Updating the Military Unique Curriculum for a Ready Medical Force.

INTRODUCTION: Previous conflicts have demonstrated the impact of physician readiness on early battlefield mortality rates. To prepare for the lethal nature of today's threat environment and the rapid speed with which conflict develops, our medical force needs to sustain a high level of readiness in order to be ready to "fight tonight." Previous approaches that have relied on on-the-job training, just-in-time predeployment training, or follow-on courses after residency are unlikely to satisfy these readiness requirements. Sustaining the successes in battlefield care achieved in Iraq and Afghanistan requires the introduction of effective combat casualty care earlier and more often in physician training. This needs assessment seeks to better understand the requirements, challenges, and opportunities to include the Military Unique Curriculum (MUC) during graduate medical education. MATERIALS AND METHODS: This needs assessment used a multifaceted methodology. First, a literature review was performed to assess how Military Unique Curricula have evolved since their initial conception in 1988. Next, to determine their current state, a needs-based assessment survey was designed for trainees and program directors (PDs), each consisting of 18 questions with a mixture of multiple choice, ranking, Likert scale, and free-text questions. Cognitive interviewing and expert review were employed to refine the survey before distribution. The Housestaff Survey was administered using an online format and deployed to Internal Medicine trainees at the Walter Reed National Military Medical Center (WRNMMC). The Program Director Survey was sent to all Army and Navy Internal Medicine Program Directors. This project was deemed to not meet the definition of research in accordance with 32 Code of Federal Regulation 219.102 and Department of Defense Instruction 3216.02 and was therefore registered with the WRNMMC Quality Management Division. RESULTS: Out of 64 Walter Reed Internal Medicine trainees who received the survey, 32 responses were received. Seven of nine PDs completed their survey. Only 12.5% of trainees felt significantly confident that they would be adequately prepared for a combat deployment upon graduation from residency with the current curriculum. Similarly, only 14.29% of PDs felt that no additional training was needed. A majority of trainees were not satisfied with the amount of training being received on any MUC topic. When incorporating additional training on MUC topics, respondents largely agreed that simulation and small group exercises were the most effective modalities to employ, with greater than 50% of both trainees and PDs rating these as most or second most preferred among seven options. Additionally, there was a consensus that training should be integrated into the existing curriculum/rotations as much as possible. CONCLUSIONS: Current Military Unique Curricula do not meet the expected requirements of future battlefields. Several solutions to incorporate more robust military unique training without creating any significant additional time burdens for trainees do exist. Despite the limitation of these results being limited to a single institution, this needs assessment provides a starting point for improvement to help ensure that we limit the impact of any "peacetime effect."

Characterizing Methods for Surveying Partner Nation Medical Capabilities.

INTRODUCTION: Medical capability surveys provide information about how U.S. forces can coordinate with partner nations to leverage partners' capabilities to deliver care to sick or injured U.S. service members. Rotating forces routinely conduct these surveys. Currently, medical capability surveys are conducted based on individual unit requirements and personnel expertise and stored locally on component-specific sites or individual computers. The lack of a systematic approach and a centralized survey depot may undermine the ability to access previous surveys, leading to redundant surveys and conflicting information, and may have critical implications for force health protection. Partner nation facilities could have capabilities that may be leveraged to care for U.S. service members when U.S. medical care is unavailable. A lack of understanding of medical capabilities at partner nation facilities may undermine the ability to plan missions that mitigate risks. MATERIALS AND METHODS: This paper presents the results of 12 semi-structured focus groups with representatives from the U.S. Africa Command Surgeon's office, the U.S. Transportation Command Patient Movement Requirements Center-East, and 9 U.S. Africa Command service components, sub-unified commands, and force providers. The focus group discussions considered questions on the following four topics: (1) methods for conducting surveys, (2) guidance about how to conduct surveys, (3) nodes of care and ancillary services included in surveys, and (4) how medical capability surveys are used to inform medical planning. The team conducted thematic analysis to identify emergent themes and subthemes. RESULTS: The team identified five primary, overarching themes: (1) guidance for conducting medical capability surveys, (2) methods and tools for conducting surveys, (3) content and focus of medical capability surveys, (4) archiving and sharing surveys, and (5) uses of medical capability surveys. CONCLUSIONS: Implementing guidance and standardized templates for conducting medical capability surveys could improve the accuracy and completeness of surveys. Templates would likely increase the likelihood that surveyors collect relevant information on key medical capabilities. Training, along with guidance and templates, would provide a common understanding of how to conduct surveys. The lack of a DoD Global Health Engagement collaborative depot for storing and sharing surveys may undermine the ability to access previous surveys to inform future surveys and, thereby, results in inefficiencies in how surveys are conducted. The DoD should consider establishing a collaborative depot for medical capability surveys along with guidance or requirements for uploading surveys. Guidance, templates, training, and a collaborative depot could improve the effectiveness and efficiency of medical planning and thereby increase mission readiness.

