.6%), and "not at all satisfied" (8.3%). Respondents were in least agreement to statements about sufficient administrative support and recognition of doing good work. Logistic regression results showed military rank as a significant predictor of negative career satisfaction as an Army physician. For Captains, the odds for being "not at all satisfied" with their military career were almost nine times that of Colonels. Also, compared to their baseline group, physicians who completed their graduate medical education training, mission critical surgeons, and physicians who worked in military treatment facilities that were either a hospital (not a medical center) or a clinic-ambulatory surgery center had a greater risk of being "not at all satisfied" with their career as an Army physician. There is significant room for improvement in MC officer career satisfaction. The drivers of satisfaction are multiple and apply differently among MC officers of varied ranks and experience. Senior officers are the ones who are the most satisfied with their military career. Results of this novel MC officer study may serve as an impetus to identify existing shortcomings and make necessary changes to retain skilled Army physicians. Army leaders should invest resources to develop and sustain initiatives that improve military career satisfaction and retention of MC officers.

Summer Enrichment Program: A Novel Pre‐Matriculation Anatomy Curriculum for Medical Students

Study ObjectivesMedical schools increasingly accept students from Alternative Academic Pathways (“Alt Path”), such as through early assurance programs or after gaps of time in education. These students may have difficulty with the rigors of medical school and need further preparation to succeed. Exposure to first‐year content, including anatomy coursework, prior to starting medical school has been shown to improve students’ academic performance. Through a novel pre‐matriculation Summer Enrichment Program (“SEP”), we sought to prepare Alt Path medical students for their transition to medical school and first‐year courses. Over the years, varying curricula have been implemented.Our objectives include: (1) evaluating the impact of including anatomy in the SEP on the performance of Icahn School of Medicine at Mount Sinai (“ISMMS”) medical students in their first‐year anatomy course, (2) comparing anatomy performance between the SEP participants and traditional path peers, and (3) understanding Alt Path students’ perceptions of preparedness and confidence in starting medical school.MethodsStudents completed a 5‐week intensive SEP the summer before starting medical school with a curriculum utilizing didactics, laboratories, review sessions, and assessments. Anatomy has been included in the SEP for the Classes of 2019 and 2021–2023 cohorts. Anatomy was not included for the Class of 2020 cohort. This provides a natural experiment for comparison of first‐year anatomy course performance between two subsequent cohorts of Alt Path students (Classes of 2019 and 2020). SEP anatomy was taught by the same faculty teaching the first‐year anatomy course. Future data analysis will include comparisons of coursework performance between Alt Path and traditional students among the Classes of 2019–2023 cohorts. For the Class of 2023 cohort, the perceived impact of the SEP on academic performance and adjustment to medical school will be evaluated using surveys and focus groups to holistically triangulate students’ experiences with the SEP.ResultsIn the Class of 2020 cohort (SEP did not include anatomy), 5 of the 8 students who marginally passed/failed the first‐year anatomy course participated in the SEP. In the Class of 2019 cohort (SEP included anatomy), only 1 of the 8 students who marginally passed/failed the anatomy course participated in the SEP. This suggests that anatomy education immediately prior to medical school in the SEP may positively impact students’ course performance. Qualitatively, Alt Path students positively reviewed the SEP and expressed sentiments of preparedness and confidence with first‐year coursework.Despite the small sample size, all SEP iterations since have included anatomy as a primary component of the curriculum. Future analysis of five Class cohorts (Classes of 2019–2023; n=700) may reveal additional insights.ConclusionMedical educators should consider pre‐matriculation programs in order to enhance medical school preparedness and performance of Alt Path students. Providing these students with educational opportunities focused on foundations prior to first‐year coursework may academically and professionally benefit such students.Support or Funding InformationThe authors received no funding for this work.

National competency frameworks for medical graduates: Is it time for the “SudanMeds”?

