Military Trauma Research Articles

ETIOPATHOGENETIC MECHANISMS OF IMMUNE DYSFUNCTION IN COMBATANTS WITH LOWER LIMB SOFT TISSUE INJURIES UNDER CHRONIC STRESS

Introduction. Combat injuries, including gunshot, shrapnel, and mine-explosive wounds, affect a significant number of soldiers in modern warfare. Notably, most of these injuries involve damage to the soft tissues of the extremities. Surgeons have expressed concerns regarding the unsatisfactory treatment outcomes in this group of combatants, attributing one of the primary challenges to the limited understanding of immune dysfunction pathogenesis in military trauma cases. This study aims to address this gap by examining immune system dysfunctions in combat-related injuries. The objective of this study is to thoroughly analyze and synthesize the key stages of immune dysfunction occurring over extended periods post-combat trauma, including the subsequent development of traumatic disease and various wound complications. Materials and Methods. The rising prevalence of combat trauma among soldiers has intensified interest in studying this issue, prompting surgeons and traumatologists to address its various medical aspects comprehensively. The literature search focused on recent publications, allowing for a targeted analysis of the immunological aspects relevant to military medical traumatology. Results. In the initial stages of severe or combined injuries affecting various tissues—such as tubular bones, joints, blood vessels, and peripheral nerves—systemic inflammatory response syndrome (SIRS) commonly occurs. This stage is marked by an intense activation of innate antibacterial and immune-protective responses, leading to a significant increase in inflammation. This initial response is soon replaced by a prolonged phase known as compensatory anti-inflammatory response syndrome. During this period, immune-protective responses sharply decrease, certain immunocompetent cells become inhibited, and lymphopenia develops. This phase is often accompanied by infectious contamination of wounds with pathogenic and opportunistic microorganisms, resulting in both local purulent-necrotic processes and potentially severe systemic complications, such as septic shock, sepsis, multiple organ failure, and others. The final stage, known as persistent inflammatory, immunosuppressive, catabolic syndrome, is characterized by the chronic progression of traumatic disease, accompanied by ongoing immune system dysfunction in combatants. Conclusion. In the early period of traumatic injury, the wounded experience sharp inflammatory processes and activation of immune defense mechanisms. At subsequent stages, severe disruptions in the functioning of the immune system, damage to internal organs, and the development of catabolic syndrome are recorded. These changes, especially those resulted from exposure to chronic combat stress preceding the injury, aggravate the processes of infectious decontamination of wounds, regeneration of damaged tissues, and the general process of combatant rehabilitation.

Development and validation of prediction models for prehospital triage of military trauma patients.

The introduction of wireless sensors will enable military care providers to continuously and remotely assess/monitor vital signs. Prediction models are needed to use such data adequately and aid military care providers in their on-scene decision-making to optimise prehospital triage and improve patient outcomes. A prospective cohort comprising data from eight Emergency Medical Services and seven inclusive trauma regions was used to develop and validate prediction models that could aid military care providers in their prehospital triage decisions. Healthy (American Society of Anesthesiologists physical status classification 1 or 2) admitted adult trauma patients (aged ≥16 and ≤50 years), who suffered from a trauma mechanism that could occur to military personnel and were transported by ambulance from the scene of injury to a hospital, were included. A full model strategy was used, including prehospital predictors that are expected to be automaticly collectible by wireless sensors or to be incorporated in a personalised device that could run the models. Models were developed to predict early critical-resource use (ECRU), severe head injury (Abbreviated Injury Scale (AIS) ≥4), serious thoracic injury (AIS ≥3) and severe internal bleeding (>20% blood loss). Model performance was evaluated in terms of discrimination and calibration. Prediction models were developed with data from 4625 patients (80.0%) and validated with data from 1157 patients (20.0%). The models had good to excellent discriminative performance for the predicted outcomes in the validation cohort, with an area under the curve of 0.80 (95% CI 0.76 to 0.84) for ECRU, 0.83 (0.76 to 0.91) for severe head injury, 0.75 (0.70 to 0.80) for serious thoracic injury and 0.85 (0.78 to 0.93) for severe internal bleeding. All models showed satisfactory calibration in the validation cohort. The developed models could reliably predict outcomes in a simulated military trauma population and potentially support prehospital care providers in their triage decisions.

