Military Surgeons Research Articles

Committee on Surgical Combat Casualty Care position statement: Neurosurgical capability for the optimal management of traumatic brain injury during deployed operations.

Experiences over the last three decades of war have demonstrated a high incidence of traumatic brain injury (TBI) resulting in a persistent need for a neurosurgical capability within the deployed theater of operations. Despite this, no doctrinal requirement for a deployed neurosurgical capability exists. Through an iterative process, the Joint Trauma System Committee on Surgical Combat Casualty Care (CoSCCC) developed a position statement to inform medical and nonmedical military leaders about the risks of the lack of a specialized neurosurgical capability. The need for deployed neurosurgical capability position statement was identified during the spring 2021 CoSCCC meeting. A triservice working group of experienced forward-deployed caregivers developed a preliminary statement. An extensive iterative review process was then conducted to ensure that the intended messaging was clear to senior medical leaders and operational commanders. To provide additional context and a civilian perspective, statement commentaries were solicited from civilian clinical experts including a recently retired military trauma surgeon boarded in neurocritical care, a trauma surgeon instrumental in developing the Brain Injury Guidelines, a practicing neurosurgeon with world-renowned expertise in TBI, and the chair of the Committee on Trauma. After multiple revisions, the position statement was finalized, and approved by the CoSCCC membership in February 2023. Challenges identified include (1) military neurosurgeon attrition, (2) the lack of a doctrinal neurosurgical capabilities requirement during deployed combat operations, and (3) the need for neurosurgical telemedicine capability and in-theater computed tomography scans to triage TBI casualties requiring neurosurgical care. Challenges identified regarding neurosurgical capabilities within the deployed trauma system include military neurosurgeon attrition and the lack of a doctrinal requirement for neurosurgical capability during deployed combat operations. To mitigate risk to the force in a future peer-peer conflict, several evidence-based recommendations are made. The solicited civilian commentaries strengthen these recommendations by putting them into the context of civilian TBI management. This neurosurgical capabilities position statement is intended to be a forcing function and a communication tool to inform operational commanders and military medical leaders on the use of these teams on current and future battlefields. Prognostic and Epidemiological; Level V.

Jean Baptiste Lucien Baudens: The father of trauma laparotomy.

Jean Baptiste Lucien Baudens (1804-1857) was a French military surgeon. He served in numerous military conflicts throughout his career. Baudens was an innovator and a leader. Going against traditional dogma, he was the first to attempt laparotomy in the setting of trauma. Although the first patient died, his second survived without further complication. Despite this historical landmark, little is known or written about him within the English literature. Jean Baptiste Lucien Baudens was a pioneer of surgery and the father of trauma laparotomy. He was a passionate educator and dedicated to the training of future surgeons. His contributions to the field of surgery deserve recognition and appreciation.

Optimizing combat readiness for military surgeons without trauma fellowship training: engaging the 'voluntary faculty' model.

Appropriate operative volume remains a critical component in mitigating surgical atrophy and maintaining clinical competency. The initiation of military-civilian surgical partnerships (MCP) has been proposed for addressing knowledge, skills, and abilities (KSA) metrics in order to address concerns over operational readiness and the low acuity experienced by military surgeons. This study investigates the first partnership for Navy surgical staff at a non-academic Military Treatment Facility (MTF) with a regional academic Army MTF and a civilian, non-academic level II trauma center devised to improve operational readiness for attending surgeons. We hypothesize that a skill sustainment MCP will allow military surgeons to meet combat readiness standards as measured by the KSA metric. A Memorandum of Understanding (MOU) was initiated between the Navy MTF (NMTF), the Army MTF (AMTF), and the civilian level II trauma center (CTC). The single military surgeon in this study was classified as 'voluntary faculty' at the CTC. Total case volume and acuity were recorded over an 11-month period. KSA metrics were calculated utilizing the standard national provider number (NPI) and the novel case-log based method. 156 cases were completed by a single surgeon over the study period, averaging 52 cases per institution. Significantly more KSAs were obtained at the CTC compared to NMTF (5954 v 2707; p < 0.001). Significantly more emergent cases were observed at the CTC compared to the MTFs (X2 = 7.1, n = 96, p < 0.05. At a single site, AMTF, a significant difference in the calculated KSA score was observed between the NPI and case-log methods (5278 v 3297; p = 0.04). The skill sustainment MCP between NMTF and CTC increased surgical readiness and exposed surgeons to increased operative acuity. The 'voluntary faculty' model reduces direct litigation exposure and encourages clinical competency for military surgeons, while remaining a deployable asset to the global military effort. IV, Therapeutic/Care Management.

