Artificial Intelligence in Military Medicine.

Artificial intelligence (AI) has garnered significant attention for its pivotal role in the national security and health care sectors. However, its utilization in military medicine remains relatively unexplored despite its immense potential. AI operates through evolving algorithms that process extensive datasets, continuously improving accuracy and emulating human learning processes. Generative AI, a type of machine learning, uses algorithms to generate new content, such as images, text, videos, audio, and computer code. These models employ deep learning to encode simplified representations of training data and generate new work resembling the original without being identical. Although many AI applications in military medicine are theoretical, the U.S. Military has implemented several initiatives, often without widespread awareness among its personnel. This article aims to shed light on two resilience initiatives spearheaded by the Joint Artificial Intelligence Center, which is now the Chief Digital and Artificial Intelligence Office. These initiatives aim to enhance commanders' dashboards for predicting troop behaviors and develop models to forecast troop suicidality. Additionally, it outlines 5 key AI applications within military medicine, including (1) clinical efficiency and routine decision-making support, (2) triage and clinical care algorithms for large-scale combat operations, (3) patient and resource movements in the medical common operating picture, (4) health monitoring and biosurveillance, and (5) medical product development. Even with its promising potential, AI brings forth inherent risks and limitations that require careful consideration and discussion. The article also advocates for a forward-thinking approach for the U.S. Military to effectively leverage AI in advancing military health and overall operational readiness.

Generating Competent Special Operations Clinicians From Military Graduate Medical Education.

Units within the Special Operations Forces (SOF) community require medically competent and operationally proficient medical providers (physicians, physician assistants, and nurse practitioners, among others) to support complex mission sets. The expectations placed on providers who successfully assess for and are selected into these units are high. These providers are not only expected to be experts in their respective subspecialities, but also to serve as staff officers, provide medical direction for SOF medics, serve as medical advisors to the command team, and provide direct medical support for kinetic operations. They are expected to perform these functions with little oversight and guidance and when geographically separated from higher units. Graduates from military Graduate Medical Education (GME) programs are extremely well-educated and can provide high quality medical care. However, they often find themselves ill-prepared for the extra demands placed upon them by the Special Operations community due to a lack of operational exposure. The authors of this paper recognized this gap and propose that the Joint Emergency Medicine Exercise (JEMX) model can help augment the body of knowledge required to perform well as a provider in a Special Operations unit.

Fluid Resuscitation in Tactical Combat Casualty Care; TCCC Guidelines Change 21-01. 4 November 2021.

Hemorrhagic shock in combat trauma remains the greatest life threat to casualties with potentially survivable injuries. Advances in external hemorrhage control and the increasing use of damage control resuscitation have demonstrated significant success in decreasing mortality in combat casualties. Presently, an expanding body of literature suggests that fluid resuscitation strategies for casualties in hemorrhagic shock that include the prehospital use of cold-stored or fresh whole blood when available, or blood components when whole blood is not available, are superior to crystalloid and colloid fluids. On the basis of this recent evidence, the Committee on Tactical Combat Casualty Care (TCCC) has conducted a review of fluid resuscitation for the combat casualty who is in hemorrhagic shock and made the following new recommendations: (1) cold stored low-titer group O whole blood (CS-LTOWB) has been designated as the preferred resuscitation fluid, with fresh LTOWB identified as the first alternate if CS-LTOWB is not available; (2) crystalloids and Hextend are no longer recommended as fluid resuscitation options in hemorrhagic shock; (3) target systolic blood pressure (SBP) resuscitation goals have been redefined for casualties with and without traumatic brain injury (TBI) coexisting with their hemorrhagic shock; and (4) empiric prehospital calcium administration is now recommended whenever blood product resuscitation is required.

Emergency Department Adaptations to COVID-19.

BACKGROUND: The COVID-19 pandemic creates unique challenges for healthcare systems. While mass casualty protocols and plans exist for trauma-induced large-scale resource utilization events, contagious infectious disease mass casualty events do not have such rigorous procedures established. COVID-19 forces Emergency Departments (EDs) to simultaneously treat seriously ill patients and evaluate large influxes of 'worried well'-while maintaining both staff and patient safety. METHODS: The objectives of this project are to create an avenue to evaluate large surges of patients while minimizing hospital-acquired infections. After identifying areas for improvement and anticipating potential failures, we devised eight healthcare delivery innovations to address those areas and meet our objectives: (1) Parallel ED Lanes (2) Universal Respiratory Precautions (3) Respiratory Drive Through (RDT) (4) Medical Company (5) Provider Triage (6) ED Quarterback Patient Liaison (EDQB) (7) Virtual Registration (8) Virtual Ward. RESULTS: To date, no staff members have contracted COVID-19 within the ED footprint. Our RDT has seen 16,994 patients and the medical company 1,109. Provider triage has redirected 465 patients, while our EDQB has interacted with 532 and redirected 93 patients for same-day appointments with their Primary Care Manager (PCM). CONCLUSION: The system of care establish at our Military Treatment Facility (MTF) has been effective in maximizing staff and patient safety, while providing a new patient-centered healthcare delivery apparatus.