Psychological Distress and Quality of Life Among Military Trauma Patients.

Military trauma has a significant impact on soldiers, affecting many aspects of their lives, with the highest impact on their quality of life and psychological wellness. This study aimed to measure psychological distress and its relationship with the quality of life among Jordanian military trauma patients. A descriptive cross-sectional study was conducted in The Hashemite Protection Departments for military causalities in Amman, Irbid, and Al-Karuk. The authors used the WHO Quality of Life Scale-Brief and Trauma Symptoms Checklist-40 scales for assessing the quality of life and psychological distress among Jordanian military trauma patients. A total of 145 trauma survivors participated in the study and responded to all questionnaires out of 173 distributed. The study was approved by the institutional review board of Al-Zaytoonah University. The result of this study revealed that military trauma survivors had high levels of psychological distress with a mean of 85.66 (SD = 19.418). The subscale of "Dissociation symptoms" had the highest rating (M = 19.92, SD = 5.096), while the "sleep disorders" subscale had the lowest rating (M = 10.000, SD = 3.501). On the quality of life scale, a moderate level of quality of life resulted among the participants with a mean of 61.620 (SD = 17.190). The "general health" subscale scored the highest among the other domains (M = 18.241, SD = 5.434), while the "physical health" domain scored the lowest (M = 4.910, SD = 2.078). Furthermore, a statistically significant negative relationship between psychological distress and quality of life was reported (r =-0.178, P < .05). Jordanian injured military persons had a moderate quality of life level and high level of psychological distress. A structured follow-up program is required to be developed to improve those patients' health and quality of life. Furthermore, additional research is needed to investigate the impact of military trauma and services on soldiers in Jordan and the Middle East.

Use of scaffolds based on polyetheretherketone tubular implant in the treatment of a gunshot multifragmentary fracture of the proximal part of the shoulder with a bone defect: a case report

BackgroundIn connection with the war in Ukraine and the use of modern high-energy weapons by the enemy, the nature of injuries have changed. These changes require improvement of approaches to the treatment of patients with gunshot and mine-explosive bone defects.Case presentationWe present the case of treatment of a 28-year-old Ukranian man with a gunshot multifragmentary fracture of the proximal humerus with a bone defect using three-dimensional printing of a polyetheretherketone frame (scaffold) for alloplastic material. The analysis of this case expands the possibilities of using three-dimensional printing technologies of polyetheretherketone scaffolds in the treatment of significant bone defects.ConclusionModern military trauma requires individualized treatment for each patient. The use of individual polyetheretherketone scaffolds in the treatment of a gunshot multifragmentary fracture with a bone defect has a positive clinical effect.

Association between the number of individuals injured in a traumatic event and posttraumatic stress disorder among hospitalized trauma patients.

Posttraumatic stress disorder (PTSD) often occurs following mass casualty events, yet the connection between the number of individuals injured in an event and PTSD risk in smaller-scale events (i.e., involving one or several injured persons)remains unclear. We conducted a registries-based study cross-referencing three databases across the continuum of care for military trauma patients hospitalized for traumatic injuries. The study population was categorized into three groups based on the number of injured individuals involved (i.e., single injured person, two to four [2-4] injured people, and five or more [≥ 5] injured people), and PTSD prevalence was assessed using long-term disability claim diagnoses. Overall, 4,030 military personnel were included (age at injury: Mdn = 20 years), and 18.3% were subsequently diagnosed with PTSD, with the highest prevalence in events involving ≥ 5 injured individuals (35.8%). Regression analyses adjusted for potential confounders revealed that being injured in an event with 2-4 injured persons, OR = 1.68, 95% CI [1.31, 2.15], or ≥ 5 injured persons, OR = 2.36, 95% CI [1.79, 3.13], was associated with increased odds of developing PTSD compared to being the sole injured person. The findings suggest a direct association between the number of injured individuals in an event and PTSD prevalence among traumatic injury survivors. The results underscore the importance of early diagnosis and interventions to prevent PTSD in individuals injured in multicasualty and mass casualty events.

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.

