Missing in action: A bibliometric analysis of military research in the medical literature since 1950.

BACKGROUND: Top-tier general and specialty scientific journals serve as a bellwether for national research priorities. We hypothesize that military-relevant publications are underrepresented in the scientific literature and that such publications decrease significantly during peacetime. METHODS: We identified high impact journals in the fields of Medicine, Surgery and Critical Care and developed Boolean searches for military-focused topics using National Library of Medicine Subject Headings terms. A PubMed search from 1950 to 2020 returned the number of research publications in relevant journals and the rate of military-focused publications by year. Rates of military publications were compared between peacetime and wartime. Publication rate trends were modeled with a quadratic function controlling for the start of active conflict and total casualty numbers. Baseline proportions of military physicians relative to the civilian sector served to estimate expected publication rates. Comparisons were performed using Pearson's Chi Square and Mann-Whitney U test, with p < 0.05 considered a significant difference. RESULTS: From 1950 to 2020, a total of 716,340 manuscripts were published in the journals queried. Of these, military-relevant manuscripts totaled 4,052 (0.57%). We found a significant difference in the rate of publication during times of peace and times of war (0.40% vs. 0.69%, p < 0.001). Subgroup analysis found significantly reduced rates of publication in medical and critical care journals during peacetime. For each conflict, the percentage of military-focused publications peaked during periods of war but then receded below baseline levels within a median of 2.5 years (interquartile range 1.5-3.8 years) during peacetime. The proportion of military-focused publications never reached the current proportion of military physicians in the workforce. CONCLUSION: There is marked reduction in rates of publication for military-focused articles in high impact journals during peacetime. Military-focused articles are underrepresented in high-impact journals. Investigators of military-relevant topics and editors of high-impact journals should seek to close this gap.

Evaluation of urological and gynecological surgeons as force multipliers for mass Casualty trauma care.

BACKGROUND: The clinical demands of mass casualty events strain even the most well-equipped trauma centers and are especially challenging in resource-limited rural, remote, or austere environments. Gynecologists and urologists care for patients with pelvic and abdominal injuries, but the extent to which they are able to serve as "force multipliers" for trauma care is unclear. This study examined the abilities of urologists and gynecologists to perform 32 trauma procedures after mentored training by expert trauma educators to inform the potential for these specialists to independently care for trauma patients. METHODS: Urological (6), gynecological surgeons (6), senior (PGY5) general surgery residents (6), and non-trauma trained general surgeons (8) completed a rigorous trauma training program (ASSET+). All participants were assessed in their trauma knowledge and surgical abilities performing 32 trauma procedures pre/post mentored training by expert trauma surgeons. Performance benchmarks were set for knowledge (80%) and independent, accurate completion of all procedural components within a realistic time window (90%). RESULTS: General surgery participants demonstrated greater trauma knowledge than gynecologists and urologists; however, none of the specialties reached the 80% benchmark. Pre-training, general surgery and urology participants outperformed gynecologists for overall procedural abilities. Post-training, only general surgeons met the 90% benchmark. Post-hoc analysis revealed no differences between the groups performing most pelvic and abdominal procedures, however knowledge associated with decision making and judgment in the provision of trauma care was significantly below the benchmark for gynecologists and urologists, even after training. CONCLUSION: For physiologically stable patients with traumatic injuries to the abdomen, pelvis or retroperitoneum, these specialists might be able to provide appropriate care; however, they would best benefit trauma patients in the capacity of highly skilled assisting surgeons to trauma specialists. These specialists should not be considered for solo resuscitative surgical care. LEVEL OF EVIDENCE: Therapeutic/Care Management, Level III/IV.

A 20-year retrospective analysis of deep venous thrombosis and pulmonary embolism among combat casualties requiring damage control laparotomy at US Military Role 2 surgical units.