A review on the melt extrusion-based fused deposition modeling (FDM): background, materials, process parameters and military applications

AbstractThe contemporary military sector needs a tailor-made product at a low cost and time. Fused Deposition Modeling (FDM) is a melt extrusion-based Additive Manufacturing technology for processing thermoplastics, composites, and biomaterials. FDM is competent in fabricating complex parts in different industries, including military, aerospace, automotive, biomedical, and jewellery. The FDM can process various materials and is ideal for fabrication prototypes, functional parts, visualization, concept proofs and fast product development. FDM is currently used in the military for novel components developments and maintenance, opening new logistics and supply chain management methods. Integrating sensors into weaponry for real-time physiological feedback and threat information is also possible. Additionally, FDM can fabricate trauma models for surgical planning and educating military surgeons. This paper presents the FDM background, filaments, and process parameters. Also, the work provides information to readers on the applications and possibilities of the FDM process from a military standpoint.

Invited Commentary: Balancing Military Surgeon Readiness and Healthcare Delivery.

Holt, Danielle MD, MSS, FACS; Propper, Brandon MD, FACS, FSVS, RPVI; Elster, Eric MD, FACS, FRCSEng (Hon) Author Information

William Attree (died 1846): Royal and army surgeon who underwent amputation of the leg at Brighton, England (1807).

William Attree (1780-1846) came from a prominent family in Brighton, England. He studied medicine at St Thomas' Hospital, London, and there was unwell for nearly 6 months with severe 'spasms' of the hand/arm/chest (1801-1802). Attree qualified Member of the Royal College of Surgeons in 1803 and served as dresser to Sir Astley Paston Cooper (1768-1841). In 1806 Attree is recorded as 'Surgeon and Apothecary' of Prince's street, Westminster. In 1806 Attree's wife died in childbirth and the following year he underwent emergency amputation of the foot in Brighton following a road traffic accident. Attree served as surgeon in the Royal Horse Artillery at Hastings, presumably in a regimental or garrison hospital. He went onto become surgeon to the Sussex County Hospital, Brighton, and Surgeon Extraordinary to two Kings: George IV and William IV. In 1843 Attree was appointed as one of the original 300 Fellows of the Royal College of Surgeons. He died in Sudbury, near Harrow. His son William Hooper Attree (1817-1875) was surgeon to Don Miguel de Braganza, the former King of Portugal. The medical literature appears to lack a history of nineteenth century doctors (especially military surgeons) with physical disability. Attree's biography goes a small way towards developing this field of enquiry.

Training in vascular trauma surgery for non-vascular surgeons: Vascular trauma surgery skills course.

The experience of general and trauma surgeons in vascular trauma management has decreased with sub-specialization of surgery and working hours restrictions. We introduce avascular trauma surgery skills course established to train German military surgeons prior to their deployment to conflict areas. The intention and implementation of the vascular trauma course for non-vascular surgeons is described in detail. In hands-on courses, participants learn and train basic vascular surgical techniques on more realistic extremity, neck, and abdominal models with pulsatile vessels. Afundamental and an advanced course each provide military as well as civilian surgeons from different non-vascular specialties with asurgical skill set including direct vessel sutures, patch angioplasty, anastomosis, thrombectomy, and resuscitative endovascular balloon occlusion of the aorta (REBOA) in order to render them capable of managing major vascular injuries. The experiences of this vascular trauma surgical skills course, initially established for military surgeons, can also be of use to all civilian general, visceral, and trauma surgeons occasionally facing traumatic or iatrogenic vascular injuries. Thus, the introduced vascular trauma course is valuable for all surgeons working in trauma centers.