Life and Limb In-Flight Surgical Intervention: Fifteen Years of Experience by Joint Medical Augmentation Unit Surgical Resuscitation Teams.

BACKGROUND: Expedient resuscitation and emergent damage control interventions remain critical tools of modern combat casualty care. Although fortunately rare, the requirement for life and limb salvaging surgical intervention prior to arrival at traditional deployed medical treatment facilities may be required for the care of select casualties. The optimal employment of a surgical resuscitation team (SRT) may afford life and limb salvage in these unique situations. METHODS: Fifteen years of after-action reports (AARs) from a highly specialized SRTs were reviewed. Patient demographics, specific details of encounter, team role, advanced emergent life and limb interventions, and outcomes were analyzed. RESULTS: Data from 317 casualties (312 human, five canines) over 15 years were reviewed. Among human casualties, 20 had no signs of life at intercept, with only one (5%) surviving to reach a Military Treatment Facility (MTF). Among the 292 casualties with signs of life at intercept, SRTs were employed in a variety of roles, including MTF augmentation (48.6%), as a transport capability from other aeromedical platforms, critical care transport (CCT) between MTFs (27.7%), or as an in-flight damage control capability directly to point of injury (POI) (18.2%). In the context of these roles, the SRT performed in-flight life and limb preserving surgery for nine patients. Procedures performed included resuscitative thoracotomy (7/9; 77.8%), damage control laparotomy (1/9; 11.1%) and extremity fasciotomy for acute lower extremity compartment syndrome (1/11; 11%). Survival following in-flight resuscitative thoracotomy was 33% (1/3) when signs of life (SOL) were absent at intercept and 75% (3/4) among patients who lost SOL during transport. CONCLUSION: In-flight surgery by a specifically trained and experienced SRT can salvage life and limb for casualties of major combat injury. Additional research is required to determine optimal SRT utilization in present and future conflicts.

The Use of Tranexamic Acid in Tactical Combat Casualty Care: TCCC Proposed Change 20-02.

The literature continues to provide strong support for the early use of tranexamic acid (TXA) in severely injured trauma patients. Questions persist, however, regarding the optimal medical and tactical/logistical use, timing, and dose of this medication, both from the published TXA literature and from the TCCC user community. The use of TXA has been explored outside of trauma, new dosing strategies have been pursued, and expansion of retrospective use data has grown as well. These questions emphasize the need for a reexamination of TXA by the CoTCCC. The most significant updates to the TCCC Guidelines are (i) including significant traumatic brain injury (TBI) as an indication for TXA, (ii) changing the dosing protocol to a single 2g IV/IO administration, and (iii) recommending TXA administration via slow IV/IO push.

Low Incidence of Death and Renal Failure in United States Military Service Members Hospitalized with Exertional Heat Stroke: A Retrospective Cohort Study.

INTRODUCTION: The goal of the current study was to characterize the rate and estimate associated mortality and morbidity of exertional heat stroke (EHS) in U.S. military service members. MATERIALS AND METHODS: The current study was a retrospective cohort medical chart review study of all active-duty U.S. military service members, hospitalized with EHS at any MTF in the world between January1, 2007 and July 1, 2014. Enrolled patients were identified by altered mental status and elevated temperatures associated with physical exercise. RESULTS: Out of 607 service members with an International Classification of Disease code indicating any type of heat injury, 48 service members met inclusion criteria for EHS. Core temperature was M = 105.8°F (41°C), standard deviation = 1.43, 90% were diagnosed with EHS prior to hospitalization, and 71% received prehospital cooling. Meantime to normothermia post-hospitalization was 56 minutes (standard deviation = 79.28). Acute kidney injury was diagnosed in 40% of patients although none developed hyperkalemia or required dialysis. Disseminated intravascular coagulation was rare (4%, n = 2) and overall observed mortality was very low (2%, n = 1). CONCLUSION: EHS is aggressively identified and treated in U.S. Military Treatment Facilities. Mortality and morbidity were strikingly low.

Community hospital experience in the emergency management of COVID-19: Preventing morbidity and preserving resources.

