Battlefield Triage and Resource Allocation during a Pandemic: Learning from the Past and Adapting for the Future.

The principle of medical triage, where patients are sorted into categories to guide the order in which they receive treatment, dates back to Baron Dominique Jean Larrey, the surgeon general of Napolean's armies. The concept evolved with military conflicts throughout the 19th century, was subsequently adapted to situations off the battlefield, and is now widely practiced where resources are limited.2 Military medical providers are taught triage principles early in their careers and its use is routinely integrated into military training scenarios and operational planning.

Mandating the COVID-19 Vaccine for U.S. Service Members: An Exploration of Ethical Arguments.

As the COVID-19 pandemic continues across the globe, the advent of novel vaccines has created a possible path to prepandemic life for many. Still, many individuals, including those in the U.S. military, remain hesitant about getting vaccinated. The U.S. Food and Drug Administration recently granted full approval to the Pfizer-BioNTech mRNA vaccine (Comirnaty). Consistent with messaging from President Biden, the Department of Defense leadership has instructed the military to prepare for mandatory vaccination. While many have praised this declaration, others have raised concerns regarding the suppression of individual service member autonomy. This commentary explains the different ethical principles relevant to individual autonomy and how they are understood in a military context and then explores the ethical arguments both for and against mandating vaccination for all U.S. service members.

Perceptions of Gender and Race Equality in Leadership and Advancement Among Military Family Physicians.

INTRODUCTION: There is increasing interest in assessing gender and race-based disparities in academic medicine and healthcare leadership in civilian medicine and the U.S. Military Health System. Approximately 15% of U.S. active duty service members are women, and racial minorities are 30% of the total active duty force. This study evaluates the following factors among uniformed services family physicians: gender and race representation in attaining early career leadership positions during training and 2 years postresidency; perceptions regarding leadership opportunities and career advancement. METHODS: Registered attendees (n = 300) of the 2016 Uniformed Services Academy of Family Physicians Annual Meeting were given a voluntary and anonymous online questionnaire. The main outcomes measured were early leadership assignments and perceptions about command/leadership support, gender roles in leadership assignment, confidence to achieve leadership goals, and being passed over for leadership positions. RESULTS: Sixty-eight percent of registered attendees completed the study questionnaire. Statistically significant results, adjusting for service, grade, race, and gender, were that non-Caucasian family physicians were less likely to be chief residents (odds ratio 0.23, 95% CI 0.01-1.00) and less likely to have leadership positions within 2 years postresidency (odds ratio 0.30, 95% CI 0.10-0.91). Female family physicians were more likely to agree that gender has a role in assigning leadership positions (odds ratio 2.33, 95% CI 1.01-5.39). There were no differences in perceptions of command support for leadership; confidence in achieving desired leadership level; or in being passed over for leadership positions. CONCLUSIONS: This study provides important information about perceived gender and race equality among uniformed services family physicians. Key findings included that non-Caucasian military family physicians were less likely to attain junior leadership positions or be assigned to academic settings; and female respondents were more likely to agree that gender has a role in assignment of leadership positions. Evaluating composite personnel records of services' family physicians would provide invaluable information to complement this study.

Uncertainty: An Uncomfortable Companion to Decision-making for Infants.

Although parents are typically the most appropriate decision-makers for their children, there are limits to this authority. Medical providers may be ethically obligated to seek state intervention against a parental decision if the parent places a child at significant and imminent risk of serious harm. When parents make medical decisions for their children, they assess both the projected benefits and risks of their choices for their family. These assessments are impacted by uncertainty, which is a common feature of neonatal intensive care. The relative presence or absence of uncertainty may impact perceptions of parental decisions and a medical provider's decision to seek state intervention to overrule parents. In this article, we propose a model integrating prognostic uncertainty into pediatric decision-making that may aid providers in such assessments. We will demonstrate how to apply this model to 3 neonatal cases and propose that the presence of greater uncertainty ought to permit parents greater latitude to incorporate family values into their decision-making even if these decisions are contradictory to the recommendations of the medical team.

Behavioral Disorders in Dementia: Appropriate Nondrug Interventions and Antipsychotic Use.