The relationship between co-occurring traumatic experiences and co-occurring mental health domains for veterans resident in Northern Ireland

IntroductionVeterans residing in Northern Ireland (NI) likely experience higher levels of co-occurring lifetime trauma exposure and associated co-occurring mental health symptoms, due to the Troubles. As NI veterans have been subject to little exploration it is difficult to know how to support them. This exploratory study explored the co-occurrence of mental health symptoms as a function of co-occurring traumatic experiences.MethodsTwo latent class analyses (LCA) were conducted on NI veteran data (n = 609). One LCA factored endorsements of 16-lifetime traumatic events, with a separate LCA exploring the co-occurrence of symptoms across six mental health domains. Mental health symptom classes were considered as a function of trauma classes, military-specific variables, gender and age.ResultsThree trauma classes were identified: High Multi Trauma (10.84%); High Combat/Conflict (47.62%); Moderate Combat Conflict (41.54%), and three mental health symptom classes: High Co-occurring Mental Health (19.38%); High Depression Moderate Anxiety/Alcohol (24.63%); Moderate Alcohol/Normative (55.99%). Significant predictors of High Co-occurring Mental Health class membership were UDR service, ‘Worst’ military trauma and High Multi Trauma class membership. Both combat classes had a negative relationship with the High Co-occurring Mental Health. Predictors of the High Depression Moderate Anxiety/Alcohol class were High Multi Trauma class membership and UDR service, with Age and Moderate Combat Class membership having a negative relationship.DiscussionNI veterans could be labelled as ‘traumatised’ due to high levels of combat/conflict exposure, yet the two combat classes seemed unrelated to membership of poorer mental health classes. UDR membership indicated that living in one’s theatre of war could have mental health implications. It was concerning that 45% experienced some co-occurring mental health symptoms with 19% experiencing the poorest symptoms. Hazardous alcohol use appeared unrelated to poor mental health. Further research is needed, utilising robust methods. No clinical inferences are to be made from this exploratory study.

Elevating Prehospital Traumatic Brain Injury Care: A Comparative Analysis of Civilian and Military Air Transport Guidelines

ObjectiveTraumatic brain injuries (TBIs) are a leading cause of death and disability worldwide. Establishing TBI guidelines is crucial for prehospital management. Civilian medical practices are often influenced by military trauma guidelines. This study provides a comparative analysis of prehospital TBI management by a civilian air medical evacuation service using civilian guidelines and military clinical practice guidelines from the Joint Trauma System of the Department of Defense. MethodsA retrospective review of 100 deidentified patient transport logs from a prominent civilian air medical service was conducted. The logs were compared with the service's patient care guidelines and the 2023 Joint Trauma System Clinical Practice Guidelines. Data were analyzed for adherence to 14 metrics. ResultsPatients showed improvement in preflight and postflight Glasgow Coma Scale scores and were managed according to recommendations on head elevation, oxygenation, blood pressure, and temperature by both organizations. Discrepancies between guidelines included differences in the management of ventilator settings, blood pressure, oxygenation, temperature, serum glucose, intracranial hypertension, suspected brain herniation, serum sodium levels, and seizure prophylaxis. ConclusionComparing civilian and military guidelines highlights areas for potential improvements in TBI management, such as integrating advanced monitoring and the implementation of (i-STAT, Abbott Laboratories, Chicago, IL) testing in air transport to enhance patient care and outcomes.

Quality ofIntegration ofAir Force Trauma Surgeons Within the Center forSustainment ofTrauma andReadiness Skills, Cincinnati: A Pilot Study.