Kupriyanov is an outstanding military field surgeon (on the 130th anniversary of his birth)

The article presents the facts concerning the life and career development of an outstanding organizer of military fi eld surgery, an excellent clinician, a wonderful teacher, a well-known public fi gure, academician of the USSR Academy of Medical Sciences, Honored Scientist of the RSFSR, Lenin Prize laureate, Hero of Socialist Labor, lieutenant general of the medical service Pyotr Andreyevich Kupriyanov.

Evidence-based Surgical Competency Outcomes from the Clinical Readiness Program.

1) Evaluate the value and strength of a competency framework for identifying and measuring performance requirements for expeditionary surgeons; 2) Verify psychometric integrity of assessment instrumentation for measuring domain knowledge and skills; 3) Identify gaps in knowledge and skills capabilities using assessment strategies; 4) Examine shared variance between knowledge and skills outcomes, and the volume and diversity of routine surgical practice. Expeditionary military surgeons provide care for patients with injuries that extend beyond the care requirements of their routine surgical practice. The readiness of these surgeons to independently provide accurate care in expeditionary contexts is important for casualty care in military and civilian situations. Identifying and closing performance gap areas are essential for assuring readiness. We implemented evidence-based processes for identifying and measuring the essential performance competencies for expeditionary surgeons. All assessment instrumentation was rigorously examined for psychometric integrity. Performance outcomes were directly measured for expeditionary surgical knowledge and skills and gap areas were identified. Knowledge and skills assessment outcomes were compared, and also compared to the volume and diversity of routine surgical practice to determine shared variance. Outcomes confirmed the integrity of assessment instrumentation and identified significant performance gaps for knowledge and skills in the domain. Identification of domain competencies and performance benchmarks, combined with best-practices in assessment instrumentation, provided a rigorous and defensible framework for quantifying domain competencies. By identifying and implementing strategies for closing performance gap areas, we provide a positive process for assuring surgical competency and clinical readiness.

Using Cosmic Rays to See the Unseeable

The discovery of x-rays in 1895 by Wilhelm Roentgen changed medicine. Where, before that time, doctors treating patients had to guess what was going on inside bodies or do invasive surgery, they were now able to peer through the skin, imaging bones and some soft tissues. Military surgeons were quick to embrace the technology, using x-rays to find bullets and shrapnel that needed removing.

401 Global Neurosurgery Advances from Trenches to Bedside: Lessons from Neurosurgical Care in War, Humanitarian Assistance, and Disaster Response

INTRODUCTION: War has influenced the development of neurosurgery. Armed conflict and mass casualty events, including Humanitarian Assistance Disaster Relief (HADR) missions, require military surgeons to innovate to meet extreme demands. Neurosurgeons serving in the military have provided a pragmatic template for global neurosurgeons to emulate in humanitarian disaster responses METHODS: We performed a narrative review of the literature examining the influence of wars and mass casualty disasters on contemporary global neurosurgery practices. RESULTS: Wartime innovations that influenced global neurosurgery include the development of triage systems and modernization with airlifts, implementation of ambulance corps, early operation on cranial injuries in hospital camps near the battlefield, use of combat body armor, and the rise of damage control neurosurgery. Workforce shortages during wars and disasters have promoted task-shifting and task-sharing in low-resource settings that catalyzed the establishment of the physician associate profession in the United States (US). Neurosurgical care has been utilized by the US as a form of "soft power" during natural and humanitarian disasters. Low-and middle-income countries (LMICs) face similar challenges in developing trauma systems and obtaining advanced technology, including neurosurgical equipment like battery-powered computed tomography scanners. These challenges— ubiquitous in low-resource settings— have underpinned innovations in triage and wound care, rapid evacuation to tertiary care centers, and minimizing infection risk. CONCLUSIONS: War and mass casualty disasters have catalyzed significant advancements in neurosurgical care both in the pre-hospital and inpatient settings. Most of these innovations originated in the military with subsequent spread to the civilian sector as military neurosurgeons and civilian neurosurgeons, who are military reservists, returned from the battlefront or other low-resource locations. LMICs have, by necessity, responded to challenges arising from resource shortages by developing innovative, context-specific care paradigms and technologies.

