Military Medical Training Research Articles

The state of psychological and immunological indicators in graduate students of a medical university

Training future doctors for professional practice usually entails building awareness and embracing the significant responsibility inherent in the field. This, in turn, leads to significant psycho-emotional stress by the time of graduation from academic institution. With the aim of identifying the correlation between homeostatic system indicators, a comparative analysis was conducted to characterize the immunological and psychological parameters of final-year medical university students, contingent upon their respective training programs. The study involved sixth-year students of the Therapeutic and Preventive Faculty [TPF] (29 individuals) and the Military Training Center [MTC] (34 individuals) of Rostov State Medical University, a Federal State Budgetary Educational Institution of Higher Education. The exclusion criteria for all participants included the presence of chronic diseases and any infectious process of any origin within three months prior to the study. The groups were similar in terms of age (23.8±1.82 and 23.9±2.2 years, respectively), gender (all male), and corresponded to health group I. Psychological evaluation was conducted employing the Spielberger–Hanin Scale to gauge levels of personal and situational anxiety. The assessment of immunological status was carried out at the Scientific Research Institute of Clinical Immunology using standard methodological approaches. Registration cards for immunopathology analysis were used to characterize health status over the year. Analysis of the obtained data from psychological questionnaires revealed that students of the Therapeutic and Preventive Faculty, compared to their counterparts from the Military Training Center, demonstrated a higher degree of situational and, particularly, personal anxiety. Differences in the immune response system between the compared groups were identified with regards to indicators that characterize both adaptive and innate immunity. These differences were expressed in a more significant number of circulating regulatory T lymphocytes, a less pronounced lytic potential of effector cells, a greater number of TLR9+ monocytes with a decrease in the proportion of cells of the monocyte series carrying HLA-DR in medical students compared to their counterparts studying in the medical service officers’ program. Thus, the period of psychological preparation in a medical university for the commencement of professional activity varies based on the characteristics of the educational process and proves to be more effective for sixth-year students of MTC. Students from the TPF exhibit more pronounced psycho-emotional stress compared to their counterparts in military medical training, leading to evident signs of immune system dysregulation. It is imperative to develop strategies for timely detection of changes in both psychological and immunological adaptive capacities.

Gamification in the Design of Virtual Patients for Swedish Military Medics to Support Trauma Training: Interaction Analysis and Semistructured Interview Study.

This study explores gamification in the design of virtual patients (VPs) to enhance the training of Swedish military medics in trauma care. The challenges related to prehospital trauma care faced on the battlefield require tailored educational tools that support military medics' education and training. The aim of the study is to investigate how to design VPs with game elements for Swedish military medics to support learning in military trauma care. By understanding the reasoning and perceptions of military medics when interacting with VPs, this study aims to provide insights and recommendations for designing VPs with game elements that are specifically tailored to their needs. The study involved 14 Swedish military medics of the Home Guard-National Security Forces participating in a tactical combat care course. Participants interacted with 3 different VP cases designed to simulate military trauma scenarios. Data were collected through think-aloud sessions and semistructured interviews. The data were analyzed using interaction analysis, structured by the unawareness, problem identification, explanation, and alternative strategies or solutions (uPEA) framework, and reflexive thematic analysis to explore participants' reasoning processes and perceptions and identify possible game elements to inform the VP design. Mapping the military medics' reasoning to the uPEA framework revealed that study participants became more creative after making a mistake followed by feedback and after receiving a prompt to make a new decision. The thematic analysis revealed 6 themes: motivation, "keep on trying"; agency in interaction with VPs; realistic tactical experience; confidence, "I know that the knowledge I have works"; social influence on motivation; and personalized learning. Participants suggested that game elements such as scoring; badges; virtual goods; progress bars; performance tables; content unlocking; hints; challenge; control; imposed choice; narrative; avatars; sensation; randomness; difficulty adapting; competition; leaderboards; social pressure; progression; and renovation can promote engagement, motivation, and support confidence in decision-making. Gamification in the design of VPs represents a promising approach to military medical training, offering a platform for medics to practice medical and tactical decision-making in a risk-free environment. The insights gained by the study may encourage designing VPs with game elements, as well as including possibly wrong decisions, their consequences, and relevant feedback, that may support military medics' reflections and decision-making.

