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Background: Medics have numerous responsibilities in the combat theater, which include performing lifesaving interventions, providing basic medical and nursing care, and caring for casualties in a variety of scenarios unique to the battlefield. An evaluation of the medic predeployment training paradigm is important and will help to understand its current state and identify areas for improvement. Therefore, the purpose of this study was to perform a focused assessment of Army medic predeployment training to identify patterns that might inform future medic training., Methods: A web-based survey was created using the Intelink.gov platform and sent by e-mail to Army medics who deployed since 2001. Medics were asked to reflect upon the predeployment training from their most recent deployment experience. There were multiple choice, Likert-type scale, and free-text response questions. Descriptive statistics were used to analyze the results., Results: There were 254 respondents who met the study inclusion criteria. Most of the respondents had their clinical competency evaluated (68.5%, n = 174). Respondents reported several acute trauma, basic nursing, and battlefield medicine skills as being critical but also felt that many of these same skills would have benefited from additional predeployment training. Most of the respondents felt very or fully confident and prepared to provide combat casualty care (74.8%, n = 190 and 74.8%, n = 190). There were 64 respondents (25.2%) who reported feeling not at all, slightly, or moderately confident, and 54 (84.4%) of these respondents described in a free-text question wanting additional training before deployment., Conclusion: Respondents reported many skills as being critical to combat casualty care, but several of these skills would have benefited from additional predeployment training. Respondents with more deployment experience or completion of more predeployment training reported feeling more confident and prepared to provide combat casualty care. A common sentiment was the desire for more training of any form before deployment., Level of Evidence: Epidemiological, level IV., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Role 2 forward surgical teams provide damage-control resuscitation and surgery for life- and limb-threatening injuries. These teams have limited resources and personnel, so understanding the anatomic injury patterns seen by these teams is vital for providing adequate training and preparation prior to deployment. The objective of this study was to describe the spectrum of injuries treated at Role 2 facilities in Afghanistan., Methods: Using Department of Defense Trauma Registry data, a retrospective, secondary data analysis was conducted. Eligible patients were all battle or non-battle-injured casualties treated by Role 2 forward surgical teams in Afghanistan from October 2005 to June 2018. Abbreviated Injury Scale (AIS) 2005 codes were used to classify each injury and Injury Severity Score (ISS) was calculated for each patient. Patients with multiple trauma were defined as patients with an AIS severity code >2 in at least two ISS body regions., Results: The data set included 10,383 eligible patients with 45,225 diagnosis entries (range, 1-27 diagnoses per patient). The largest number of injuries occurred in the lower extremity/pelvis/buttocks (23.9%). Most injuries were categorized as minor (39.4%) or moderate (38.8%) in AIS severity, while the largest number of injuries categorized as severe or worse occurred in the head (13.5%). Among head injuries, 1,872 injuries were associated with a cerebral concussion or diffuse axonal injury, including 50.6% of those injuries being associated with a loss of consciousness. There were 1,224 patients with multiple trauma, and the majority had an injury to the extremities/pelvic girdle (58.2%). Additionally, 3.7% of all eligible patients and 10.5% of all patients with multiple trauma did not survive to Role 2 discharge., Conclusion: The injury patterns seen in recent conflicts and demonstrated by this study may assist military medical leaders and planners to optimize forward surgical care in future environments, on a larger scale, and utilizing less resources., Level of Evidence: Epidemiological, Level III.

Managing multicenter clinical trials (MCTs) is demanding and complex. The Randomized controlled Evaluation of high-volume hemofiltration in adult burn patients with Septic shoCk and acUte kidnEy injury (RESCUE) trial was a prospective, MCT involving the impact of high-volume hemofiltration continuous renal replacement therapy on patients experiencing acute kidney injury and septic shock. Ten clinical burn centers from across the United States were recruited to enroll a target sample size of 120 subjects. This manuscripts reviews some of the obstacles and knowledge gained while coordinating the RESCUE trial. The first subject was enrolled in February 2012, 22 months after initial IRB approval and 29 months from the time the grant was awarded. The RESCUE team consisted of personnel at each site, including the lead site, a data coordination center, data safety monitoring board, steering committees, and the sponsor. Seven clinical sites had enrolled 37 subjects when enrollment stopped in February 2016. Obstacles included changes in institutional review boards, multiple layers of review, staffing changes, creation and amendment of study documents and procedures, and finalization of contracts. Successful completion of a MCT requires a highly functional research team with sufficient patient population, expertise, and research infrastructure. Additionally, realistic timelines must be established with strategies to overcome challenges. Inevitable obstacles should be discussed in the pretrial phase and continuous correspondence must be maintained with all relevant research parties throughout all phases of study., (Published by Oxford University Press on behalf of the American Burn Association 2020.)