An incredible amount of information has been published regarding inpatient management of patients with COVID-19. Although this is vitally important, critical interventions that occur in the emergency department (ED) can have a profound impact on the individual patient and the healthcare system as a whole.  Much has been written regarding care in large centers, but there has been little discussion regarding similar patients in community settings. Prior to the pandemic, large centers were able to accept patients that outstripped the resources in community hospital settings, but currently we foresee that many community centers will begin to manage more complex cases without referral. As physicians in a medium-sized community academic center, we aim to enumerate community-hospital-relevant guidance for ED care that focuses on adherence to available evidence-based medicine, including early aggressive supplemental oxygenation, awake proning, and methods to improve oxygenation and ultimately delay intubation as long as safely possible.  Equally importantly, it was recognized early that adjustments to medication regimens (eg, sedation) and personal protective equipment (PPE) use must be made in the ED to conserve those same resources for long-term use in inpatient units and improve the functionality of the hospital system as a whole. It is our hope that this article may serve as a framework for similar community-based hospitals to create their own protocols to optimize resource utilization, staff safety, and patient care.

Risk Associated With Autologous Fresh Whole Blood Training.

Fresh whole blood (FWB) is increasingly being recognized as the ideal resuscitative fluid for hemorrhagic shock. Because of this, military units are working to establish the capability to give FWB from a walking blood bank donor in environments that are unsupported by conventional blood bank services. Therefore, many military units are performing autologous blood transfusion training. In this training, a volunteer has a unit of blood collected and then transfused back into the same donor. The authors report their experience performing an estimated 3408 autologous transfusions in training and report no instances of hemolytic transfusion reactions or other major complications. With appropriate control measures in place, autologous FWB training is low-risk training.

Novel use of FaceTime video calling in a deployed setting to assist with the care of a military working dog

Summary: In deployed settings, veterinary recourses are limited and nonveterinary medical providers frequently are required to provide medical treatment to military working dogs (MWDs) until veterinary specialty care can be provided. We present the case of a critically ill MWD who presented initially to a Canadian NATO Role II facility in Iraq that lacked immediate veterinary support. Through the use of FaceTime interactive video calling, the Role II medical providers were able to consult with the MWD unit's veterinarian in the United States and provide effective evaluation, treatment and prioritization of medical evacuation (MEDEVAC). FaceTime video calling was extremely effective and should be considered in future situations where specialist care is not immediately available and transmission of visual information would be beneficial.

Injuries Sustained During Modern Army Combatives Tournaments.

INTRODUCTION: Injuries sustained during Modern Army Combatives (MAC) tournaments can result in variable recovery time for involved competitors and unpredictable loss of readiness for military units. A paucity of MAC data is available to guide military medical providers and unit commanders on expected injuries or loss of readiness. Literature reviewing mixed martial arts competitions offers some insight but demonstrates variation in fight outcomes resulting in injuries ranging from 8.5% to 70% and it is difficult to effectively extrapolate such data to predict MAC tournament injuries. MATERIALS AND METHODS: This study retrospectively reviews pre- and post-competition medical records from two MAC tournaments held at Fort Hood in 2014 and 2015 to provide descriptive clinical information on injury patterns to practitioners and military commanders. RESULTS: Records from a total of 195 competitors with a mean age of 24.4 yr were analyzed with a total of 67 injuries, 29 of which resulted in duty limitations (14.8% of participants). Competitors participating in less-restrictive mixed martial arts style fighting (Advanced MAC) were 4.3 times more likely to sustain an injury than those limited to upper body grappling events (95% confidence interval 2.30-8.16). Military Acute Concussion Evaluations were reliably recorded both pre- and post-competition in 44% of total participants with no significant statistical difference between pre- and post-tournament evaluations. Duty profile limitations of injured competitors averaged 1 mo in duration. CONCLUSIONS: MAC tournaments result in injury rates comparable with other combative sports and military training courses.

Ultrasound Versus Landmarks for Great Toe Arthrocentesis.

BACKGROUND: Several studies have demonstrated ultrasound (US) is superior to traditional landmark (LM)-based techniques for large and medium joint aspiration; however, no studies of sufficient size have evaluated these interventions in the smaller toe joints. The purpose of this study was to determine if US provides an advantage over LM for successful first-pass aspiration of first metatarsophalangeal joint (1st MTPJ) effusions. METHODS: A cross-over, cadaveric trial evaluating the interventions of US and LM. Eighteen emergency medicine residents performed four US and four LM aspirations each of 1st MTPJ effusions simulated in fresh-frozen cadavers. The initial intervention utilized was randomized. The primary outcome measured was aspiration success or failure. A secondary outcome measured was time in seconds taken to complete a successful aspiration. RESULTS: A total of 144 1st MTPJ aspirations were attempted-72 by US and 72 by LM. US was the initial intervention used in 9 of 18 (50%) participants. Fifty-seven of 72 (79.2%) US attempts were successful, while 53 of 72 (73.6%) LM attempts were successful (95% confidence interval 69.5%, 83.3%; p = 0.56). Successful US aspirations took 43.7 seconds (±31.0), whereas successful LM aspirations averaged 34.0 seconds (±24.3). The mean difference in time to successful aspiration was 9.7 seconds (95% confidence interval 20.3, -0.9; p = 0.07). There was no statistically significant difference in success and time between US and LM. CONCLUSION: In this study, US did not prove superior to LM for first-pass aspiration of 1st MTPJ effusions.