A Serious Game for Enhancing Rescue Reasoning Skills in Tactical Combat Casualty Care: Development and Deployment Study.

Serious games (SGs) have emerged as engaging and instructional digital simulation tools that are increasingly being used for military medical training. SGs are often compared with traditional media in terms of learning outcomes, but it remains unclear which of the 2 options is more efficient and better accepted in the process of knowledge acquisition. This study aimed to create and test a scenario-based system suitable for enhancing rescue reasoning skills in tactical combat casualty care. To evaluate the effectiveness of the SGs, a randomized, observational, comparative trial was conducted. A total of 148 members from mobile medical logistics teams were recruited for training. Pre- and posttraining assessments were conducted using 2 different formats: a video-based online course (n=78) and a game simulation (n=70). We designed 3 evaluation instruments based on the first 2 levels of the Kirkpatrick model (reaction and learning) to measure trainees' satisfaction, knowledge proficiency, and self-confidence. There were 4 elements that made up the learning path for the SGs: microcourses (video-based online courses), self-test, game simulation, and record query. The knowledge test scores in both groups were significantly higher after the intervention (t154=-6.010 and t138=-7.867, respectively; P<.001). For 5 simulation cases, the average operation time was 13.6 (SD 3.3) minutes, and the average case score was 279.0 (SD 57.6) points (from a possible total of 500 points), with a score rate of only 44% (222/500 points) to 67% (336/500 points). The results indicated no significant difference in trainees' satisfaction between the 2 training methods (P=.04). However, the game simulation method outperformed the video-based online course in terms of learning proficiency (t146=-2.324, P=.02) and self-perception (t146=-5.492, P<.001). Despite the high satisfaction reported by trainees for both training methods, the game simulation approach demonstrated superior efficiency and acceptance in terms of knowledge acquisition, self-perception, and overall performance. The developed SG holds significant potential as an essential assessment tool for evaluating frontline rescue skills and rescue reasoning in mobile medical logistics teams.

Stress and resilience among military medical students completing a high-fidelity military medical simulation

Background High-fidelity medical simulations can help students successfully navigate the stressors of medical training and practice. Because sufficiently high stress levels can interfere with learning, the balance of stress and resilience factors during simulation training should be carefully curated. However, student experiences of stress and resilience during high-fidelity simulations are seldom well characterized, especially in military medical training. With this in mind, the authors investigated students’ lived experiences of stress and resilience during a well-established high-fidelity simulation at a military medical school. Methods Fourth-year active-duty military medical students (n = 23) from the United States Air Force, Army, and Navy who were attending Operation Bushmaster – a 5-day, high-fidelity military medical simulation – were interviewed during and after the simulation. Data were analyzed via a hermeneutic phenomenological qualitative approach. Another 21 students reported their stress levels and trait mindfulness. Experts rated their performance at Operation Bushmaster. Results Participant narratives pointed towards major internal stressors, including chronic uncertainty and fluctuating motivation, and external stressors, such as weather and equipment-related challenges. Narratives also identified multiple factors that mitigated stress, including the use of mindfulness skills (especially mindful/tactical breathing), giving/receiving social support, shifting perspectives to centre connections between Operation Bushmaster and students’ professional purpose, and positive self-talk that gave participants permission to make mistakes and learn from them. There was a moderate positive correlation between mindfulness and performance at Operation Bushmaster. Conclusions These stress and resilience factors are critical leverage points for educators seeking to optimize learning during Operation Bushmaster and other high-fidelity simulation trainings. Future research should continue to examine how the balance of these factors impacts medical students’ immediate learning (e.g. regarding medical decision-making, skill and leadership) and longer-term ability to successfully navigate the stressors of the medical profession.

Empowering Maneuvers: Boldly Mobilizing Military Medical Research and Training within the Kingdom of Saudi Arabia to Safeguard a Nation and its People.