BACKGROUND: Combat casualties receiving damage control laparotomy at forward deployed, resource-constrained US Military Role 2 surgical units (R2) require multiple evacuations, but the added risk of venous thromboembolism (VTE) in this population has not been defined. To fill this gap, we retrospectively analyzed 20 years of Department of Defense Trauma Registry (DoDTR) data to define the VTE rate in this population. METHODS: DoDTR from 2002 to 2023 was queried for US Military combat casualties requiring damage control laparotomy at R2. All deaths were excluded in subsequent analysis. Rates of VTE were assessed, and subgroup analysis was performed on patients requiring massive transfusion. RESULTS: DoDTR (n = 288) patients were young (mean age 25 years), predominantly male (98%) with severe (mean ISS 26), mostly penetrating injury (76%), and high mortality. VTE rate was high: 15.8% (DVT: 10.3% and PE 7.1%). In the massively transfused population, the VTE rate was even higher (26.7% vs 10.2%, p < 0.001). CONCLUSIONS: This is the first report that combat casualties requiring damage control laparotomy at R2 have such high VTE rates. Therefore, for military casualties, we propose screening ultrasound upon arrival to each subsequent capable echelon of care and low threshold for initiating thromboprophylaxis. LEVEL OF EVIDENCE: Prognostic and Epidemiological, Level IV.

The Key to Combat Readiness Is a Strong Military-Civilian Partnership.

INTRODUCTION: In peacetime, it is challenging for Army Forward Resuscitative Surgical Teams (FRST) to maintain combat readiness as trauma represents <0.5% of military hospital admissions and not all team members have daily clinical responsibilities. Military surgeon clinical experience has been described, but no data exist for other members of the FRST. We test the hypothesis that the clinical experience of non-physician FRST members varies between active duty (AD) and Army reservists (AR). METHODS: Over a 3-year period, all FRSTs were surveyed at one civilian center. RESULTS: Six hundred and thirteen FRST soldiers were provided surveys and 609 responded (99.3%), including 499 (81.9%) non-physicians and 110 (18.1%) physicians/physician assistants. The non-physician group included 69% male with an average age of 34 ± 11 years and consisted of 224 AR (45%) and 275 AD (55%). Rank ranged from Private to Colonel with officers accounting for 41%. For AD vs. AR, combat experience was similar: 50% vs. 52% had ≥1 combat deployment, 52% vs. 60% peri-deployment patient load was trauma-related, and 31% vs. 32% had ≥40 patient contacts during most recent deployment (all P > .15). However, medical experience differed for AD and AR: 18% vs. 29% had >15 years of experience in practice and 4% vs. 17% spent >50% of their time treating critically injured patients (all P < .001). These differences persisted across all specialties, including perioperative nurses, certified registered nurse anesthetists, operating room (OR) techs, critical-care nurses, emergency room (ER) nurses, licensed practical nurse (LPN), and combat medics. CONCLUSIONS: This is the first study of clinical practice patterns in AD vs. AR, non-physician members of Army FRSTs. In concordance with previous studies of military surgeons, FRST non-physicians seem to be lacking clinical experience as well. To maintain readiness and to provide optimal care for our injured warriors, the entire FRST, not just individuals, should embed within civilian centers.

Heart Rate Complexity in US Army Forward Surgical Teams During Pre Deployment Training.