Introduction: The combat experience during the re-entry stages of Operation Inherent Resolve was distinct from other recent operations, but there is no published literature regarding these "initial entry operations" experiences among forward surgical teams (FSTs) deployed to Role 2 facilities A descriptive analysis of patients treated by FSTs may provide valuable information for Role 2 surgical teams preparing to deploy in support of initial entry operations. The purpose of this analysis was to describe injury mechanism, wounding patterns and interventions performed by a small FST in the re-entry phase in Iraq., Materials and Methods: From July 17, 2015 to January 31, 2016, a split surgical team with two surgeons and an ER physician documented care for all patients treated by their FST located in Iraq. Given their austere environment, FSTs have limited holding capacity, blood supply, and ability to triage and perform advanced procedures. Patients, who arrived to the Role 2 in asystole, were ineligible for the study. The patient population was Iraqi Security Forces as well as Iraqi civilians. No follow-up data were obtained. Using descriptive statistics, we described the basic demographics, health status, blood utilization, injury severity, and injury pattern of the patient population., Results: The final study population included 300 Iraqi casualties. The majority of patients (96%) were discharged alive. Many patients were 16 years or older (96%), male (96%), Iraqi soldiers (86%), and injured during battle (96%). Over one-third of patients (35%) had a form of metabolic acidosis, 7% were hypothermic, and 18% were in shock at admission. The median amount of blood products used was 6 (interquartile ranges (IQR) = 2-12) units, while the median red blood cells:fresh frozen plasma ratio was 1.2:1. Six or more units of blood were given to 67 (22%) patients. The top three diagnoses were laceration (n = 197, 21%), penetrating injury (n = 185, 19%), and fracture (n = 174, 18%). A high number of injuries occurred in the extremities/pelvis and buttocks (n = 360, 38%) and in the abdomen and pelvic contents (n = 145, 15%). Over a quarter of patients (26%) had critical injuries (i.e., military injury severity score ≥25)., Conclusions: Given the Role 2 configuration, these results demonstrate FSTs must be capable of managing critically ill patients with markedly limited resources. This management will include general operations in both adult and pediatric patients, resuscitation with a limited blood supply, and patient assessment with minimal to no diagnostic tools. This analysis can inform resident training, pre-deployment training, as well as sustainment training for surgeons after residency., (© The Author(s) 2019. Published by Oxford University Press on behalf of Association of Military Surgeons of the United States. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Acute kidney injury (AKI) after severe burns is historically associated with a high mortality. Over the past two decades, various modes of renal replacement therapy (RRT) have been used in this population. The purpose of this multicenter study was to evaluate demographic, treatment, and outcomes data among severe burn patients treated with RRT collectively at various burn centers around the United States. After institutional review board approval, a multicenter observational study was conducted. All adult patients aged 18 or older, admitted with severe burns who were placed on RRT for acute indications but not randomized into a concurrently enrolling interventional trial, were included. Across eight participating burn centers, 171 subjects were enrolled during a 4-year period. Complete data were available in 170 subjects with a mean age of 51 ± 17, percent total body surface area burn of 38 ± 26% and injury severity score of 27 ± 21. Eighty percent of subjects were male and 34% were diagnosed with smoke inhalation injury. The preferred mode of therapy was continuous venovenous hemofiltration at a mean delivered dose of 37 ± 19 (ml/kg/hour) and a treatment duration of 13 ± 24 days. Overall, in hospital, mortality was 50%. Among survivors, 21% required RRT on discharge from the hospital while 9% continued to require RRT 6 months after discharge. This is the first multicenter cohort of burn patients who underwent RRT reported to date. Overall mortality is comparable to other critically ill populations who undergo RRT. Most patients who survive to discharge eventually recover renal function.

Background: Timely and optimal care can reduce mortality among critically injured combat casualties. US military Role 2 surgical teams were deployed to forward positions in Afghanistan on behalf of the battlefield trauma system. They received prehospital casualties, provided early damage control resuscitation and surgery, and rapidly transferred casualties to Role 3 hospitals for definitive care. A database was developed to capture Role 2 data., Methods: A retrospective review and descriptive analysis were conducted of battle-injured casualties transported to US Role 2 surgical facilities in Afghanistan from February 2008 to September 2014. Casualties were analyzed by mortality status and location of death (pretransport, intratransport, or posttransport), military affiliation, transport time, injury type and mechanism, combat mortality index-prehospital (CMI-PH), and documented prehospital treatment., Results: Of 9,557 casualties (median age, 25.0 years; male, 97.4%), most (95.1%) survived to transfer from Role 2 facility care. Military affiliation included US coalition forces (37.4%), Afghanistan National Security Forces (23.8%), civilian/other forces (21.3%), Afghanistan National Police (13.5%), and non-US coalition forces (4.0%). Mortality differed by military affiliation (p < 0.001). Among fatalities, most were Afghanistan National Security Forces (30.5%) civilian/other forces (26.0%), or US coalition forces (25.2%). Of those categorized by CMI-PH, 40.0% of critical, 11.2% of severe, 0.8% of moderate, and less than 0.1% of mild casualties died. Most fatalities with CMI-PH were categorized as critical (66.3%) or severe (25.9%), whereas most who lived were mild (56.9%) or moderate (25.4%). Of all fatalities, 14.0% died prehospital (pretransport, 5.8%; intratransport, 8.2%), and 86.0% died at a Role 2 facility (posttransport). Of fatalities with documented transport times (median, 53.0 minutes), most (61.7%) were evacuated within 60 minutes., Conclusions: Role 2 surgical team care has been an important early component of the battlefield trauma system in Afghanistan. Combat casualty care must be documented, collected, and analyzed for outcomes and trends to improve performance., Level of Evidence: Therapeutic/Care Management, level IV.