In 2023 Alkhathami and colleagues from the Prince Sultan Military College of Health Sciences highlighted the Kingdom of Saudi Arabia's transformative upgrades across various sectors, notably including enhancements to the healthcare system, and called for action to extend these upgrades to the military healthcare field. Prompted by this call to action, the leadership of the military healthcare system swiftly commenced initiatives, acting in less than three months from this pivotal appeal. In January 2023 the first author ordered a decree via the General Directorate of Armed Forces Medical Services of Saudi Arabia, in collaboration with US central Command and international partners, to host the 3rd International Conference of Military Medicine. The event graciously welcoming more than 1000 military representatives from 20 participating nations. The Military Medical Conference, fostering a global military community dialogue on the necessity to explore collective capacities to endure and overcome humanitarian challenges, thereby sustaining health, promoting well-being, and nurturing life through strategies that align with the insights of Alkhathami et al. (2023). The response and the need underlined by the original article are discussed by the Major General, staff of the Saudi Military Medical Services and academics from the University of Sharjah.

Emerging Trends in the Prevalence of Military Medicine Interest Groups and Specialty Tracks at U.S. Medical Schools.

A challenge confronting health care is the national physician shortage, notably impacting the DoD's recruitment of military physicians. To address this, the Health Professions Scholarship Program is annually awarded to medical students to facilitate their transition into the U.S. Armed Forces. There is a glaring absence of military medical education in civilian schools to accommodate the unique interests of these students. While medical schools have adapted with interest groups and specialty tracks, the current presence of military medicine interest groups (MMIGs) and military medicine specialty tracks (MMSTs) remains under-explored. This study aimed to (1) update the prevalence of MMIGs in U.S. medical institutions, (2) identify the presence of MMSTs, and (3) compare military medicine involvement between allopathic and osteopathic programs. The study was approved for exempt status from the Kansas City University Institutional Review Board (study number 20,211,568-1). In a cross-sectional analysis, surveys were sent to 208 U.S. medical schools, with responses from student services or available public data from 200 institutions included in the final analysis. A secondary survey was sent to respondents who provided MMIG or MMST contacts. Results indicated that 62% (n = 124/200) of schools currently have an established MMIG, a modest growth from 56% (n = 70/125) in 2015 (p = .14). MMST prevalence, however, is minimal at 2.5% (5/200). Osteopathic institutions demonstrated a significantly greater engagement in military medicine education (88.7%) compared to allopathic schools (52.4%) (p < .001). This research underscores the need for comprehensive military medical training in medical schools to meet the interests and career aspirations of their students. Future studies should also evaluate the efficacy of MMIGs and MMSTs in preparing students for military medical roles.

Civilian and Military Medical School Graduates' Readiness for Deployment: Areas of Strength and Opportunities for Growth.

Past research has examined civilian and military medical schools' preparation of physicians for their first deployment. Most recently, our research team conducted a large-scale survey comparing physicians' perceptions of their readiness for their first deployment. Our results revealed that military medical school graduates felt significantly more prepared for deployment by medical school than civilian medical school graduates. In order to further investigate these results and deepen our understanding of the two pathways' preparation of military physicians, this study analyzed the open-ended responses in the survey using a qualitative research design. We used a descriptive phenomenological design to analyze 451 participants' open-ended responses on the survey. After becoming familiar with the data, we coded the participants' responses for meaningful statements. We organized these codes into major categories, which became the themes of our study. Finally, we labeled each of these themes to reflect the participants' perceptions of how medical school prepared them for deployment. Four themes emerged from our data analysis: (1) Civilian medical school equipped graduates with soft skills and medical knowledge for their first deployment; (2) Civilian medical school may not have adequately prepared graduates to practice medicine in an austere environment to include the officership challenges of deployment; (3) Military medical school prepared graduates to navigate the medical practice and operational aspects of their first deployment; and (4) Military medical school may not have adequately prepared graduates for the realism of their first deployment. Our study provided insight into the strengths and areas for growth in each medical school pathway for military medical officers. These results may be used to enhance military medical training regardless of accession pathway and increase the readiness of military physicians for future large-scale conflicts.