INTRODUCTION: For trauma triage, the US Army has developed a portable heart rate complexity (HRC) monitor, which estimates cardiac autonomic input and the activity of the hypothalamic-pituitary-adrenal (HPA) axis. We hypothesize that autonomic/HPA stress associated with predeployment training in U.S. Army Forward Surgical Teams will cause changes in HRC. MATERIALS AND METHODS: A prospective observational study was conducted in 80 soldiers and 10 civilians at the U.S. Army Trauma Training Detachment. Heart rate (HR, b/min), cardiac output (CO, L/min), HR variability (HRV, ms), and HRC (Sample Entropy, unitless), were measured using a portable non-invasive hemodynamic monitor during postural changes, a mass casualty (MASCAL) situational training exercise (STX) using live tissue, a mock trauma (MT) STX using moulaged humans, and/or physical exercise. RESULTS: Baseline HR, CO, HRV, and HRC averaged 72 ± 11b/min, 5.6 ± 1.2 L/min, 48 ± 24 ms, and 1.9 ± 0.5 (unitless), respectively. Supine to sitting to standing caused minimal changes. Before the MASCAL or MT, HR and CO both increased to ~125% baseline, whereas HRV and HRC both decreased to ~75% baseline. Those values all changed an additional ~5% during the MASCAL, but an additional 10 to 30% during the MT. With physical exercise, HR and CO increased to >200% baseline, while HRV and HRC both decreased to 40 to 60% baseline; these changes were comparable to those caused by the MT. All the changes were P < 0.05. CONCLUSIONS: Various forms of HPA stress during Forward Surgical Team STXs can be objectively quantitated continuously in real time with a portable non-invasive monitor. Differences from resting baseline indicate stress anticipating an impending STX whereas differences between average and peak responses indicate the relative stress between STXs. Monitoring HRC could prove useful to field commanders to rapidly and objectively assess the readiness status of troops during STXs or repeated operational missions. In the future, health care systems and regulatory bodies will likely be held accountable for stress in their trainees and/or obliged to develop wellness options and standardize efforts to ameliorate burnout, so HRC metrics might have a role, as well.

Tactical Combat Casualty Care Training, Knowledge, and Utilization in the US Army.

INTRODUCTION: Tactical Combat Casualty Care (TCCC) is the execution of prehospital trauma skills in the combat environment. TCCC was recognized by the 2018 Department of Defense Instruction on Medical Readiness Training as a critical wartime task. This study examines the training, understanding, and utilization of TCCC principles and guidelines among US Army medical providers and examines provider confidence of medics in performing TCCC skills. MATERIALS AND METHODS: A cross-sectional survey, developed by members of the Committee on TCCC, was distributed to all US Army Physicians and Physician Assistants via anonymous electronic communication. RESULTS: A total of 613 completed surveys were included in the analyses. Logistic regression analyses were conducted on: TCCC test score of 80% or higher, confidence with medic utilization of TCCC, and medic utilization of ketamine in accordance with TCCC. CONCLUSIONS: <60% of respondents expressed confidence in the ability of the medics to perform all TCCC skills. Supervising providers who that believed 80 to 100% of their medics had completed TCCC training had more confidence in their medic's TCCC abilities. With TCCC, a recognized lifesaver on the battlefield, continued training and utilization of TCCC concepts are paramount for deploying personnel.

Exercise-Induced Changes in Compensatory Reserve and Heart Rate Complexity.

BACKGROUND: Portable noninvasive Heart Rate Complexity (HRC) and Compensatory Reserve Measurement (CRM) monitors have been developed to triage supine combat casualties. Neither monitor has been tested in upright individuals during physical exercise. This study tests the hypothesis that exercise evokes proportional changes in HRC and CRM.METHODS: Two instruments monitored volunteers (9 civilian and 11 soldiers) from the Army Trauma Training Department (ATTD) before, during, and following physical exercise. One recorded heart rate (HR, bpm), cardiac output (CO, L · min-1), heart rate variability (HRV, root mean square of successive differences, ms), and HRC (Sample Entropy, unitless). The other recorded HR, pulse oximetry (Spo2, %), and CRM (%).RESULTS: Baseline HR, CO, HRV, HRC, and CRM averaged 72 ± 1 bpm, 5.6 ± 1.2 L · min-1, 48 ± 24 ms, 1.9 ± 0.5, and 85 ± 10% in seated individuals. Exercise evoked peak HR and CO at > 200% of baseline, while HRC and CRM were simultaneously decreased to minimums that were ≤ 50% of baseline (all P < 0.001). HRV changes were variable and unreliable. Spo2 remained consistently above 95%. During a 60 min recovery, HR and CRM returned to baseline on parallel tracks (t1/2=11 ± 8 and 18 ± 14 min), whereas HRC recovery was slower than either CRM or HR (t1/2=40 ± 18 min, both P < 0.05).DISCUSSION: Exercise evoked qualitatively similar changes in CRM and HRC. CRM recovered incrementally faster than HRC, suggesting that vasodilation, muscle pump, and respiration compensate faster than cardiac autonomic control in young, healthy volunteers. Both HRC and CRM appear to provide reliable, objective, and noninvasive metrics of human performance in upright exercising individuals.Mulder MB, Eidelson SA, Buzzelli MD, Gross KR, Batchinsky AI, Convertino VA, Schulman CI, Namias N, Proctor KG. Exercise-induced changes in compensatory reserve and heart rate complexity. Aerosp Med Hum Perform. 2019; 90(12):1009-1015.