Orthopaedic surgery as seen by artists and by surgeons: science or art?

Artists, including painters, are interested in capturing the essence of the world around them, including surgery. Therefore, we explored the world of orthopaedic surgery through the eyes of artists. We asked how artists and painters have captured the artistic vision of orthopaedic surgery by describing the operation, tools and techniques used, and the patients and surgeons involved. The evolution of medical science and the importance of an orthopaedic surgeon art in society during different centuries were evaluated from ancient civilizations to the modern world. The symbolic representation of orthopaedic surgery and orthopaedic surgeons was analyzed over time, to reflect changes in medical practice and societal attitudes towards orthopaedic surgery. Ancient Egypt is where the first instances of painting a shoulder dislocation reduction were discovered. The first report of organized surgical care is found in Homer's epic poem "Iliad," even if executing surgical operations and artistic representation was undoubtedly done in many ancient civilizations. Orthopaedic surgeons according to the period were represented as gods, saints, monks, heroic figures, military surgeons, and sometimes politics. However, the orthopaedic surgeon was rarely considered an artist by those who are real artists. Paintings often showed orthopedists in action, with blood and tools, emphasizing the gritty reality of the surgical profession, sometimes with some stereotypes (gargantuan figure, gorilla). However, the common thread is the recognition of the skill, knowledge, and dedication required to be a surgeon and the importance of their work in helping people live healthier and more active lives. Overall, painters have depicted orthopedic surgeons as skilled professionals who are dedicated to helping their patients achieve better health and mobility. Their depictions have evolved over time, reflecting changes in medical practice and the wider culture. However, the essential message remains the same: orthopaedic surgeons play a vital role in helping people live healthier, more active lives.

Characterizing Moral Injury and Distress in US Military Surgeons Deployed to Far-Forward Combat Environments in Afghanistan and Iraq

Moral injury and distress (MID), which occurs when individuals have significant dissonance with their belief system and overwhelming feelings of being powerless to do what is believed to be right, has not been explored in the unique population of military surgeons deployed far forward in active combat settings. Deployed military surgeons provide care to both injured soldiers and civilians under command-driven medical rules of engagement (MROE) in variably resourced settings. This practice setting has no civilian corollary for comparison or current specific tool for measurement. To characterize MID among military surgeons deployed during periods of high casualty volumes through a mixed-methods approach. This qualitative study using convergent mixed methods was performed from May 2020 to October 2020. Participants included US military surgeons who had combat deployments to a far-forward role 2 treatment facility during predefined peak casualty periods in Iraq (2003-2008) and Afghanistan (2009-2012), as identified by purposeful snowball sampling. Data analysis was performed from October 2020 to May 2021. Measure of Moral Distress for Healthcare Professionals (MMD-HP) survey and individual, semistructured interviews were conducted to thematic saturation. The total cohort included 20 surgeons (mean [SD] age, 38.1 [5.2] years); 16 (80%) were male, and 16 (80%) had 0 or 1 prior deployment. Deployment locations were Afghanistan (11 surgeons [55%]), Iraq (9 surgeons [45%]), or both locations (3 surgeons [15%]). The mean (SD) MMD-HP score for the surgeons was 104.1 (39.3). The primary thematic domains for MID were distressing outcomes (DO) and MROE. The major subdomains of DO were guilt related to witnessing horrific injuries; treating pregnant women, children, and US soldiers; and second-guessing decisions. The major subdomains for MROE were forced transfer of civilian patients, limited capabilities and resources, inexperience in specialty surgical procedures, and communication with command. Postdeployment manifestations of MID were common and affected sleep, medical practice, and interpersonal relationships. In this qualitative study, MID was ubiquitous in deployed military surgeons. Thematic observations about MID, specifically concerning the domains of DO and MROE, may represent targets for further study to develop an evaluation tool of MID in this population and inform possible programs for identification and mitigation of MID.