Ukrainian Healthcare Professionals' Experiences During Operation Gunpowder: Implications for Increasing and Enhancing Training Partnerships.

Because of the diverse backgrounds of their healthcare professionals, Ukrainian military medicine needs expanded and enhanced military medical training to increase their readiness in the war against Russia. During March 2023, eight Ukrainian healthcare professionals participated in Operation Gunpowder, a high-fidelity prolonged casualty care simulation conducted by the USU as a part of its Military Unique Curriculum. In order to evaluate their experiences, we interviewed each healthcare professional and analyzed the data to determine common themes. The participants first described the challenges of operational medicine in Ukraine. They then described the benefits of simulation training such as learning how to navigate a resource-limited operational environment, learning prolonged casualty care, and enhancing leadership and teamwork. Finally, they discussed how they planned to implement training such as Operation Gunpowder in Ukraine in order to increase force readiness. After experiencing the prolonged casualty care simulation training, the Ukrainian participants believed Operation Gunpowder to be a valuable training tool due to its ability to help them overcome the current challenges they are facing in their war against Russia. They described how they would integrate similar training in Ukraine, and follow-up correspondence revealed the success of these efforts. Other universities and institutions are likewise called to use their knowledge and resources to help train Ukrainian health professionals using simulation-based training or other education modalities.

Military Medical Training at the Central Institute for the Advanced Medical Education in the Second Half of the 1930s

The paper describes the initial stage in the organization of military medical training at the Central Institutefor Advanced Medical Education (CIAME), now the Russian Medical Academy for Continuous Professional Educationat the Ministry of Health of the Russian Federation, Moscow. The problem statement in this study is the first of itskind in Russian historiography. The research relied on the documents found in the Russian State Archive of Scientificand Technical Documentation and the Archive of the Russian Medical Academy of Continuous Professional Education.The decision to establish a military medical department at the CIAME was made in 1936. The authors identified the main tasks and challenges the new department had to face, as well as solution methods, areas of theoretical and practical training,and curriculum. The article also describes the role of the CIAME in the Battle of Khalkhin Gol in 1939 and the WinterWar of 1939–1940. In the second half of the 1930s, the CIAME medical staff acquired experience in military medicaltraining and medical care in combat conditions, which proved invaluable during the Great Patriotic War of 1941–1945.

A Comparison of HPSP and USU Graduates’ Preparation for Residency

ABSTRACT Introduction Military medical students enter residency through two main pathways: (1) The Uniformed Services University (USU) and (2) the Armed Services Health Professions Scholarship Program (HPSP). The purpose of this study was to compare how these two pathways prepare military medical students for residency. Methods We conducted semi-structured interviews with 18 experienced military residency program directors (PDs) in order to explore their perceptions of the preparedness of USU and HPSP graduates. We used a transcendental phenomenological qualitative research design to bracket our biases and guide our data analysis. Our research team coded each of the interview transcripts. We then organized these codes into themes, which served as the results of our study. Results Five themes emerged from our data regarding the residents’ preparedness: (1) Ability to navigate the military culture, (2) understanding of the military’s medical mission, (3) clinical preparation, (4) ability to navigate the Military Health System (MHS), and (5) teamwork. The PDs described how USU graduates better understand the military’s medical mission and are more easily able to navigate the military culture and the MHS because of their lived experiences during military medical school. They also discussed the various levels of clinical preparation of HPSP graduates, in contrast to the USU graduates’ more consistent skills and abilities. Finally, the PDs believed both groups to be strong team players. Conclusions USU students were consistently prepared for a strong start to residency because of their military medical school training. HPSP students often experienced a steep learning curve because of the newness of the military culture and MHS.