The First 30 Months Experience in the Non-Doctrinal Operation Inherent Resolve Medical Theater.

INTRODUCTION: U.S. military forces were redeployed in 2014 in support of Operation Inherent Resolve (OIR), operating in an austere theater without the benefit of an established medical system. We seek to describe the prehospital and hospital-based care delivered in this medically immature, non-doctrinal theater. MATERIALS AND METHODS: We queried the Department of Defense Trauma Registry (DODTR) for all encounters associated with OIR from August 2014 through June 2017. We sought all available prehospital and hospital-based data. RESULTS: There were a total of 826 adults that met inclusion; 816 were from Iraq and the remaining 10 were from Syria. The median age was 21 years and the most frequent mechanism of injury was explosives (47.7%). Median composite injury severity scores were low (9, IQR 2.75-14) and the most frequent seriously injured body region was the extremities (23.0%). Most subjects (94.9%) survived to hospital discharge. Open fractures were the most frequent major injury (26.0%). In the prehospital setting, opioids were the most frequently administered medication (9.3%) and warming blanket application (48.7%) and intravenous line placement (24.8%) were the most frequent interventions. In the emergency department, Focused Assessment with Sonography in Trauma exams (64.3%) was the most frequently performed study and endotracheal intubations were the most frequent (29.9%) procedure. In the operating room, the most frequently performed procedure was exploratory laparotomy (12.3%). CONCLUSIONS: Host nation military males injured by explosion comprised the majority of casualties. Open fracture was the most common major injury. Hence, future research should focus upon the unique challenges of delivering care to members of partner forces with particular focus upon interventions to optimize outcomes among patients sustaining open fractures.

A 12-Year Analysis of Nonbattle Injury Among US Service Members Deployed to Iraq and Afghanistan.