Objectives: The military uses "just-in-time" training to refresh deploying medical personnel on skills necessary for medical and surgical care in the theater of operations. The burden of pediatric care at Role 2 facilities has yet to be characterized; pediatric predeployment training has been extremely limited and primarily informed by anecdotal experience. The goal of this analysis was to describe pediatric care at Role 2 facilities to enable data-driven development of high-fidelity simulation training and core knowledge concepts specific to the combat zone., Setting and Patients: A retrospective review of the Role 2 Database was conducted on all pediatric patients (< 18 yr) admitted to Role 2 in Afghanistan from 2008-2014., Interventions: Three cohorts were determined based on commercially available simulation models: Group 1: less than 1 year, Group 2: 1-8 years, Group 3: more than 8 years. The groups were sub-stratified by point of injury care, pre-hospital management, and Role 2 facility medical/surgical management., Measurements and Main Results: Appropriate descriptive statistics (chi square and Student t test) were utilized to define demographic and epidemiologic characteristics of this population. Of 15,404 patients in the Role 2 Database, 1,318 pediatric subjects (8.5%) were identified. The majority of patients were male (80.0%) with a mean age of 9.5 years (± SD, 4.5). Injury types included: penetrating (56%), blunt (33%), and burns (7%). Mean transport time from point of injury to Role 2 was 198 minutes (±24.5 min). Mean Glasgow Coma Scale and Revised Trauma Score were 14 (± 0.1) and 7.0 (± 1.4), respectively. Role 2 surgical procedures occurred for 424 patients (32%). Overall mortality was 4% (n = 58)., Conclusions: We have described the epidemiology of pediatric trauma admitted to Role 2 facilities, characterizing the spectrum of pediatric injuries that deploying providers should be equipped to manage. This analysis will function as a needs assessment to facilitate high-fidelity simulation training and the development of "pediatric trauma core knowledge concepts" for deploying providers.

Since 2009, out-of-hospital care of junctional hemorrhage bleeding from the trunk-appendage junctions has changed, in part, due to the newly available junctional tourniquets (JTs) that have been cleared by the US Food and Drug Administration. Given four new models of JT available in 2014, several military services have begun to acquire, train, or even use such JTs in care. The ability of users to be trained in JT use has been observed by multiple instructors. The experience of such instructors has been broad as a group, but their experience as individuals has been neither long nor deep. A gathering into one source of the collective experience of trainers of JT users could permit a collation of useful information to include lessons learned, tips in skill performance, identification of pitfalls of use to avoid, and strategies to optimize user learning. The purpose of the present review is to record the experiences of several medical personnel in their JT training of users to provide a guide for future trainers., (2015.)

The administration of blood products to battlefield casualties in the prehospital arena has contributed significantly to the survival of critically injured patients in Afghanistan over the past 5 years. Given as part of an established military "chain of survival," blood product administration has represented a step-change improvement in capability for both UK and US tactical aeromedical evacuation (TACEVAC) platforms. The authors explore current concepts, analyzing and exploring themes associated with early use of blood products (fresh frozen plasma [FFP] and red blood cells [RBCs]), and they compare and evaluate a US/UK study analyzing the differences and recommending future strategy. The subject matter expert (SME) consensus guidelines developed for use by the US Army Air Ambulance units commonly known as call sign "DUSTOFF." These TACEVAC assets in Afghanistan were validated in this retrospective study. Using statistical analysis, the authors were able to ascertain that the current DUSTOFF SME-derived guidelines offer a sensitivity of 63.04% and a specificity of 89.07%. By adjusting the indicators to include a single above-ankle amputation with a systolic blood pressure (SBP) less than 90 mmHg and pulse greater than 120/min, the sensitivity could be increased to 67.39% while maintaining the specificity at 89.07%. In our data set, a single amputation above the ankle, in combination with an SBP of less than 100 mmHg and a pulse of greater than 120/min, increased the sensitivity to 76% but with a slight drop in specificity to 86%. Further study of military prehospital casualty data is under way to identify additional physiological parameters that will allow simple scoring tools in the remote setting to guide the administration of prehospital blood products., (2014.)

As the only burn center in the Department of Defense, the U.S. Army Institute of Surgical Research is the primary location for care of service members with burn injuries. The combat operations in Iraq and Afghanistan during the past decade have caused an increase in burn patients. As a result of this increased need, advancements in care were developed. The speed and precision of transporting patients from the battlefield to the burn center has improved over previous conflicts. Technological advancements to support treating complications of burn wound healing were leveraged and are now integrated into daily practice. Clinical decision support systems were developed and deployed at the burn center as well as to combat support hospitals in combat zones. Technology advancements in rehabilitation have allowed more service members to return to active duty or live productive civilian lives. All of these advancements were developed in a patient-centered, interdisciplinary environment where the nurses are integrated throughout the research process and clinical practice with the end goal of healing combat burns in mind.