Evaluation of the Frequency of Academic Failure and its Influencing Factors in Medical Students of a Military Training Center

Background: Students’ academic failure (AF) is one of the main problems of various universities. In the meantime, the academic decline of medical students is more critical because this field is related to society’s health with high occupational sensitivity. Objectives: The present study was conducted to evaluate the AF level of medical students and the factors affecting it in a military medical training center. Methods: This cross-sectional analytical study was conducted on 184 medical students using a questionnaire. After collecting the data, the students were divided into three categories: Students with at least one academic probation semester, students with a total average of basic sciences between 12 and 15, and students with a total average of basic sciences more than 15. Then, AF levels and factors that affect them were investigated. Results: The results showed that the frequency of students with AF was 25%. In addition, there was a significant relationship between AF and some variables, including marital status, residence status, date of entry into university, national entrance exam score, national entrance exam rank, diploma grade average, amount of daily study, content, and grouping (of internal university factors) and family problems (of extramural factors). In contrast, there was no significant correlation between AF and other variables, including gender, age of entry into university, father’s education level, mother’s education level, and other intra-university and extra-university factors. Conclusions: Based on the results, the officials and academic advisors in universities must pay attention to the issues and problems related to unmarried students with a longer duration of education in Universities to prevent AF among students. Students who live in the dormitory should also consider this issue. The level of education and learning of students can be increased by providing the necessary advice and training and a better standard of living in the dormitories, especially for single students.

PRINCIPLES OF MILITARY MEDICAL TRAINING IN THE CONTEXT OF DIGITAL TRANSFORMATION IN HEALTHCARE

The work is devoted to the problem of military medical training in the context of digital transformation in healthcare. The aim of this work is to justify and highlight the directions for implementing specific principles of military medical training in the context of digital transformation in healthcare. The expediency of specific principles in military medical training (the principle of innovation, the principle of orientation to network services, and the principle of reliance on digital tools) is substantiated; the content and essence of specific principles have been clarified; directions for the implementation of specific principles in the process of military medical training are determined. It is shown that the need for an innovative focus in military medical training is driven by several factors, including organizational innovations that contribute to the effective transformation of the healthcare system, digital innovations aimed at automating processes related to medical data, innovative medical technologies, and pharmaceutical and medical-technical innovations associated with the use of advanced methods for diagnosis, treatment, and patient care. It is established that the principle of orientation towards network services allows for effectively combining formal, informal, and informal education for military doctors, fostering lifelong self-education skills. We specify that the principle of orientation towards network services involves familiarizing military doctors with the results of fundamental research in the medical field and relies on the open access to full-text digital publications, both domestic and international. The principle of reliance on digital tools recognizes the potential of digital tools and the appropriateness of their use in the process of military medical training.

The Impact of Special Operations Medics and Corpsmen on Military Medical Student Training: A Qualitative Study.

Operation Gunpowder is a high-fidelity military medical field practicum conducted by the Uniformed Services University of Health Sciences, Bethesda, MD. During this multi-day combat simulation, Special Operations Medics and Corpsmen teach military medical students how to treat patients in an austere, resource-limited environment. To investigate the effectiveness of this teaching model, our research team used a qualitative phenomenological design to explore medical students' experiences being taught by Special Operations Medics and Corpsmen during Operation Gunpowder. We found two themes regarding the medical students' personal and professional development: an increased understanding of medics' skills and capabilities and the realization of their future roles as educators and leaders. Our study suggests that the use of Special Operations Corpsmen and Medics in medical student training is a valuable model for both military and civilian medical education and training.

Evacuation of Non-ST Elevation Myocardial Infarction in West Africa: 19 Hours of Lessons Learned in Prolonged Casualty Care and En Route Care.

Trauma casualty care has historically been the cornerstone of special operations military medical training. A recent case of myocardial infarction at a remote base of operations in Africa highlights the importance of foundational medical knowledge and training. A 54-year-old government contractor supporting operations in the AFRICOM area of responsibility (AOR) presented to the Role 1 medic with substernal chest pain with onset during exercise. Abnormal rhythm strips concerning for ischemia were obtained from his monitors. A MEDEVAC to a Role 2 facility was arranged and executed. At the Role 2 a non-ST-elevation myocardial infarction (NSTEMI) was diagnosed. The patient was emergently evacuated on a lengthy flight to a civilian Role 4 treatment facility for definitive care. He was found to have a 99% occlusion of the left anterior descending (LAD) coronary artery, as well as a 75% occlusion of the posterior coronary artery and a chronic 100% occlusion of the circumflex artery. The LAD and posterior arteries were stented, and the patient made a favorable recovery. This case highlights the importance of preparedness for medical emergencies and care of medically critical patients in remote and austere locations.