Importance: Nonbattle injury (NBI) among deployed US service members increases the burden on medical systems and results in high rates of attrition, affecting the available force. The possible causes and trends of NBI in the Iraq and Afghanistan wars have, to date, not been comprehensively described. Objectives: To describe NBI among service members deployed to Iraq and Afghanistan, quantify absolute numbers of NBIs and proportion of NBIs within the Department of Defense Trauma Registry, and document the characteristics of this injury category. Design, Setting, and Participants: In this retrospective cohort study, data from the Department of Defense Trauma Registry on 29 958 service members injured in Iraq and Afghanistan from January 1, 2003, through December 31, 2014, were obtained. Injury incidence, patterns, and severity were characterized by battle injury and NBI. Trends in NBI were modeled using time series analysis with autoregressive integrated moving average and the weighted moving average method. Statistical analysis was performed from January 1, 2003, to December 31, 2014. Main Outcomes and Measures: Primary outcomes were proportion of NBIs and the changes in NBI over time. Results: Among 29 958 casualties (battle injury and NBI) analyzed, 29 003 were in men and 955 were in women; the median age at injury was 24 years (interquartile range, 21-29 years). Nonbattle injury caused 34.1% of total casualties (n = 10 203) and 11.5% of all deaths (206 of 1788). Rates of NBI were higher among women than among men (63.2% [604 of 955] vs 33.1% [9599 of 29 003]; P < .001) and in Operation New Dawn (71.0% [298 of 420]) and Operation Iraqi Freedom (36.3% [6655 of 18 334]) compared with Operation Enduring Freedom (29.0% [3250 of 11 204]) (P < .001). A higher proportion of NBIs occurred in members of the Air Force (66.3% [539 of 810]) and Navy (48.3% [394 of 815]) than in members of the Army (34.7% [7680 of 22 154]) and Marine Corps (25.7% [1584 of 6169]) (P < .001). Leading mechanisms of NBI included falls (2178 [21.3%]), motor vehicle crashes (1921 [18.8%]), machinery or equipment accidents (1283 [12.6%]), blunt objects (1107 [10.8%]), gunshot wounds (728 [7.1%]), and sports (697 [6.8%]), causing predominantly blunt trauma (7080 [69.4%]). The trend in proportion of NBIs did not decrease over time, remaining at approximately 35% (by weighted moving average) after 2006 and approximately 39% by autoregressive integrated moving average. Assuming stable battlefield conditions, the autoregressive integrated moving average model estimated that the proportion of NBIs from 2015 to 2022 would be approximately 41.0% (95% CI, 37.8%-44.3%). Conclusions and Relevance: In this study, approximately one-third of injuries during the Iraq and Afghanistan wars resulted from NBI, and the proportion of NBIs was steady for 12 years. Understanding the possible causes of NBI during military operations may be useful to target protective measures and safety interventions, thereby conserving fighting strength on the battlefield.

Unrealized potential of the US military battlefield trauma system: DOW rate is higher in Iraq and Afghanistan than in Vietnam, but CFR and KIA rate are lower.

LEVEL OF EVIDENCE: Observational/retrospective/historic controls, level IV.

Military use of tranexamic acid in combat trauma: Does it matter?

BACKGROUND: Tranexamic acid (TXA) has been previously reported to have a mortality benefit in civilian and combat-related trauma, and was thus added to the Joint Theater Trauma System Damage Control Resuscitation Clinical Practice Guideline. As part of ongoing system-wide performance improvement, the use of TXA has been closely monitored. The goal was to evaluate the efficacy and safety of TXA use in military casualties and provide additional guidance for continued use. METHODS: A total of 3,773 casualties were included in this retrospective, observational study of data gathered from a trauma registry. The total sample, along with three subsamples for massive transfusion patients (n = 784), propensity-matched sample (n = 1,030), and US/North Atlantic Treaty Organization (NATO) military (n = 1,262), was assessed for administration of TXA and time from injury to administration of TXA. Outcomes included mortality and occurrence of pulmonary embolism and deep vein thrombosis. Multivariable proportional hazards regression models with robust standard error estimates were used to estimate hazard ratios (HR) for assessment of outcomes while controlling for covariates. RESULTS: Results of univariate and multivariate analyses of the total sample (HR, 0.97; 95% confidence interval [CI], 0.62-1.53; p = 0.86), massive transfusion sample (HR, 0.84; 95% CI, 0.46-1.56; p = 0.51), propensity-matched sample (HR, 0.68; 95% CI, 0.27-1.73; p = 0.34), and US/NATO military sample (HR, 0.76; 95% CI, 0.30-1.92; p = 0.48) indicate no statistically significant association between TXA use and mortality. Use of TXA was associated with increased risk of pulmonary embolism in the total sample (HR, 2.82; 95% CI, 2.08-3.81; p < 0.001), massive transfusion sample (HR, 3.64; 95% CI, 1.96-6.78; p = 0.003), US/NATO military sample (HR, 2.55; 95% CI, 1.73-3.69; p = 0.002), but not the propensity-matched sample (HR, 3.36; 95% CI, 0.80-14.10; p = 0.10). TXA was also associated with increased risk of deep vein thrombosis in the total sample (HR, 2.00; 95% CI, 1.21-3.30; p = 0.02) and US/NATO military sample (HR, 2.18; 95% CI, 1.20-3.96; p = 0.02). CONCLUSION: In the largest study on TXA use in a combat trauma population, TXA was not significantly associated with mortality, due to lack of statistical power. However, our HR estimates for mortality among patients who received TXA are consistent with previous findings from the CRASH-2 trial. At the same time, continued scrutiny and surveillance of TXA use in military trauma, specifically for prevention of thromboembolic events, is warranted. LEVEL OF EVIDENCE: Therapeutic, level IV.