Differences in Disease Non-battle Injury Between Combatant Commands.

INTRODUCTION: Disease and non-battle injury (DNBI) have historically been a major or primary medical burden in expeditionary military populations. The United States has multiple deployed populations conducting operations across the world. This study aims to determine if DNBI rates are different between military populations by comparing the United States Africa Command (USAFRICOM) and United States Central Command (USCENTCOM) areas of responsibility. MATERIALS AND METHODS: The study period was from January 1, 2017 to December 31, 2021. Individual evacuation data including date, necessary specialty care, and combatant command (CCMD) were acquired via United States Transportation Command Regulating and Command & Control Evacuation System. Total population data was acquired from USAFRICOM and USCENTCOM headquarters. Total inpatient and outpatient encounters at each CCMD were acquired via Theater Medical Data Store. The proportions and evacuation rates of DNBI types within USAFRICOM and USCENTCOM were compared. RESULTS: USCENTCOM had significantly higher proportions of outpatient and inpatient services for mental disorders, musculoskeletal diseases, and neurologic conditions compared to USAFRICOM. USCENTCOM had a significantly lower evacuation rate compared to USAFRICOM for every year analyzed: 2017 (P-value < .0001; relative risk [RR] = 0.834; 95% CI = 0.80-0.87), 2018 (P-value < .0001; RR = 0.818; 95% CI = 0.78-0.85), 2019 (P-value < .0001; RR = 0.785; 95% CI = 0.75-0.82), 2020 (P-value < .0001; RR = 0.889; 95% CI = 0.84-0.94), and 2021 (P-value < .0001; RR = 0.868; 95% CI = 0.83-0.91). CONCLUSIONS: The evacuation rates of different categories of DNBI vary between CCMDs. There will be CCMD-specific factors that impact the effectiveness of initiatives to reduce the DNBI burden.

An Analysis of Patient Movements during Sustained Combat Operations in the US Central Command: Implications for Remote Support Capabilities.

BACKGROUND: The US Central Command (CENTCOM) area of responsibility (AOR) spans 20 nations in the Middle East, Central, and South Asia. Evacuations outside this AOR include all injury types and severities; however, it remains unclear what proportion of evacuations were due to disease and non-battle injuries (DNBI). Understanding these patterns may be useful for defining future medical support requirements for multi domain operations (MDO). We sought to analyze encounters obtained from the Transportation Command Regulating and Command and Control Evacuation System (TRAC2ES) data for medical evacuations within CENTCOM. METHODS: We obtained all encounters within TRAC2ES from February 2009 to November 2018. We analyzed data using entered demographic data and keyword categorization of free text information provided by the medical officer requesting patient movement. RESULTS: There were 50,036 patient movement requests entered into TRAC2ES originating from the CENTCOM AOR for both military and civilian personnel. After removal of ineligible entries (for example, military working dogs), the number of eligible subjects was 49,259, 13 percent combat (n equals 6,389) and 87 percent were noncombat (n equals 42,870). The primary age group requiring evacuation was 18 through 29 (59 percent) and were mostly male (87 percent). Most went by routine status (80 percent), followed by priority (16 percent). Most of the transfers originated from Afghanistan (58 percent) and Iraq (22 percent), with Germany serving as the primary destination (79 percent). Results showed the total number of patient evacuations increased from 2009 to 2010 and then decreased from 2011 to 2017. The most frequent body region associated with the transfer was the extremities for both combat (54 percent) and noncombat (32 percent). CONCLUSIONS: Out of theater disease and non combat injury evacuation rates were nearly 7 times higher than for combat related injuries. Our results highlight the need for additional research and development resources of DNBI related medical care. As we move into future MDO with limited evacuation capabilities, we will need support solutions to cover the full gamut of DNBI.