Организация оказания помощи раненым офтальмологического профиля в современных вооруженных конфликтах: состояние и перспективы

The main feature of modern armed conflicts is the use of new weapons and, as a result, changes in the nature and structure of eye injuries. This feature, on the one hand, and the rapid progress of medical science, on the other hand, require a rapid response to the changing operational situation using the resources of modern ophthalmology in order to provide care to wounded and injured ophthalmic patients efficiently and rationally. There are some differences in approaches to pre-hospital self- and mutual aid to the wounded with ophtalmic injuries on the battlefield in different schools of military medical training and tactical medicine. Some use a binocular bandage, while others use a rigid eye shield. The complexity and variety of visual injuries require good practical skills and experience in order to perform high-quality surgical treatment of perforated corneal and scleral wounds in open eye trauma. This necessitates a thorough training of specialists with practical skills. The issue of medical supply of units providing specialized care at the stages of medical evacuation, which includes a military ophthalmologist, is particularly significant. The problem of reasonable and rational update of the ophthalmological equipment at the stages of medical evacuation requires active discussion. There is still the question of the use of effective protective equipment for the eye during combat operations, which, without limiting visual function, could prevent combat eye injuries, most often caused by small fragments and secondary wounding projectiles.

Performance gains from adaptive eXtended Reality training fueled by artificial intelligence

While virtual, augmented, and mixed reality technologies are being used for military medical training and beyond, these component technologies are oftentimes utilized in isolation. eXtended Reality (XR) combines these immersive form factors to support a continuum of virtual training capabilities to include full immersion, augmented overlays that provide multimodal cues to personalize instruction, and physical models to support embodiment and practice of psychomotor skills. When combined, XR technologies provide a multi-faceted training paradigm in which the whole is greater than the sum of the constituent capabilities in isolation. When XR applications are adaptive, and thus vary operational stressors, complexity, learner assistance, and fidelity as a function of trainee proficiency, substantial gains in training efficacy are expected. This paper describes a continuum of XR technologies and how they can be coupled with numerous adaptation strategies and supportive artificial intelligence (AI) techniques to realize personalized, competency-based training solutions that accelerate time to proficiency. Application of this training continuum is demonstrated through a Tactical Combat Casualty Care training use case. Such AI-enabled XR training solutions have the potential to support the military in meeting their growing training demands across military domains and applications, and to provide the right training at the right time.

Warfare and the launch of medical reform in Britain, 1793–1811

AbstractUntil the beginning of the nineteenth century, registering and regulating the training of any medical practitioners in Britain had rarely been attempted, unlike in many other European countries. During the Revolutionary War with France, fevers swept through British armies, leading to numerous fatalities and crushing military defeats, especially in the disastrous expedition to St Domingo. The problem, as forcibly advocated by Robert Jackson, the leading expert on military fevers, seemed to be poor medical care due to both lack of compulsory medical training and the unsuitability of whatever training was available for army medical practitioners. With the simultaneous rapid advance of French military and civilian medical training and the threat of a French invasion, regulating British medical training and excluding the unqualified became a military necessity, and suddenly medical reform was receiving widespread attention. Emphasising the benefits to the Britain’s fighting ability, the reform effort, led by Edward Harrison, a very provincial Lincolnshire physician, under the patronage of Sir Joseph Banks, the President of the Royal Society, gained the support of leading politicians, including three Prime Ministers. For a short time, comprehensive medical reform seemed inevitable: but the opposition of the medical corporations, especially the London College of Physicians, could not be circumvented, and although Harrison persisted in his efforts for 6 years, no legislation was achieved. Nevertheless, within months, the Association of Apothecaries continued the process by pressing for a more limited reform, culminating in the 1815 Apothecaries Act. The long march towards the full regulation of doctors in Britain was started by the perceived military needs of the country during the war with France.