While previous studies have analyzed military surgeon experience within military-civilian partnerships (MCPs), there has never been an assessment of how well military providers are integrated within an MCP. The Center for Sustainment of Trauma and Readiness Skills, Cincinnati supports the Critical Care Air Transport Advanced Course and maintains the clinical skills of its staff by embedding them within the University of Cincinnati Medical Center. We hypothesized that military trauma surgeons are well integrated within University of Cincinnati Medical Center and that they are exposed to a similar range of complex surgical pathophysiology as their civilian partners. After Institutional Review Board approval, Current Procedural Terminology (CPT) codes were abstracted from billing data for trauma surgeons covering University of Cincinnati Hospitals in 2019. The number of trauma resuscitations and patient acuity metrics were abstracted from the Trauma Registry and surgeon Knowledge, Skills, and Abilities clinical activity (KSA-CA) scores were calculated using their CPT codes. Finally, surgeon case distributions were studied by sorting their CPT codes into 23 categories based on procedure type and anatomic location. Appropriate, chi-squared or Mann-Whitney U-tests were used to compare these metrics between the military and civilian surgeon groups and the metrics were normalized by the group's full-time equivalent (FTE) to adjust for varying weeks on service between groups. Data were available for two active duty military and nine civilian staff. The FTEs were significantly lower in the military group: military 0.583-0.583 (median 0.583) vs. civilian 0.625-1.165 (median 1.0), P = 0.04. Per median FTE and surgeon number, both groups performed a similar number of trauma resuscitations (civilian 214 ± 54 vs. military 280 ± 13, P = 0.146) and KSA-CA points (civilian 55,629 ± 25,104 vs. military 36,286 ± 11,267; P = 0.582). Although the civilian surgeons had a higher proportion of hernia repairs (P < 0.001) and laparoscopic procedures (P = 0.006), the CPT code categories most relevant to combat surgery (those relating to solid organ, hollow viscus, cardiac, thoracic, abdominal, and tissue debridement procedures) were similar between the surgeon groups. Finally, patient acuity metrics were similar between groups. This is the first assessment of U.S. Air Force trauma surgeon integration relative to their civilian partners within an MCP. Normalized by FTE, there was no difference between the two groups' trauma experience to include patient acuity metrics and KSA-CA scores. The proportion of CPT codes that was most relevant to expeditionary surgery was similar between the military and civilian partners, thus optimizing the surgical experience for the military trauma surgeons within University of Cincinnati Medical Center. The methods used within this pilot study can be generalized to any American College of Surgeons verified Trauma Center MCP, as standard databases were used.

Hypothermia and the Global War on Terror: 18 Years of Minimal Progress.

The association between hypothermia, coagulopathy, and acidosis in trauma is well described. Hypothermia mitigation starts in the prehospital setting; however, it is often a secondary focus after other life-saving interventions. The deployed environment further compounds the problem due to prolonged evacuation times in rotary wing aircraft, resource limitations, and competing priorities. This analysis evaluates hypothermia in combat casualties and the relationship to resuscitation strategy with blood products. Using the data from the Department of Defense Joint Trauma Registry from 2003 to 2021, a retrospective analysis was conducted on adult trauma patients. Inclusion criteria was arrival at the first military treatment facility (MTF) hypothermic (<95ºF). Study variables included: mortality, year, demographics, battle vs non-battle injury, mechanism, theater of operation, vitals, and labs. Subgroup analysis was performed on severely injured (15 < ISS < 75) hypothermic trauma patients resuscitated with whole blood (WB) vs only component therapy. Of the 69,364 patients included, 908 (1.3%) arrived hypothermic; the vast majority of whom (N = 847, 93.3%) arrived mildly hypothermic (90-94.9°F). Overall mortality rate was 14.8%. Rates of hypothermia varied by year from 0.7% in 2003 to 3.9% in 2014 (P <0.005). On subgroup analysis, mortality rates were similar between patients resuscitated with WB vs only component therapy; though base deficit values were higher in the WB cohort (-10 vs -6, P < 0.001). Despite nearly 20 years of combat operations, hypothermia continues to be a challenge in military trauma and is associated with a high mortality rate. Mortality was similar between hypothermic trauma patients resuscitated with WB vs component therapy, despite greater physiologic derangements on arrival in patients who received WB. As the military has the potential to conduct missions in environments where the risk of hypothermia is high, further research into hypothermia mitigation techniques and resuscitation strategies in the deployed setting is warranted.

Nontechnical Skills Assessment in Acute Care Trauma Simulations: A Mixed Methods Approach Using Eye Tracking and Behavioral Marker Systems.