Paying it forward: Four-year analysis of the Eastern Association for the Surgery of Trauma Mentoring Program.

BACKGROUND: Mentorship programs in surgery are used to overcome barriers to clinical and academic productivity, research success, and work-life balance. We sought to determine if the Eastern Association for the Surgery of Trauma (EAST) Mentoring Program has met its goals of fostering academic and personal growth in young acute care surgeons. METHODS: We conducted a systematic program evaluation of EAST Mentoring Program's first 4 years. Demographic information was collected from EAST records, mentorship program applications, and mentee-mentor career development plans. We reviewed the career development plans for thematic commonalities and results of a structured, online questionnaire distributed since program inception. A mixed methods approach was used to better understand the program goals from both mentee and mentor perspectives, as well as attitudes and barriers regarding the perceived success of this career development program. RESULTS: During 2012 to 2015, 65 mentoring dyads were paired and 60 completed the program. Of 184 surveys distributed, 108 were returned (57% response rate). Respondents were evenly distributed between mentees and mentors (53 vs. 55, p = 0.768). In participant surveys, mentoring relationships were viewed to focus on research (45%), "sticky situations" (e.g., communication, work-life balance) (27%), education (18%), or administrative issues (10%). Mentees were more focused on research and education versus mentors (74% vs. 50%; p = 0.040). Mentees felt that goals were "always" or "usually" met versus mentors (89% vs. 77%; p = 0.096). Two barriers to successful mentorship included time and communication, with most pairs communicating by email. Most respondents (91%) planned to continue the relationship beyond the EAST Mentoring Program and recommended the experience to colleagues. CONCLUSION: Mentee satisfaction with the EAST Mentoring Program was high. Mentoring is a beneficial tool to promote success among EAST's young members, but differences exist between mentee and mentor perceptions. Revising communication expectations and time commitment to improve career development may help our young acute care surgeons.

Army Air Ambulance Blood Product Program in the Combat Zone and Challenges to Best Practices.

BACKGROUND: Identify challenges and best practices in the development of an austere air ambulance transfusion program. METHODS: A search of PubMed using combinations of the key terms 'prehospital,' 'blood product,' 'red blood cells,' 'damage control resuscitation,' 'transfusion,' 'air ambulance,' 'medical evacuation,' and 'medevac' yielded 196 articles for further analysis, with 14 articles suitable for addressing the background of prehospital transfusion within a helicopter. Retrospective analysis of unclassified briefs, after action reports, and procedures was also undertaken along with interview of subject matter experts. The initial series of 15 transfusions were discussed telephonically among flight crew, trauma surgeons, and lab specialists. Review of Joint Theater System data was readily available for 84 U.S. Army air ambulance transfusions between May-December 2012, with December marking the redeployment of the 25(th) Combat Aviation Brigade. RESULTS: Standardized implementation enabled safe blood product administration for 84 causalities from May-December 2012 without blood product shortage, expiration, or transfusion reaction. Challenges included developing transfusion competency, achieving high quality blood support, countering the potential for anti-U.S. sentiment, and diversity in coalition transfusion practices. DISCUSSION: Blood product administration aboard the air ambulance is logistically complex, requiring blood bank integration. Repetitive training enabled emergency medical technicians (EMTs) with basic medical training to safely perform transfusion in accordance with clinical operating guidelines. In the austere environment, logistic factors are significant challenges and political sensitivities are important considerations. Best practices may facilitate new en route transfusion programs. Powell-Dunford N, Quesada JF, Gross KR, Shackelford SA. Army air ambulance blood product program in the combat zone and challenges to best practices. Aerosp Med Hum Perform. 2016; 87(8):728-734.