The Power of Cooperation: A Quantitative Analysis of the Benefit of Civilian Partnerships on the Academic Output of Military Surgeons.

Military-civilian partnerships are crucial to maintaining the skills of active duty surgeons and sustaining readiness. There have been no publications to date that report the quantitative effect of these partnerships on academic research. To address this question, the Hirsch indices (H-indices) of active duty surgeons with a civilian affiliation (CA) were compared to those without. As a secondary outcome, H-indices of military surgeons with and without an appointment to the Uniformed Services University (USU) were similarly compared. We hypothesized that military surgeons with a CA would have a higher H-index as compared to those without. Rosters of active duty military surgeons were obtained confidentially through each branch consultant. H-indices were found on Scopus. Graduation dates and hospital affiliations were identified via public Doximity, LinkedIn profiles, and hospital biographies. Rosters were cross-referenced with USU appointments. Stata software was used for final analysis. Military surgeons without a civilian association have a median H-index of 2 versus 3 in those with such an affiliation (P = .0002). This pattern is also seen in average number of publications, at 3 and 5 articles (P < .0001). When further stratified by branch, Air Force surgeons have median H-indices of 2.5 and 1 with and without a CA, respectively (P = .0007). The Army surgeons follow a similar pattern, with median H-indices of 5 and 3 for those with and without affiliations, respectively (P = .0021). This significance does not hold in the Naval subgroup. Similar results are found for the secondary outcome of USU appointment, with median H-indices of 3 and 2 in those with and without CAs, respectively (P < .0001). In the multivariable negative binomial regression model, both CA and USU appointment significantly increased H-index in the overall cohort, with incidence rate ratios of 1.32 (95% CI = 1.08, 1.61) and 1.56 (95% CI = 1.28, 1.91), respectively. This article provides objective evidence that there is a benefit to military-civilian partnerships on the academic output of military surgeons. These relationships should continue to be fostered and expanded.

The Glenoid Track Paradigm Does Not Reliably Affect Military Surgeons’ Approach to Managing Shoulder Instability

To report the frequencies of surgical stabilization procedures performed by military shoulder surgeons and to use decision tree analysis to describe how bipolar bone loss affects surgeons' decision to perform arthroscopic versus open stabilization procedures. The Military Orthopaedics Tracking Injuries and Outcomes Network (MOTION) database was queried for anterior shoulder stabilization procedures from 2016 to 2021. A nonparametric decision tree analysis was used to generate a framework for classifying surgeon decision making based on specified injury characteristics (labral tear location, glenoid bone loss [GBL], Hill-Sachs lesion [HSL] size, and on-track vs off-track HSL). A total of 525 procedures were included in the final analysis, with a mean patient age of 25.9 ± 7.2 years and a mean GBL percentage of 3.6% ± 6.8%. HSLs were described based on size as absent (n= 354), mild (n= 129), moderate (n= 40), and severe (n= 2) and as on-track versus off-track in 223 cases, with 17% (n= 38) characterized as off-track. Arthroscopic labral repair (n= 428, 82%) was the most common procedure, whereas open repair (n= 10, 1.9%) and glenoid augmentation (n= 44, 8.4%) were performed infrequently. Decision tree analysis identified a GBL threshold of 17% or greater that resulted in an 89% probability of glenoid augmentation. Shoulders with GBL less than 17% combined with a mild or absent HSL had a 95% probability of an isolated arthroscopic labral repair, whereas a moderate or severe HSL resulted in a 79% probability of arthroscopic repair with remplissage. The presence of an off-track HSL did not contribute to the decision-making process as defined by the algorithm and data available. Among military shoulder surgeons, GBL of 17% or greater is predictive of a glenoid augmentation procedure whereas HSL size is predictive of remplissage for GBL less than 17%. However, the on-track/off-track paradigm does not appear to affect military surgeons' decision making. Level III, retrospective cohort study.