The condition of trauma patients and the urgent need for timely resuscitation present unique challenges to trauma teams. These difficulties are exacerbated for military trauma teams in combat environments. Consequently, there is a need for continued improvement of nontechnical skills (NTS) training for trauma teams. However, current approaches to NTS assessment rely on subjective ratings, which can introduce bias. Accordingly, objective methods of NTS evaluation are needed. Eye-tracking (ET) methods have been applied to studying communication, situation awareness, and leadership in many health care settings, and could be applied to studying physicians' NTS during trauma situations. In this study, we aimed to assess the relationship between trauma team leaders' objective gaze patterns and subjective expert NTS ratings during patient care simulations. After Institutional Review Board approval, 9 trauma teams from first-year post-graduate general surgery and emergency medicine residents were recruited to participate in 1 of 2 trauma simulations (a difficult airway case and a multi-patient trauma). Each scenario lasted approximately 15 minutes. All team leaders wore a mobile ET system to evaluate gaze metrics-time to first fixation (TTFF), average fixation duration (AFD), and total percentage of the scenario (TPS) focused on Areas of Interest (AOI), which included patient, care team, diagnostic equipment, and patient care equipment. Trained faculty raters completed the Non-Technical Skills for Surgeons (NOTSS) assessment tool and the Trauma Non-Technical Skills (T-NOTECHS) scale. One-way analysis of variance, Kruskal-Wallis, and appropriate post-hoc pairwise comparison tests were run to assess differences between ET metrics across AOI groups. Spearman's Rho tests were used to assess correlations between ET and subjective NTS ratings. Compared to other NTS domains, trauma teams scored relatively poorly on communication across both T-NOTECHS (3.29$ \pm $0.61, maximum = 5) and NOTSS (2.87$ \pm $0.66, maximum = 4). We found significant differences in trauma team leaders' TTFF between teammates and the patient (Team: 1.56 vs Patient: 29.82 seconds, P < .001). TTFF on the diagnostic equipment was negatively correlated (P < .05) to multiple measures of subjective NTS assessments. There were no significant differences in AFD between AOIs, and AFD on teammates was positively correlated (P < .05) to communication and teamwork. There were significant differences in TPS across most AOI pairs (P < .05), and the average TPS fixated was highest on the patient (32%). Finally, there were several significant correlations between additional ET and NTS metrics. This study utilized a mixed methods approach to assess trauma team leaders' NTS in simulated acute care trauma simulations. Our results provide several objective insights into trauma team leaders' NTS behaviors during patient care simulations. Such objective insights provide a more comprehensive understanding of NTS behaviors and can be leveraged to guide NTS training of trauma physicians in the future. More studies are needed to apply these methods to capture NTS from a larger sample of teams in both simulated and real trauma environments.

Who Says You can't go FAST at Night? Use of a Novel Ultrasound-Capable Night Vision Device for Prehospital Medical Personnel to Identify Noncompressible Truncal Hemorrhage.

Early detection of abdominal hemorrhage via ultrasound has life-saving implications for military and civilian trauma. However, strict adherence to light discipline may prohibit the use of ultrasound devices in the deployed setting. Additionally, current night vision devices remain noncompatible with ultrasound technology. This study sought to assess an innovative night vision device with ultrasound capable picture-in-picture display via a intraabdominal hemorrhage model to identify noncompressible truncal hemorrhage in blackout conditions. 8 post mortem fetal porcine specimens were used and divided into 2 groups: intrabdominal hemorrhage (n = 4) vs no hemorrhage (n = 4). Intrabdominal hemorrhage was modeled via direct injection of 200mL of normal saline into the peritoneal cavity. Under blackout conditions, 5 participants performed a focused assessment with sonography for trauma (FAST) exam on each model using the prototype ultrasound-capable night vision device. Of the 40 FAST exams performed, 95% (N = 38) resulted in the correct identification of intraabdominal hemorrhage. Of the incorrectly identified exams, both were false positives resulting in a 100% sensitivity, 90% specificity, 91% positive predictive value, and a 100% negative predictive value. All participants noted the novel device was easy to use and provided superior visualization for performing FAST exams under blackout conditions. The ultrasound-enabled night vision prototype demonstrated promising results in identifying noncompressible truncal hemorrhage while maintaining strict light discipline in blackout conditions. Further research efforts should be directed at assessing the ability of providers to perform procedures in blackout conditions using the ultrasound-enabled prototype night vision device.

Non-therapeutic laparotomies in military trauma (2009-2014).