Competency-based medical education has emerged recently as a novel model of medical training driven by its ability to reconcile the desired attributes in future physicians and address the overarching and demanding issues of the discipline in this century. The rising concerns of social accountability, patient safety, and cost effectiveness of medical education programs have contributed significantly to the popularity of this paradigm worldwide. This is translated in turn to the evolution of national competency frameworks for medical graduates that are increasingly implemented in different jurisdictions to standardize and ensure equivalent outcomes of medical curricula and readiness of their graduates to better serve their communities. Medical education in Sudan is deeply rooted in the history of the nation and the continent and is tinged with remarkable success and achievements. It is challenged nowadays with unprecedented expansion in basic medical education which may hinder the quality of medical schools’ programs and their graduates. This article explores the feasibility of one such framework in Sudan: the “SudanMeds” to ensure minimum standards and comparability of medical schools’ curricula and their outcomes across the Country. The framework would also arm the regulatory bodies with a tool for accreditation and recognition of basic medical education programs in Sudan and reflect quality assurance in their settings. Once this approach is deemed feasible, the contribution of all stakeholders from the highest top to the bottom – the government, the regulatory bodies, the public and civil organizations, and the medical schools’ community – is required to allow for creation, implementation, and follow-up of the “SudanMeds” framework.
 Keywords: Sudan, competency-based medical education, national competency frameworks, medical schools, basic medical education

Influence of Acetazolamide on Hand Strength and Manual Dexterity During a 30-h Simulated High Altitude Exposure.

High altitude missions pose significant challenges to Warfighter medical readiness and performance. Decreased circulating oxygen levels cause a decrease in exercise performance and can cause debilitating symptoms associated with acute mountain sickness, especially with rapid ascent. Acetazolamide (AZ) is known to minimize symptoms of acute mountain sickness, but it is unknown whether this medication alters hand strength and manual dexterity during altitude exposure. Ten male volunteers (22±4yr, 75.9±13.7kg, 174.9±9.3cm) participated in two separate 30h simulated altitude exposures (496mmHg, equivalent to 3,500m, 20°C, 20% RH) in a hypobaric chamber. Participants were given either a placebo or 250mg of AZ twice daily for 3.5d (2 sea-level [SL] days + the 30h altitude exposure) in a randomized, single-blind, crossover design. During SL and both altitude (ALT) exposures, hand function tests were performed, including hand grip and finger pinch strength tests, as well as the Purdue Pegboard (PP) and magazine loading tests to assess manual dexterity. Paired T tests and two-way repeated measure analysis of variance were used as appropriate to evaluate the effects of AZ and ALT. The value of p<0.05 was accepted for statistical significance. There were no influences of acute ALT exposure or AZ treatment on hand strength (eg, grip strength; SL: 39.2±5.5kg vs. ALT: 41.5±6.9kg, p>0.05) or dexterity (eg, PPassembly; placebo: 35.5±5.3 vs. AZ: 34.3±4.6, p>0.05) in our volunteers. Two dexterity tests (PPsum and magazine loading) showed improvements over time at ALT, regardless of treatment, where scores were improved after 10h of exposure compared to at 1h (eg, magazine loading: 56±12 vs. 48±10, p<0.001). This pattern was not seen in the PPassembly test or any strength measurements. Our results suggest that 500mg/d of AZ does not influence hand strength or manual dexterity during a 30h exposure to 3,500m simulated ALT. Acute ALT exposure (1h) did not influence dexterity or strength, although some measures of dexterity showed improvements as exposure time increased. We conclude that use of AZ to optimize medical readiness at ALT is unlikely to impair the Warfighter's ability to complete mission tasks that depend on hand function.

Virtual on-call increases medical student preparedness for practice.

Medical EducationVolume 54, Issue 5 p. 482-482 REALLY GOOD STUFF: Lessons learned through innovation in medical education Virtual on-call increases medical student preparedness for practice Rynda Nitiahpapand, Rynda NitiahpapandAuthors contributed equally as first authorSearch for more papers by this authorThomas Western, Thomas WesternAuthors contributed equally as first authorSearch for more papers by this authorMatthew Byrne, Corresponding Author Matthew Byrne mhvbyrne@doctors.org.uk orcid.org/0000-0002-2414-352X Authors contributed equally as first author Correspondence Matthew Byrne, Bedford Hospital Trust, Bedford, Bedfordshire, UK. Email: mhvbyrne@doctors.org.ukSearch for more papers by this authorLucia Curran, Lucia CurranSearch for more papers by this author Rynda Nitiahpapand, Rynda NitiahpapandAuthors contributed equally as first authorSearch for more papers by this authorThomas Western, Thomas WesternAuthors contributed equally as first authorSearch for more papers by this authorMatthew Byrne, Corresponding Author Matthew Byrne mhvbyrne@doctors.org.uk orcid.org/0000-0002-2414-352X Authors contributed equally as first author Correspondence Matthew Byrne, Bedford Hospital Trust, Bedford, Bedfordshire, UK. Email: mhvbyrne@doctors.org.ukSearch for more papers by this authorLucia Curran, Lucia CurranSearch for more papers by this author First published: 13 March 2020 https://doi.org/10.1111/medu.14099Citations: 1 Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article.Citing Literature Volume54, Issue5May 2020Pages 482-482 RelatedInformation