Analysis of injury patterns and roles of care in US and Israel militaries during recent conflicts: Two are better than one.

BACKGROUND: As new conflicts emerge and enemies evolve, military medical organizations worldwide must adopt the "lessons learned." In this study, we describe roles of care (ROCs) deployed and injuries sustained by both US and Israeli militaries during recent conflicts. The purpose of this collaborative work is facilitate exchange of medical data among allied forces in order to advance military medicine and facilitate strategic readiness for future military engagements that may involve less predictable situations of evacuation and care, such as prolonged field care. METHODS: This retrospective study was conducted for the periods of 2003 to 2014 from data retrieved from the Department of Defense Trauma Registry and the Israel Defense Force (IDF) Trauma Registry. Comparative analyses included ROC capabilities, casualties who died of wounds, as well as mechanism of injury, anatomical wound distribution, and Injury Severity Score of US and IDF casualties during recent conflicts. RESULTS: Although concept of ROCs was similar among militaries, the IDF supports increased capabilities at point of injury and Role 1 including the presence of physicians, but with limited deployment of other ROCs; conversely, the US maintains fewer capabilities at Role 1 but utilized the entire spectrum of care, including extensive deployment of Roles 2/2+, during recent conflicts. Casualties from US forces (n = 19,005) and IDF (n = 2,637) exhibited significant differences in patterns of injury with higher proportions of casualties who died of wounds in the US forces (4%) compared with the IDF (0.6%). CONCLUSIONS: As these data suggest deployed ROCs and injury patterns of US and Israeli militaries were both conflict and system specific. We envision that identification of discordant factors and common medical strategies of the two militaries will enable strategic readiness for future conflicts as well as foster further collaboration among allied forces with the overarching universal goal of eliminating preventable death on the battlefield.

Battlefield Documentation of Tactical Combat Casualty Care in Afghanistan.

Performance improvement is reliant on information and data, as you cannot improve what you do not measure. The US military went to war in 2001 without an integrated trauma care system to collect and analyze combat casualty care data. By 2006, the conflict in Afghanistan began appreciating the capture and consolidation of hospital care documentation into the Department of Defense Trauma Registry. In contrast, a paucity of documentation has existed for prehospital or tactical combat casualty care (TCCC). Using the 75th Ranger casualty documentation model established in 2005, the Joint Trauma System developed a casualty data collection system for prehospital care using the TCCC Card, the TCCC After Action Report (AAR), and the Prehospital Trauma Registry. In 2013, this system was mandated for use by US forces in Afghanistan. The Joint Trauma System also created and deployed a prehospital team to be an integral part of the Joint Theater Trauma System in Afghanistan. This prehospital team provided prehospital training and facilitated prehospital data capture. Described and analyzed in this report are prehospital data captured in Afghanistan from 2013 to 2014 using the TCCC Card and the TCCC AAR.

Evaluation of role 2 (R2) medical resources in the Afghanistan combat theater: Initial review of the joint trauma system R2 registry.