Combat casualties are frequently injured in austere settings where modern imaging modalities are unavailable. Exploratory laparotomies are often performed in these settings when there is suspicion for intra-abdominal injury. Prior studies of combat casualties reported non-therapeutic laparotomy (NTL) rates as high as 32%. Given improvements in combat casualty care over time, we evaluated NTLs performed during later years of the wars in Iraq and Afghanistan. Military personnel with combat-related injuries (6/1/2009-12/31/2014) who underwent exploratory laparotomy based on concern for abdominal injury (i.e. not performed for proximal vascular control or fecal diversion) and were evacuated to Landstuhl Regional Medical Center (Germany) before being transferred to participating U.S. military hospitals were assessed. An NTL was defined as a negative laparotomy without substantial intra-abdominal injuries requiring repair. Characteristics, indications for laparotomy, operative findings, and outcomes were examined. Among 244 patients who underwent laparotomies, 41 (16.8%) had NTLs and 203 (83.2%) had therapeutic laparotomies (i.e. positive findings). Patients with NTLs had more computed tomography scans concerning for injury (48.8% vs 27.1%; p = 0.006), less penetrating injury mechanisms (43.9% vs 71.9%; p < 0.001), and lower Injury Severity Scores (26 vs 33; p = 0.003) compared to patients with therapeutic laparotomies. Patients with NTLs were also less likely to be admitted to the intensive care unit (70.7 vs 89.2% for patients with therapeutic laparotomies; p = 0.007). No patients with NTLs developed abdominal surgical site infections (SSI) compared to 16.7% of patients with therapeutic laparotomies (p = 0.002). There was no significant difference in mortality between the groups (p = 0.198). Our proportion of NTLs was lower than reported from earlier years during the wars in Iraq and Afghanistan. No infectious complications from NTLs (i.e. abdominal SSIs) were identified. Nevertheless, surgeons should continue to have a low threshold for exploratory laparotomy in military patients in austere settings with concern for intra-abdominal injury.

Blood far forward: A cross-sectional analysis of prehospital transfusion practices in the Canadian Armed Forces

BackgroundCanadian Armed Forces (CAF) operate in environments that challenge patient care, especially trauma. Military personnel often find themselves in remote settings without conventional healthcare facilities. Treating traumatic injuries, particularly hemorrhagic shock, often necessitates prehospital blood transfusion. This study aims to present an overview of the current CAF prehospital transfusion practices. Furthermore, the study compared current and developing protocols against expert-recommended guidelines. MethodsA cross-sectional survey design was employed to describe and compare CAF prehospital blood transfusion practices and protocols against expert recommendations. Topics included protocols, equipment, and procedures. An online survey targeted medical leadership and providers within CAF, with data collected from August 15 to December 15, 2023. Results were summarized descriptively. This study received approval from the Unity Health Toronto Research Ethics Board (REB 23–087). ResultsUnits and teams with prehospital blood transfusion capabilities were contacted, achieving a 100 % response rate. Within CAF, Canadian Special Operations Forces Command (CANSOFCOM), Mobile Surgical Resuscitation Team (MSRT), and Canadian Medical Emergency Response Team (CMERT) possess these capabilities, established between 2013 and 2018. These programs are crucial for military operations. CAF has access to standard blood components, cold Leuko-Reduced Whole Blood (LrWB), and factor concentrates from Canadian Blood Services (CBS), available for both domestic and international missions given adequate planning and favorable conditions. Key findings indicate high adherence to recommended practices, some variability in the transfusion process, and potential benefits of standardizing prehospital transfusion practices. ConclusionsThis study provided insights into CAF's implementation of prehospital transfusion practices, highlighting high adherence to national expert recommendations and the importance of structured protocols in military prehospital trauma management. Implications of key findingsCAF's approach and adoption of prehospital transfusion protocols lay a strong foundation for managing trauma patients in remote settings and for expanding prehospital transfusion capabilities across CFHS deployed assets. Further research is needed to advance military trauma care by adapting prehospital blood transfusion to dynamic tactical landscapes and evolving technologies.

The only winner in war is medicine: Safeguarding military trauma lessons learned through a military surgery partnership with the American Association for the Surgery of Trauma.

The only winner in war is medicine: Safeguarding military trauma lessons learned through a military surgery partnership with the American Association for the Surgery of Trauma.