Sleep disturbances and predictors of nondeployability among active-duty Army soldiers: an odds ratio analysis of medical healthcare data from fiscal year 2018

BackgroundThe impact of sleep disorders on active-duty soldiers’ medical readiness is not currently quantified. Patient data generated at military treatment facilities can be accessed to create research reports and thus can be used to estimate the prevalence of sleep disturbances and the role of sleep on overall health in service members. The current study aimed to quantify sleep-related health issues and their impact on health and nondeployability through the analysis of U.S. military healthcare records from fiscal year 2018 (FY2018).MethodsMedical diagnosis information and deployability profiles (e-Profiles) were queried for all active-duty U.S. Army patients with a concurrent sleep disorder diagnosis receiving medical care within FY2018. Nondeployability was predicted from medical reasons for having an e-Profile (categorized as sleep, behavioral health, musculoskeletal, cardiometabolic, injury, or accident) using binomial logistic regression. Sleep e-Profiles were investigated as a moderator between other e-Profile categories and nondeployability.ResultsOut of 582,031 soldiers, 48.4% (n = 281,738) had a sleep-related diagnosis in their healthcare records, 9.7% (n = 56,247) of soldiers had e-Profiles, and 1.9% (n = 10,885) had a sleep e-Profile. Soldiers with sleep e-Profiles were more likely to have had a motor vehicle accident (pOR (prevalence odds ratio) =4.7, 95% CI 2.63–8.39, P ≤ 0.001) or work/duty-related injury (pOR = 1.6, 95% CI 1.32–1.94, P ≤ 0.001). The likelihood of nondeployability was greater in soldiers with a sleep e-Profile and a musculoskeletal e-Profile (pOR = 4.25, 95% CI 3.75–4.81, P ≤ 0.001) or work/duty-related injury (pOR = 2.62, 95% CI 1.63–4.21, P ≤ 0.001).ConclusionNearly half of soldiers had a sleep disorder or sleep-related medical diagnosis in 2018, but their sleep problems are largely not profiled as limitations to medical readiness. Musculoskeletal issues and physical injury predict nondeployability, and nondeployability is more likely to occur in soldiers who have sleep e-Profiles in addition to these issues. Addressing sleep problems may prevent accidents and injuries that could render a soldier nondeployable.

Musculoskeletal Injuries and United States Army Readiness. Part II: Management Challenges and Risk Mitigation Initiatives

Noncombat injuries ("injuries") threaten soldier health and United States (U.S.) Army medical readiness, accounting for more than twice as many outpatient medical encounters among active component (AC) soldiers as behavioral health conditions (the second leading cause of outpatient visits). Noncombat musculoskeletal injuries (MSKIs) account for more than 80% of soldiers' injuries and 65% of medically nondeployable AC soldiers. This review focuses on MSKI risk reduction initiatives, management, and reporting challenges within the Army. The authors will summarize MSKI risk reduction efforts and challenges affecting MSKI management and reporting within the U.S. Army. This review focuses on (1) initiatives to reduce the impact of MSKIs and risk for chronic injury/pain or long-term disability and (2) MSKI reporting challenges. This review excludes combat or battle injuries. Primary risk reduction Adherence to standardized exercise programming has reduced injury risk among trainees. Preaccession physical fitness screening may identify individuals at risk for injury or attrition during initial entry training. Forward-based strength and conditioning coaching (provided in the unit footprint) and nutritional supplementation initiatives are promising, but results are currently inconclusive concerning injury risk reduction. Forward-based access to MSKI care provided by embedded athletic trainers and physical therapists within military units or primary care clinics holds promise for reducing MSKI-related limited duty days and nondeployability among AC soldiers. Early point-of-care screening for psychosocial risk factors affecting responsiveness to MSKI intervention may reduce risk for progression to chronic pain or long-term disability. Operational MSKI metrics enable commanders and clinicians to readily identify soldiers with nonresolving MSKIs. Monthly injury reports to Army leadership increase command focus on soldiers with nonresolving MSKIs. Standardized exercise programming has reduced trainee MSKI rates. Secondary risk reduction initiatives show promise for reducing MSKI-related duty limitations and nondeployability among AC soldiers; timely identification/evaluation and appropriate, early management of MSKIs are essential. Tertiary risk reduction initiatives show promise for identifying soldiers whose chronic musculoskeletal conditions may render them unfit for continued military service.Clinicians must document MSKI care with sufficient specificity (including diagnosis and external cause coding) to enable large-scale systematic MSKI surveillance and analysis informing focused MSKI risk reduction efforts. Historical changes in surveillance methods and injury definitions make it difficult to compare injury rates and trends over time. However, the U.S. Army's standardized injury taxonomy will enable consistent classification of current and future injuries by mechanism of energy transfer and diagnosis. The Army's electronic physical profiling system further enablesstandardized documentation of MSKI-related duty/work restrictions and mechanisms of injury. These evolving surveillance tools ideally ensure continual advancement of military injury surveillance and serve as models for other military and civilian health care organizations.