BACKGROUND: A Role 2 registry (R2R) was developed in 2008 by the US Joint Trauma System (JTS). The purpose of this project was to undertake a preliminary review of the R2R to understand combat trauma epidemiology and related interventions at these facilities to guide training and optimal use of forward surgical capability in the future. METHODS: A retrospective review of available JTS R2R records; the registry is a convenience sample entered voluntarily by members of the R2 units. Patients were classified according to basic demographics, affiliation, region where treatment was provided, mechanism of injury, type of injury, time and method of transport from point of injury (POI) to R2 facility, interventions at R2, and survival. Analysis included trauma patients aged ≥18 years or older wounded in year 2008 to 2014, and treated in Afghanistan. RESULTS: A total of 15,404 patients wounded and treated in R2 were included in the R2R from February 2008 to September 2014; 12,849 patients met inclusion criteria. The predominant patient affiliations included US Forces, 4,676 (36.4%); Afghan Forces, 4,549 (35.4%); and Afghan civilians, 2,178 (17.0%). Overall, battle injuries predominated (9,792 [76.2%]). Type of injury included penetrating, 7,665 (59.7%); blunt, 4,026 (31.3%); and other, 633 (4.9%). Primary mechanism of injury included explosion, 5,320 (41.4%); gunshot wounds, 3,082 (24.0%); and crash, 1,209 (9.4%). Of 12,849 patients who arrived at R2, 167 (1.3%) were dead; of 12,682 patients who were alive upon arrival, 342 (2.7%) died at R2. CONCLUSION: This evaluation of the R2R describes the patient profiles of and common injuries treated in a sample of R2 facilities in Afghanistan. Ongoing and detailed analysis of R2R information may provide evidence-based guidance to military planners and medical leaders to best prepare teams and allocate R2 resources in future operations. Given the limitations of the data set, conclusions must be interpreted in context of other available data and analyses, not in isolation. LEVEL OF EVIDENCE: Epidemiologic study, level IV.

The Military Injury Severity Score (mISS): A better predictor of combat mortality than Injury Severity Score (ISS).

BACKGROUND: The Military Injury Severity Score (mISS) was developed to better predict mortality in complex combat injuries but has yet to be validated. METHODS: US combat trauma data from Afghanistan and Iraq from January 1, 2003, to December 31, 2014, from the US Department of Defense Trauma Registry (DoDTR) were analyzed. Military ISS, a variation of the ISS, was calculated and compared with standard ISS scores.Receiver operating characteristic curve, area under the curve, and Hosmer-Lemeshow statistics were used to discriminate and calibrate between mISS and ISS. Wilcoxon-Mann-Whitney, t test and χ tests were used, and sensitivity and specificity calculated. Logistic regression was used to calculate the likelihood of mortality associated with levels of mISS and ISS overall. RESULTS: Thirty thousand three hundred sixty-four patients were analyzed. Most were male (96.8%). Median age was 24 years (interquartile range [IQR], 21-29 years). Battle injuries comprised 65.3%. Penetrating (39.5%) and blunt (54.2%) injury types and explosion (51%) and gunshot wound (15%) mechanisms predominated. Overall mortality was 6.0%.Median mISS and ISS were similar in survivors (5 [IQR, 2-10] vs. 5 [IQR, 2-10]) but different in nonsurvivors, 30 (IQR, 16-75) versus 24 (IQR, 9-23), respectively (p < 0.0001). Military ISS and ISS were discordant in 17.6% (n = 5,352), accounting for 56.2% (n = 1,016) of deaths. Among cases with discordant severity scores, the median difference between mISS and ISS was 9 (IQR, 7-16); range, 1 to 59. Military ISS and ISS shared 78% variability (R = 0.78).Area under the curve was higher in mISS than in ISS overall (0.82 vs. 0.79), for battle injury (0.79 vs. 0.76), non-battle injury (0.87 vs. 0.86), penetrating (0.81 vs. 0.77), blunt (0.77 vs. 0.75), explosion (0.81 vs. 0.78), and gunshot (0.79 vs. 0.73), all p < 0.0001. Higher mISS and ISS were associated with higher mortality. Compared with ISS, mISS had higher sensitivity (81.2 vs. 63.9) and slightly lower specificity (80.2 vs. 85.7). CONCLUSION: Military ISS predicts combat mortality better than does ISS. LEVEL OF EVIDENCE: Prognostic and epidemiologic study, level III.