Mastering multicasualty trauma care with the Trauma Non-technical Skills Scale.

Multicasualty events present complex medical challenges. This is the first study to investigate the role of nontechnical skills in prehospital multicasualty trauma care. We assessed the feasibility of using the Trauma Nontechnical Skills Scale (T-NOTECHS) instrument, which has not yet been investigated to evaluate these scenarios. We conducted an observational study involving military medical teams with Israel Defense Forces Military Trauma Life Support training to assess the T-NOTECHS' utility in predicting prehospital medical team performance during multicasualty event simulations. These teams were selected from a pool of qualified military Advanced Life Support providers. Simulations were conducted in a dedicated facility resembling a field setting, with video recordings to ensure data accuracy. Teams faced a single multicasualty scenario, assessed by two instructors, and were evaluated using a 37-item checklist. The T-NOTECHS scores were analyzed using regression models to predict simulation performance. We included 27 teams for analysis, led by 28% physicians and 72% paramedics. Interrater reliability for simulation performance and T-NOTECHS scores showed good agreement. Overall T-NOTECHS scores were positively correlated with simulation performance scores ( R = 0.546, p < 0.001). Each T-NOTECHS domain correlated with simulation performance. The Communication and Interaction domain explained a unique part of the variance ( β = 0.406, p = 0.047). Assessment and Decision Making had the highest correlation ( R = 0.535, p < 0.001). These domains significantly predicted specific items on the simulation performance checklist. Cooperation and Resource Management showed the least correlation with checklist items. This study confirms the T-NOTECHS' reliability in predicting prehospital trauma team performance during multicasualty scenarios. Key nontechnical skills, especially Communication and Interaction, and Assessment and Decision Making, play vital roles. These findings underscore the importance of training in these skills to enhance trauma care in such scenarios, offering valuable insights for medical team preparation. Diagnostic Tests or Criteria; Level III.

Virtual-reality exposure treatment for first responder PTSD: a pilot investigation

Introduction: There is increasing recognition that first responders’ exposure to multiple traumatic events puts them at risk for the development of emotional distress, including depression, substance misuse, posttraumatic stress disorder (PTSD), and suicide. Despite this increased risk and higher prevalence of PTSD and other trauma-related disorders, there are few data on treatment for first responders.Method: This investigation describes the outcome of an intensive outpatient program (IOP), initially developed for military trauma, as applied to the treatment of first responders with PTSD. This treatment is unique in that it utilizes virtual reality to enhance the immersion into the exposure scene. Furthermore, we assessed the utility of both fixed-length and unbounded-length exposure sessions.Results: The results indicate that the intervention was feasible to implement and did not produce iatrogenic effects. Participants reported significantly reduced symptoms of PTSD and related emotional distress, reduced disability, and improved daily functioning. These positive outcomes were maintained at 3-month follow-up. There was no difference in outcomes between the fixed- and unbounded-length sessions.Discussion: These results suggest that an efficacious, short-term intervention incorporating virtual reality has the potential to quickly return first responders to their profession.

Treating wartime injuries amidst attack: insights from a medical facility on the edge of combat