Effects of Brief Depression and Anxiety Management Training on a US Army Division's Primary Care Providers.

There is a nation-wide gap between the prevalence of mental illness and the availability of psychiatrists. This places reliance on primary care providers (PCPs) to help meet some of these mental health needs. Similarly, the US Army expects its PCPs to be able to manage common mental illnesses such as anxiety and depression. Therefore, PCPs must be able to close their psychiatric skills gaps via lifelong learning. Following needs assessment of PCPs in a US Army division, the curriculum was developed. Objectives targeted pharmacological management of depression and anxiety. Behavioral intervention skills were also taught to treat insomnia. Didactics and case-based small groups were used. A novel psychotropic decisional tool was developed and provided to learners to assist and influence their future psychiatric practice. Pre-training, immediate post-training, and 6-month assessments were done via survey to evaluate confidence and perceived changes in practice. The curriculum was executed as a quality improvement project using the Plan, Do, Study, Act framework. Among 35 learners, immediate confidence in selecting optimal psychotropic and perceived knowledge, skill to change the dose or type of medication, and confidence in prescribing behavioral sleep improved significantly with large effect sizes. At 6-month follow-up, learners reported that they were more likely to adjust medications for anxiety or depression and were more likely to start a new medication for anxiety or depression because of the training with moderate effect sizes. Use and satisfaction with the psychotropic decisional tool are also reported. Our psychotropic decisional tool illustrates a novel algorithmic approach for operationalizing the management of depression and anxiety. Similar approaches can improve the skills of a variety of PCPs in the management of psychiatric disorders. Further studies in the military operational setting are needed to assess the effects of similar educational interventions on access to behavioral health care, suicidal behaviors, and unit medical readiness.

“Return to duty” as an outcome metric in military concussion research: Problems, pitfalls, and potential solutions

Objective “Return to duty” (RTD) is often used as an outcome metric in military concussion research, but is inconsistently defined across studies and presents several key problems to researchers. Using results from the Defense and Veterans Brain Injury Center’s (DVBIC) Progressive Return to Activity (PRA) study, we highlight problems with RTD, and suggest solutions to inform future efforts. Method 116 service members (SMs) were enrolled in one of two groups (pre-implementation and post-implementation of the PRA Clinical Recommendation [CR]). Data, including the Neurobehavioral Symptom Inventory (NSI-22), was collected within 72-hours of injury (baseline), and at 1-week, 1-month, 3-months, and 6-months post-injury. Our analyses focused on three time points: baseline, approximate RTD date, and post-RTD follow-up, with RTD data captured via self-report and electronic medical record (EMR). Secondary analyses included comparisons across PRA-CR implementation groups. Results Of those SMs (<50% of the sample) with both self-reported and EMR RTD dates, dates largely did not match (range 1 to 36 days). RTD (either date) also did not indicate symptom recovery, with >50% of SMs reporting “abnormally high” symptom levels (i.e., NSI-22 total ≥75th percentile) at RTD, and over 50% of SMs reporting at least one significant symptom (i.e., any NSI-22 item ≥ 2) after RTD. Conclusions Our data demonstrate challenges encountered with a RTD outcome metric. Military concussion researchers should strive to use a well-defined RTD outcome metric. We propose defining RTD as a return to deployment readiness. Further, researchers should utilize Department of Defense definitions of Individual Medical Readiness and Deployment Limiting conditions to increase specificity of a RTD outcome metric. Improving the way RTD is captured will improve confidence that tools used after a SM sustains concussion are adequately informing RTD decisions.