Timeline of Psychological and Physiological Effects Occurring During Military Deployment on a Medical Team.

BACKGROUND: The negative effects of deployment on military mental health is a topic of major interest. Predeployment and postdeployment assessments are common, but to date there has been little to no intradeployment assessment of military members. This study attempts to determine the physiological and psychiatric effects on Servicemembers over the course of deployment, to provide a baseline data set and to allow for better prediction, prevention, and intervention on these negative effects. METHODS: A retrospective analysis was performed on physiological and psychiatric data collected on a single deployed medical team between 16 January 2020 and 12 July 2020. Patient health screening questionnaires (PHQ-9) and physiological measurements were completed serially twice weekly on five active-duty military volunteers for the entirety of a scheduled 6-month deployment. RESULTS: Depression symptom development followed a linear trend (p = .0149) and severity followed a quadratic trend (p < .001) over a length of a deployment. Weight (p = .435) and pulse (p = .416) were not statistically altered. Mean arterial pressure (MAP) had a statistically significant reduction (p < .001). CONCLUSION: In this specific population, there was a linear relationship between time deployed and depression symptoms and severity. Depression symptom severity decreases toward the end of deployment but does not return to baseline before deployment's end.

Best Medical Advice: Providing Medical Leadership in Uncertain Times.

Military physicians must often balance medical and operational priorities when providing advice to operational commanders. This case describes how a Navy Medical Corps Officer serving with a Marine Corps helicopter squadron during the initial stages of the COVID-19 pandemic helped manage risk.

Clinical utilization of deployed military surgeons.

BACKGROUND: Combat casualty care has been shaped by the prolonged conflicts in Southwest Asia, namely Afghanistan, Iraq, and Syria. The utilization of surgeons in austere locations outside of Southwest Asia and its implication on skill retention and value have not been examined. This study hypothesizes that surgeon utilization is low in the African theater. This lack of activity is potentially damaging to surgical skill retention and patient care. METHODS: Military case logs of surgeons deployed to Africa under command of Special Operations Command Africa between January 1, 2016, and January 1, 2020, were examined. Cases were organized based on population served, general type of procedure, current procedural terminology codes, and location. RESULTS: Twenty deployment caseloads representing 74% of the deployments during the period were analyzed. In 3,294 days, 101 operations were performed, which included 45 on combat/terrorism related injuries and 19 on US personnel. East and West African deployments, combat, and noncombat zones, respectively, were compared. East Africa averaged 4.1 ± 3.8 operations per deployment, and West Africa, 7.3 ± 8.0 (p = 0.2434). In East Africa, 56.1% of total operations were related to combat/terrorism, compared with 29.6% of total operations in West Africa (p = 0.0077). West Africa had a significantly higher proportion of elective (p = 0.0002) and humanitarian cases (p = <0.0001). CONCLUSION: Surgical cases for military surgeons were uncommon in Africa. The low volumes have implications for skill retention, morale, and sustainability of military surgical end strength. Reduction in deployment lengths, deployment location adjustments, and/or skill retention strategies are required to ensure clinical peak performance and operational readiness. Failure to implement changes to current practices to optimize surgeon experience will likely decrease surgical readiness and could contribute to decreased retention of deployable military surgeons to support global operations. LEVEL OF EVIDENCE: Economic/decision, level III.

Isolating Populations to Control Pandemic Spread in an Austere Military Environment.

BACKGROUND: The COVID-19 pandemic has been a struggle for medical systems throughout the world. In austere locations in which testing, resupply, and evacuation have been limited or impossible, unique challenges exist. This case series demonstrates the importance of population isolation in preventing disease from overwhelming medical assets. METHODS: This is a case series describing the outbreak of COVID-19 in an isolated population in Africa. The population consists of a main population with a Role 2 capability, with several supported satellite populations with a Role 1 capability. Outbreaks in five satellite population centers occurred over the course of the COVID-19 pandemic from its start on approximately 1 March 2020 until 28 April 2020, when a more robust medical asset became available at the central evacuation hub within the main population. RESULTS: Population movement controls and the use of telehealth prevented the spread within the main population at risk and enabled the setup of medical assets to prepare for anticipated widespread disease. CONCLUSION: Isolation of disease in the satellite populations and treating in place, rather than immediately moving to the larger population center's medical facilities, prevented widespread exposure. Isolation also protected critical patient transport capabilities for use for high-risk patients. In addition, this strategy provided time and resources to develop infrastructure to handle anticipated larger outbreaks.