BackgroundProviding emergency care during conflict poses unique challenges for frontline hospitals. Barzilai Medical Center (BUMCA) in Ashkelon, Israel is a Level I trauma center located close to the Gaza border. During the November 2023 escalation of conflict, BUMCA experienced surging numbers of civilian and military trauma patients while also coming under rocket fire.MethodsWe conducted a retrospective review of BUMCA operational records and 827 de-identified patient records from October 7–14, 2023. Records provided data on daily patient volumes, injury patterns, resource constraints, and impacts of rocket attacks on hospital function. Basic demographic data was obtained including age, gender, injury severity scores, and disposition.ResultsOf the 827 patients brought to BUMCA, most (n = 812, 98.2%) presented through the emergency department. Tragically, 99 individuals were pronounced dead on arrival. Injury severity assessments found nearly half (47%) had minor injuries such as lacerations, contusions and sprains, while 25% exhibited moderate injuries like deep lacerations and fractures. 15% sustained severe or critical injuries including severe head injuries. The largest age group consisted of adults aged 19–60 years. No pediatric patients were admitted despite proximity to residential neighborhoods. The majority of cases (61%) involved complex polytrauma affecting multiple body regions. BUMCA served as both the primary treatment facility and a triage hub, coordinating secondary transports to other trauma centers as needed. Patient volumes fluctuated unpredictably from 30 to an overwhelming 125 daily, straining emergency services. Resources faced shortages of beds, medical staff, supplies and disruptions to power from nearby missile impacts further challenging care delivery.ConclusionDespite facing surging demand, unpredictable conditions and external threats, BUMCA demonstrated resilience in maintaining emergency trauma services through an adaptive triage approach and rapid surges in capacity. Their experience provides insights for improving frontline hospital preparedness and continuity of care during conflict through advance contingency planning and surge protocols. Analysis of patient outcomes found a mortality rate of 15% given the complex, multi-region injuries sustained by many patients. This study highlights the challenges faced and strengths exhibited by medical professionals operating under hazardous conditions in minimizing loss of life.Patient and public involvement in researchGiven that the study analyzed patient data from a hospital treating casualties of an ongoing armed conflict, directly engaging patients or the public during the sensitive research process could have posed risks. The volatile security situation and restrictions and protections in place amidst the crisis made it not feasible or appropriate to involve them in the study’s design, methods, reporting of results, or dissemination plans. Our aim was to conduct this retrospective analysis in a way that did not endanger those affected or compromise the hospital’s emergency response operations.

A trauma expert consensus: Capabilities are required early to improve survivability from traumatic injury.

Mortality reviews examine US military fatalities resulting from traumatic injuries during combat operations. These reviews are essential to the evolution of the military trauma system to improve individual, unit, and system-level trauma care delivery and inform trauma system protocols and guidelines. This study identifies specific prehospital and hospital interventions with the potential to provide survival benefits. US Special Operations Command fatalities with battle injuries deemed potentially survivable (2001-2021) were extracted from previous mortality reviews. A military trauma review panel consisting of trauma surgeons, forensic pathologists, and prehospital and emergency medicine specialists conducted a methodical review to identify prehospital, hospital, and resuscitation interventions (e.g., laparotomy, blood transfusion) with the potential to have provided a survival benefit. Of 388 US Special Operations Command battle-injured fatalities, 100 were deemed potentially survivable. Of these (median age, 29 years; all male), 76.0% were injured in Afghanistan, and 75% died prehospital. Gunshot wounds were in 62.0%, followed by blast injury (37%), and blunt force injury (1.0%). Most had a Maximum Abbreviated Injury Scale severity classified as 4 (severe) (55.0%) and 5 (critical) (41.0%). The panel recommended 433 interventions (prehospital, 188; hospital, 315). The most recommended prehospital intervention was blood transfusion (95%), followed by finger/tube thoracostomy (47%). The most common hospital recommendations were thoracotomy and definitive vascular repair. Whole blood transfusion was assessed for each fatality: 74% would have required ≥10 U of blood, 20% would have required 5 to 10 U, 1% would have required 1 to 4 U, and 5% would not have required blood products to impact survival. Five may have benefited from a prehospital laparotomy. This study systematically identified capabilities needed to provide a survival benefit and examined interventions needed to inform trauma system efforts along the continuum of care. The determination was that blood transfusion and massive transfusion shortly after traumatic injury would impact survival the most. Expert Opinion; Level V.

The thin red line: Blood planning factors and the enduring need for a robust military blood system to support combat operations.

Battlefield lessons learned are forgotten; the current name for this is the Walker Dip. Blood transfusion and the need for a Department of Defense Blood Program are lessons that have cycled through being learned during wartime, forgotten, and then relearned during the next war. The military will always need a blood program to support combat and contingency operations. Also, blood supply to the battlefield has planning factors that have been consistent over a century. In 2024, it is imperative that we codify these lessons learned. The linchpins of modern combat casualty care are optimal prehospital care, early whole blood transfusion, and forward surgical care. This current opinion comprised of authors from all three military Services, the Joint Trauma System, the Armed Services Blood Program, blood SMEs and the CCC Research Program discuss two vital necessities for a successful military trauma system: (1) the need for an Armed Services Blood Program and (2) Planning factors for current and future deployed military ere is no effective care for wounded soldiers, and by extension there is no effective military medicine.