Vascular Emergency Surgery: Simulated Exercises for Limb Salvage (VESSELS)—development of a simulation model and curriculum for the military general surgeon

Vascular Emergency Surgery: Simulated Exercises for Limb Salvage (VESSELS)—development of a simulation model and curriculum for the military general surgeon

Jean Baptiste Lucien Bauden's Clinique des Plaies D'Armes a Feu: The First English Translation of the First Trauma Laparotomy.

Historically, abdominal trauma was managed nonoperatively with rest and local wound cares. Jean Baptiste Lucien Baudens (1804-1857) was a French military surgeon and performed the first 2 trauma laparotomies. The first patient died but the second survived. Laparotomy in trauma has since evolved, now a life-saving intervention and a fundamental tool in the management of abdominal trauma. Baudens documented these case reports in his 1836 work Clinical Reports of Gun Wounds (Clinique des Plaies D'Armes a Feu). The work of Baudens has been largely unrecognized and underappreciated in the English literature. This manuscript serves as the first translation of this event.

Learning trauma surgery through cytoreductive surgery

ObjectivesRegarding war surgery (WS), the initial and continuing education of French military gastrointestinal surgeons (FMGIS) is considered flawed and inappropriate. This results from the low incidence of gastrointestinal (GI) trauma, its predominantly non-surgical management, and a daily surgical practice that strongly differs from WS. Conversely, cytoreductive surgery (CRS) of peritoneal metastases has similarities with WS which led us to assess its potential contribution to the initial and continuing education of FMGIS in WS. MethodsWe reported the activities of the GI surgery departments of the military teaching hospitals of Percy and Begin. The first one dedicated to traumatology and the second to CRS. We then specifically looked into the surgical procedures conducted by the FMGIS during deployment from January 2004 to December 2014. ResultsAmongst the 600 severe trauma patients admitted to the Percy trauma center between January 2019 and December 2020, 17 underwent abdominal surgery with a total of 25 procedures performed. During the same period, 61 patients undertook CRS in Begin with an average of 7 surgical processes per patient carried out and a total of 418 abdominal surgical procedures. Outside abdominal packing and nephrectomy (not performed in CRS), the numbers of splenectomy, gastrointestinal / gynecological resections (hysterectomy and/or adnexectomy), or liver resection were higher during CRS compared to abdominal trauma surgery with 10 times less patients (10 vs 1, 43 vs 9, 20 vs 0, 6 vs 0, respectively). ConclusionCRS, through its similarities with WS, seemed to be an appropriate tool for the initial and continuing education of FMGIS in WS and, to an extent, of civilian trauma surgeons who could eventually treat terrorist attacks casualties on the national territory.

Teaching has changed … but have the students?

Teaching has changed … but have the students?

Relevance of a Simulation Model to Microvascular Surgery for Military Surgical Residents.

Microsurgical training is an asset for deployed military orthopaedic surgeons who frequently treat hand or nerve injuries in the field. The objective of this study was to evaluate a microvascular surgery simulation model intended to prepare residents prior to their enrolment in conventional microsurgery degree training. An experimental study was conducted to evaluate technical progress and satisfaction of military surgical residents using a model based on Japanese noodles with four tests of increasing difficulty. Objective endpoints included instruments handling, distribution, and quality of stitches, as well as anastomoses duration. Responses to the Structured Assessment of Microsurgery Skill self-assessment questionnaire were also analyzed. Nine residents from different specialties participated in the study. Their anastomoses quality and average satisfaction significantly increased between the first and the last session (p < 0.05). Conversely, the average operating time decreased significantly over the sessions (p < 0.001). This simulation model seems to constitute a satisfactory initiation to microsurgery and could limit the use of animal models. It could also be included in the continuing education of military surgeons who have an occasional microsurgical practice during deployments.