Impact of climate change on disaster events in metropolitan cities -trend of disasters reported by Taiwan national medical response and preparedness system

BackgroundTaiwan is geographically located in a zone that is vulnerable to earthquakes, typhoons, floods, and landslide hazards and has experienced various disasters. Six Regional Emergency Medical Operation Centers (REMOCs) are integrated and administered by the Ministry of Health and Welfare (MOHW) to be responsible for emergency situations during disastrous events, such as the emission of chemical toxicants, traffic accidents, industrial materials containment, and typhoons. ObjectiveTo analyze events reported by the six REMOCs during the 2014 to 2018 for the government policy reference. MethodsData were collected from injured and death toll reports provided by local designated hospitals in the emergency medical reporting system. Disaster events were categorized into three categories: natural disaster (NDs), disasters associated with technology (DTs), and disasters associated with security/violence/others (DSVOs). The three categories were further subdivided into sub-categories. Variables considered for trend analyses included the number of wounded and deaths, event characteristics, date/time, and triage. The frequency of disaster events among the six REMOCs was compared using the chi-square test. We used the global information system (GIS) to describe the distribution of events in Taiwan metropolitan cities. The α-level was set at 0.05. ResultsOf 580 events during the study period, the distribution of disaster characteristics in the jurisdictions of the six REMOCs were different. The majority of disaster events were DTs (64.5%), followed by NDs (24.5%) and DSVOs (11.0%). Events for the three disaster categories in the six REMOCs were different (χ2-test, p < 0.001). Furthermore, for the Taipei branch (Northern Taiwan), other NDs, especially heatwaves and cold spells, were most reported in New Taipei City (92.2%) and showed an increasing annual trend; for the Kaohsiung branch (Southern Taiwan), DT events were the most reported, especially in Kaohsiung City; and for the Taichung branch (Central Taiwan), DSVOs were the most reported, especially in Taichung City. ConclusionOur data revealed that extreme weather precautions reported in the Taipei branch were increasing. Disaster characteristics were different in each metropolitan city. Upgrading the ability to respond to natural disasters is ineluctable.

Qatar Health 2020: A global conference setting the tone to host one of the most popular sporting competitions in the world

Welcome to this special issue of the Journal of Emergency Medicine, Trauma and Acute Care (JEMTAC) dedicated primarily to Qatar Health 2020 Conference and presenting a selection of abstracts on various topics in response to a late call for free paper oral or poster presentation submissions (). Qatar Health 2020 was a collaborative event between Hamad Medical Corporation and the Qatar Ministry of Public Health, chaired by Dr. Abdul Wahab Al Musleh and organized as a multidisciplinary academic meeting open to healthcare professionals and experts from different backgrounds and countries. The theme of the congress was “Mass gatherings Healthcare Services: Emergency and Disaster Management” in preparation for the FIFA World Cup 2022 and also concentrates on presenting best practices and evidence of a trauma system approach to mass casualty events. Hosting one of the most popular sporting events in the world is a significant undertaking that requires a lot of preparation at a national level to ensure the well-being of athletes, supporters, and various professional groups and volunteers supporting such activity, whilst also still providing the required services to the rest of the population. Mass gathering medicine is defined as “the public health challenges to hosting events attended by a large enough number of people, at a specific site, for a defined period of time, likely to strain both the planning and response to the mass gathering of a community, state, or nation.” Whether it is in relation to the potential spread of infectious diseases, terrorist attacks, or accidents, medical preparedness and emergency response are key. The range of submissions received for Qatar Health 2020 in connection with the known and potential impact of mass gatherings in terms of healthcare response is a testimony of the importance of good preparation which involves a significant ramp up in healthcare manpower and physical resources, public health campaigns, interagency collaboration, considerations for the environmental and cultural context, and exercises to test and rehearse plans (). This special issue also includes two abstracts from the first Qatar Trauma Nurse Symposium which took place at the end of 2019 and was jointly organized by the Trauma Nursing Department and the Nursing and Midwifery Education and Research Department of Hamad Medical Corporation under the leadership of Ms. Asmaa Mosa Al-Atey. Finally, we would like to close this editorial by wishing success to the resurging JEMTAC journal and congratulating all participants that made Qatar Health 2020 Conference and the Qatar Trauma Nurse Symposium such successful events. We look forward to featuring the work presented at future events held in Qatar as well as full articles directly submitted to the journal for Open Access publication. The Editorial Board will endeavor within the next couple of years to make it a regular publication with good quality and informative contents for everyone interested in emergency medicine, trauma, acute and pre-hospital care.