Training of NBC Reconnaissance Specialists for Special Tasks Performance

Combat training is the main content of the daily activities of commanders (chiefs), command and control bodies (headquarters) and troops. The purpose of this work is to summarize the experience of training of NBC reconnaissance specialists, obtained during the training of NBC reconnaissance specialists in the period from December 2018 to March 2020 on the basis of military units of the Shikhany garrison. The main forms of this training were lectures, practical and control exercises in military-political, special, fire, technical, military-medical training, in NBC protection, driving, military topography and communications training. The personnel received practical skills in identifying hazardous chemicals, explosives and toxic chemicals simulators with chemical reconnaissance and chemical control devices.

Pediatric Thoracic Trauma Mortality in Iraq and Afghanistan Compared to the United States National Trauma Data Bank.

The authors compared pediatric thoracic patients in the Joint Theatre Trauma Registry (JTTR) to those in the National Trauma Data Bank (NTDB) to assess differences in patient mortality rates and mortality risk accounting for age, injury patterns, and injury severity. Patients less than 19 years of age with thoracic trauma were identified in both the JTTR and NTDB. Multiple logistic regression, χ2, Student's t-test, or Mann-Whitney U test were used as indicated to compare the two groups. Pediatric thoracic trauma patients seen in Iraq and Afghanistan (n = 955) had a significantly higher mortality rate (15.1 vs. 6.0%, P <.01) than those in the NTDB (n = 9085). After controlling for covariates between the JTTR and the NTDB, there was no difference in mortality (odds ratio for mortality for U.S. patients was 0.74, 95% CI 0.52-1.06, P = .10). The patients seen in Iraq or Afghanistan were significantly younger (8 years old, interquartile ratio (IQR) 2-13 vs. 15, IQR 10-17, P <.01) had greater severity of injuries (injury severity score 17, IQR 12-26 vs. 12, IQR 8-22, P <.01), had significantly more head injuries (29 vs. 14%, P <.01), and over half were exposed to a blast. Pediatric patients with thoracic trauma in Iraq and Afghanistan in the JTTR had similar mortality rates compared to the civilian population in the NTDB after accounting for confounding covariates. These findings indicate that deployed military medical professionals are providing comparable quality of care in extremely challenging circumstances. This information has important implications for military preparedness, medical training, and casualty care.

Rationale and Implementation of a Novel Special Operations Medical Officer Course.

The Air Force Special Warfare Medical Officer Course was created to address the lack of operationally focused, job-specific clinical training for medical officers (MOs). This course addresses the gap in knowledge, skill, and application of operational medicine, as well as the behavioral health, human performance, education, and medical oversight of Operators. The course was designed around the senior author's decade of experience piecing together training for his own role as a pararescue flight surgeon and informed by 5 years of flight surgeon courses, lessons learned from case studies of ill-prepared deployed physicians, and input from prehospital medicine subject matter experts. Air Force pararescue and special tactics flight surgeons, physician assistants, and an independent duty medical technician (IDMT) attended. The course consisted of 10 full weekdays of didactics and skills sessions covering theory and application of operational medicine, human performance optimization, behavioral health for Operators, adult education theory, principles of prehospital clinical oversight, and other expeditionary concepts. The course culminated with combat casualty care scenario-based exercises, in which the providers performed operational medicine in full kit with weapons and simulation rounds. For many logistical and practical reasons, civilian medical experience, traditional military medical training, existing special operations medical courses, and "merit badge" card classes are not adequate preparation for this specialized role. Focused, job-specific training should be provided to Special Operations Forces Medical Officers (SOFMO) and, ultimately, to any MO deploying in support of medics or combatants. The goal is to maximize the success of military medical operations while reducing the morbidity and mortality of combat and training casualties. This operationally focused MO course can serve as a model for the future training of SOFMO and has stimulated discussion for consideration of a joint approach to prehospital medical training.