The Development and Implementation of Specimens for Accident Forensic Toxicology Investigation Kit for Special Operations Forces.

INTRODUCTION: After a vehicle rollover led to the death of a military member in Central Africa in 2018, it became apparent there was a significant gap in the capability to collect toxicology samples of Service Members involved in accidents and mishaps at remote Special Operations Forces locations in Africa. Multiple misconceptions surrounding sample collection, procedures for laboratory evaluation, and methods for shipment signaled the importance of establishing a procedure and a plan to provide the necessary medical inventory to properly collect and ship samples. MATERIALS AND METHODS: The Special Operations Command Africa (SOCAFRICA) Surgeon's Office gathered the appropriate supplies for collection of forensic toxicology samples, and simultaneously developed a step-by-step checklist to safely and correctly perform urine and blood collection. The procedures were further improved after the completion of cognitive interviews with a Navy corpsman and Army Civil Affairs medic. Multiple shipping iterations occurred to ensure safe movement and arrival of samples at Armed Forces Medical Examiner System Dover AFB. Two Separate Specimens for Accident Forensic Toxicology Investigation Kits were generated to accommodate personnel typically associated with accidents involving vehicles and aircraft. RESULTS: SOCAFRICA's toxicology kit supports legal and medical chain of custody requirements for investigations, and provides deployed forces in Africa with a mechanism to collect and ship samples from Africa to Dover AFB. The kits are provided to ensure these samples are successfully analyzed, thereby removing any ambiguity surrounding an accident or mishap. CONCLUSION: SOCAFRICA established a prepared kit with all of the materials for sample collection, accompanied by step-by-step descriptions of the procedure, and clear guidance on the proper completion of the requisite paperwork that meets medico-legal requirements.

A Tiered Framework for Organizing and Categorizing Medical Interoperability.

Developing, cultivating, and sustaining medical interoperability strengthens the support we provide to the warfighter by presenting our Commanders options and efficiencies to the way we can enable their operations. As our national security and defense strategies change the way our forces are employed to address our security risks throughout the world, some military commands will find they cannot provide adequate medical care without working in concert with willing and available partners.This article proposes a tiered framework that allows medical personnel to further describe and organize their engagement activities around the concept and practicalities of medical interoperability. As resources become diverted to other theaters or missions expand beyond assigned capabilities, medical interoperability provides Commanders with options to medically enable their missions through their partnerships with others. This framework links and connects activities and engagements to build partner capacity with long-term or regional interoperability among our partners and challenges engagement planners to consider ways to build interoperability at all four tiers when planning or executing health engagements and global health development. Using this framework when planning or evaluating an engagement or training event will illuminate opportunities to develop interoperability that might have otherwise been unappreciated or missed.

Moving Beyond Accidental Leadership: A Graduate Medical Education Leadership Curriculum Needs Assessment.

BACKGROUND: Despite calls for greater physician leadership, few medical schools, and graduate medical education programs provide explicit training on the knowledge, skills, and attitudes necessary to be an effective physician leader. Rather, most leaders develop through what has been labeled "accidental leadership." A survey was conducted at Walter Reed to define the current status of leadership development and determine what learners and faculty perceived as key components of a leadership curriculum. METHODS: A branching survey was developed for residents and faculty to assess the perceived need for a graduate medical education leadership curriculum. The questionnaire was designed using survey best practices and established validity through subject matter expert reviews and cognitive interviewing. The survey instrument assessed the presence of a current leadership curriculum being conducted by each department, the perceived need for a leadership curriculum for physician leaders, the topics that needed to be included, and the format and timing of the curriculum. Administered using an online/web-based survey format, all 2,041 house staff and educators at Walter Reed were invited to participate in the survey. Descriptive statistics were conducted using SPSS (version 22). RESULTS: The survey response rate was 20.6% (421/2,041). Only 17% (63/266) of respondents stated that their program had a formal leadership curriculum. Trainees ranked their current leadership abilities as slightly better than moderately effective (3.22 on a 5-point effectiveness scale). Trainee and faculty availability were ranked as the most likely barrier to implementation. Topics considered significantly important (on a 5-point effectiveness scale) were conflict resolution (4.1), how to motivate a subordinate (4.0), and how to implement change (4.0). Respondents ranked the following strategies highest in perceived effectiveness on a 5-point scale (with 3 representing moderate effectiveness): leadership case studies (3.3) and small group exercises (3.2). Online power points were reported as only slightly effective (1.9). Free text comments suggest that incorporating current duties, a mentoring and coaching component, and project based would be valuable to the curriculum. DISCUSSION: Few training programs at Walter Reed have a dedicated leadership curriculum. The survey data provide important information for programs considering implementing a leadership development curriculum in terms of content and delivery.