Behavioral and psychological symptoms of dementia pose management challenges for caregivers and clinicians. Firstline nonpharmacologic treatments include eliminating physical and emotional stressors, modifying the patient's environment, and establishing daily routines. Family members and caregivers benefit from education about dementia symptoms and reminders that the behaviors are normal and unintentional. Cognitive and emotion-oriented interventions, sensory stimulation interventions, behavior management techniques, and other psychosocial interventions are modestly effective. In refractory cases, physicians may choose to prescribe off-label antipsychotics. Aripiprazole has the most consistent evidence of symptom improvement; however, this improvement is small. Olanzapine, quetiapine, and risperidone have inconsistent evidence of benefit. Physicians should use the smallest effective dose for the shortest possible duration to minimize adverse effects, most notably an increased mortality risk. Other adverse effects include anticholinergic and antidopaminergic effects, extrapyramidal symptoms, neuroleptic malignant syndrome, postural hypotension, metabolic syndrome, cardiac arrhythmia, and sedation. Patients should be monitored for these effects while receiving treatment; however, laboratory monitoring may be limited to patients receiving long-term therapy.

Perceived clinical skill degradation of Army family physicians after deployment.

BACKGROUND AND OBJECTIVES: Deployment away from regular clinical practice is necessary for Army family physicians, but no current information identifies specific procedures or clinical encounters where they feel less comfortable after deployment. This study identifies specific clinical areas and amount of perceived degradation in skills after deployment to combat zones. METHODS: Active duty Army family physicians were invited to participate in a web-based and anonymous survey rating comfort level performing clinical encounters or procedures prior to and after military deployment. Participants rated their comfort level using a 5-point Likert scale. The analysis included descriptive statistics about each physician's deployment history. The composite data for each clinical encounter or procedure were analyzed with McNemar's Chi-Square test. RESULTS: A total of 179 eligible Army family physicians (54% of total) fully completed the instrument, with 39% deploying once and 10% deploying more than five times in their career. Deployments ranged from 1 to >24 months, with 42% having a last deployment of 12 months duration. With statistical significance, providers reported being less comfortable post-deployment with managing first-trimester bleeding, ACLS codes, acute abdominal pain, asthma exacerbations, central line placement, chest pain, COPD exacerbations, CVA/hypertensive emergency, lumbar puncture, neonatal fevers, pediatric codes, sepsis/septic shock, and vaginal delivery. These physicians reported statistically significant increased comfort with the care of major trauma after deployment. CONCLUSIONS: Family physicians deploying to support combat operations feel less comfortable with critical clinical skills across the spectrum of care. Refresher training could be provided with standardized approach to these needs with a goal of maintaining full scope primary care providers.

Surrogate and patient discrepancy regarding consent for critical care research.

OBJECTIVE: Critically ill patients frequently display impaired decision-making capacity due to their underlying illness and the use of sedating medications. Healthcare providers often rely on surrogates to make decisions for medical care and participation in clinical research. However, the accuracy of surrogate decisions for a variety of critical care research studies is poorly understood. DESIGN: Cross-sectional observational study. SETTING: Academic medical center. PATIENTS: Medical intensive care unit patients and their designated surrogates. INTERVENTION: Patients were asked whether they would consent to participate in hypothetical research studies of increasing complexity, and surrogates independently indicated whether they would consent to enroll the patient in the same scenarios. RESULTS: Overall, 69 medical intensive care unit patients were enrolled into the study. The majority of surrogates were either the spouse (58%) or parent (22%) of the patient. The percentage of patients that would agree to participate in a research study and the percentage of surrogates that would agree to have the patient enrolled into a research study both declined as the risk of the study increased (p < .001 for both analyses). In addition, the overall discrepancy, the false-negative rates, and the false-positive rates between patient and surrogates were greater as the risk of the study increased (p < .001, p < .001, and p = .049, respectively). κ values for all seven scenarios demonstrated less-than-moderate agreement (range 0.03-0.41). CONCLUSIONS: There are significant discrepancies in the willingness to participate in various types of clinical research proposals between critically ill patients and their surrogate decision makers. The results of this study raise concerns about the use of surrogate consent for inclusion of critically ill patients into research protocols.