Soldier-Centered Care: A Concept Analysis.

It is critical for the U.S. Army Medical Department to acknowledge the distinctive medical needs of soldiers and conceptualize soldier-centered care as a unique concept. In addition to the nationally recognized standards of patient-centered care, soldier-centered care includes provisions for the priorities of soldier health and wellness, injury prevention, illness and injury management, and the preservation of physical performance and medical readiness. The development of soldier-centered care as a distinctive concept may strengthen the evidence base for interventions that support improvements to soldier care and thus, enhance health outcomes specific to soldiers. The purpose of this article is to analyze the concept of soldier-centered care, clarify the meaning of soldier-centered care, and propose a theoretical definition. Rodgers' evolutionary concept analysis method was used to search and analyze the literature for related terms, attributes, antecedents, and consequences and to create a theoretical definition for soldier-centered care. The results of this concept analysis indicated that soldier-centered care is realized through the presence of nine attributes: operational alignment of care, provider and support staff therapeutic competence, management of transitions and care coordination, technology and accessibility, management of limited and lost work days, trust and expectation management, leadership support, continuity, and access to care. Soldier-centered care is focused on health and wellness promotion, disease and injury prevention, and early diagnosis and treatment of acute injuries in the primary care setting to facilitate timely injury recovery, reduce reinjury, and prevent long-term disabilities. The result of soldier-centered care is enhanced physical performance, medical readiness, and deployability for soldiers. Based on the literature analysis, the following theoretical definition of soldier-centered care is proposed: Soldier-centered care is individualized, comprehensive healthcare tailored to the soldier's unique medical needs delivered by a care team of competent primary care providers and support staff who prioritize trust and expectation management, operational alignment of care, leadership support, care coordination, and the management of limited and lost workdays through the use of evidence-based practice approaches that employ innovative information technology to balance access to care and continuity. The concept of soldier-centered care often emerges in discussions about optimal physical performance and medical readiness for soldiers. Although soldier-centered care and patient-centered care have similar conceptual underpinning, it is important to clarify the unique physical and medical requirements for soldiers that differentiate soldier-centered care from patient-centered care. Implementing the defining attributes of soldier-centered care in the U.S. Army primary care setting may improve the quality of care and health outcomes for soldiers. When defining performance metrics for primary care models of care, the U.S. Army Medical Department must consider assessing outcomes specific to the soldier population. Developing empirical indicators for the attributes of soldier-centered care will support meaningful testing of the concept.

Tactical Combat Casualty Care Training, Knowledge, and Utilization in the US Army.

Tactical Combat Casualty Care (TCCC) is the execution of prehospital trauma skills in the combat environment. TCCC was recognized by the 2018 Department of Defense Instruction on Medical Readiness Training as a critical wartime task. This study examines the training, understanding, and utilization of TCCC principles and guidelines among US Army medical providers and examines provider confidence of medics in performing TCCC skills. A cross-sectional survey, developed by members of the Committee on TCCC, was distributed to all US Army Physicians and Physician Assistants via anonymous electronic communication. A total of 613 completed surveys were included in the analyses. Logistic regression analyses were conducted on: TCCC test score of 80% or higher, confidence with medic utilization of TCCC, and medic utilization of ketamine in accordance with TCCC. <60% of respondents expressed confidence in the ability of the medics to perform all TCCC skills. Supervising providers who that believed 80 to 100% of their medics had completed TCCC training had more confidence in their medic's TCCC abilities. With TCCC, a recognized lifesaver on the battlefield, continued training and utilization of TCCC concepts are paramount for deploying personnel.