Special Forces Medical Sergeants' perceptions and beliefs regarding their current medical sustainment program: implications for the field.

BACKGROUND: Special Forces Medical Sergeants (SFMS) are trained to provide trauma and medical care in support of military operations and diplomatic missions throughout the world with indirect physician oversight. This study assessed their perceptions of the current program designed to sustain their medical skills. METHODS: An Internet-based survey was developed using the constructs of the Theory of Reasoned Action/Planned Behavior and validated through survey best practices. RESULTS: Of the 334 respondents, 92.8% had deployed at least once as an SFMS. Respondents reported spending 4 hours per week sustaining their medical skills and were highly confident that they could perform their duties on a no-notice deployment. On a 5-point, Likert-type response scale, SFMS felt that only slight change is needed to the Special Operations Medical Skills Sustainment Course (mean: 2.17; standard deviation [SD]: 1.05), while moderate change is needed to the Medical Proficiency Training (mean: 2.82; SD: 1.21) and nontrauma modules (mean: 3.02; SD: 1.22). Respondents desire a medical sustainment program that is provided by subject matter experts, involves actual patient care, incorporates new technology, uses hands-on simulation, and is always available. CONCLUSIONS: SFMS are challenged to sustain their medical skills in the current operational environment, and barriers to medical training should be minimized to facilitate sustainment training. Changes to the current medical sustainment program should incorporate operator-level perspectives to ensure acceptability and utility but must be balanced with organizational realities. Improving the medical sustainment program will prepare SFMS for the challenges of future missions.

Firebase medicine: extending the Role I aid station.

The unique nature of counterinsurgency warfare in Afghanistan highlights the tactical and technical challenges of the non-contiguous battlefield. Although remote military outposts distant from their support hubs help project NATO power, they also operate without the advantages of a secure rear area or interior lines of communication. Commonly referred to as 'firebases', these outposts typically house a platoon or company-sized element and present numerous challenges to the delivery of medical care and support. Medical planners and providers can mitigate many of these inherent risks through targeted interventions designed to increase the capabilities of these remote outposts. These interventions include focused higher-level trauma and non-trauma medical training for both medical and non-medical personnel, expanded equipment lists, ongoing medical education, training and rehearsals, and a proven and redundant communications plan.

Presence and treatment of air hunger in severely ill patients.

Air hunger at end-of-life poses challenges to providers who attempt to comfort while not diminishing mental capacities. We examined the presence, methods of assessment, and treatment of air hunger. This observational study prospectively screened 198 consecutive medicine admissions for increased risk of near-term death. These patients in turn were screened for dyspnea. Patients screening positive were assessed on admission and the next day with the Visual Analog Scale (VAS), modified Borg Scale, and the American Thoracic Society (ATS) Shortness of Breath Scale. Additionally, resident physician opinions of patient dyspnea level were assessed using the same tools. Treatments focused on alleviating air hunger were recorded. Thirty-nine percent of patients were at risk for near-term death and of these, 53% (95% CI: 41-65%) reported air hunger. All dyspnea scales improved to a statistically and clinically significant degree (Borg p=0.007, VAS p<0.0005, ATS p=0.008). There was statistically significant agreement between Borg-VAS and between Borg-ATS with a trend toward significance with ATS-VAS. Physician assessment of dyspnea showed poor agreement with patients. A median of three treatments were received by patients but dyspnea improvement did not correlate with the type, number, or specific combination of therapies. Dyspnea is common near end-of-life. Borg or VAS scales appear useful in assessing terminal dyspnea and can be employed in assessing terminal air hunger. No individual treatment or combination of treatments significantly improved patients' dyspnea. However, air hunger significantly improved with hospitalization.