Pediatric Trauma: Management From an Austere Prospective.

Pediatric trauma represents a notable proportion of casualties encountered by Combat medics, physician assistants, and physicians while in the deployed setting. Most of these resuscitation teams receive limited pediatric- specific training and suffer subsequent emotional stress due the perceived high-stakes nature of caring for gravely wounded children. Even when children survive long enough to arrive at combat support hospitals, there remain high risks for morbidity and mortality for many of them. There are numerous reports of the epidemiological characteristics of these pediatric patients, the common mechanisms of injury, the hospital lengths of stay, and calls for pediatric-specific equipment and specialist presence in-theatre. There is scant literature, however, on child-specific battlefield resuscitation and training for initial providers, and we believe that, with appropriately tailored pediatric resuscitation education and training strategies, there is some potential for a reduction in the morbidity and mortality associated with childhood combat injury.

Clinical Image: Visual Estimation of Blood Loss.

Military prehospital providers frequently have to make important clinical decisions with only limited objective information and vital signs. Because of this, accurate estimation of blood loss, at the point of injury, can augment any available objective information. Prior studies have shown that individuals significantly overestimate the amount of blood loss when the amount of hemorrhage is small, and they tend to underestimate the amount of blood loss with larger amounts of hemorrhage. Furthermore, the type of surface on which the blood is deposited can impact the visual estimation of the amount of hemorrhage. To aid providers with the ability to accurately estimate blood loss, we took several units of expired packed red blood cells and deposited them in different ways on varying surfaces to mimic the visual impression of combat casualties.

Exertional heat stroke: clinical significance and practice indications for special operations medics and providers.

Exertional heat stroke is an acute injury associated with high morbidity and mortality, and is commonly encountered within military and Special Operations environments. With appropriate planning, rapid diagnosis, and aggressive treatment significant mortality reduction can be obtained. Planning for both training and real world operations can decrease the patient?s morbidity and mortality and increase the chances of successful handling of a patient with exertional heat stroke. The mainstay of treatment is rapid reduction of the core body temperature. This is paramount both at the field level of care as well as in a clinical setting. Diligent surveillance for commonly encountered complications includes anticipating electrolyte abnormalities, rhabdomyolysis, acute renal failure, and hepatic injuries. Treatment with dantrolene may be indicated in patients with continued hyperthermia despite aggressive traditional treatment.

Acetazolamide 125 mg BD is not significantly different from 375 mg BD in the prevention of acute mountain sickness: the prophylactic acetazolamide dosage comparison for efficacy (PACE) trial.

750 mg per day of acetazolamide in the prevention of acute mountain sickness (AMS), as recommended in the meta-analysis published in 2000 in the British Medical Journal, may be excessive and is controversial. To determine if the efficacy of low-dose acetazolamide 125 mg bd (250 mg), as currently used in the Himalayas, is significantly different from 375 mg bd (750 mg) of acetazolamide in the prevention of AMS, we designed a prospective, double-blind, randomized, placebo-controlled trial. The participants were sampled from a diverse population of (non-Nepali) trekkers at Namche Bazaar (3440 m) in Nepal on the Everest trekking route as they ascended to study midpoints (4280 m/4358 m) and the endpoint, Lobuje (4928 m), where data were collected. Participants were randomly assigned to receive 375 mg bd of acetazolamide (82 participants), 125 mg bd of acetazolamide (74 participants), or a placebo (66 participants), beginning at 3440 m for up to 6 days as they ascended to 4928 m. The results revealed that composite AMS incidence for 125 mg bd was similar to the incidence for 375 mg bd (24% vs. 21%, 95% confidence interval, -12.6%, 19.8%), in contrast to significantly greater AMS (51%) observed in the placebo group (95% confidence interval for differences: 8%, 46%; 12%, 49% for low and high comparisons, respectively). Both doses of acetazolamide improved oxygenation equally (82.9% for 250 mg daily and 82.8% for 750 mg daily), while placebo endpoint oxygen saturation was significantly less at 80.7% (95% confidence interval for differences: 0.5%, 3.9% and 0.4%, 3.7% for low and high comparisons, respectively). There was also more paresthesia in the 375-mg bd group (p < 0.02). We conclude that 125 mg bd of acetazolamide is not significantly different from 375 mg bd in the prevention of AMS; 125 mg bd should be considered the preferred dosage when indicated for persons ascending to altitudes above 2500 m.