Refocusing the Military Health System to Support Role 4 Definitive Care in future large-scale combat operations.

ABSTRACT: The last twenty years of sustained combat operations during the Global War on Terror generated significant advancements in combat casualty care. Improvements in point-of-injury, en route, and forward surgical care appropriately aligned with the survival, evacuation, and return to duty needs of the small-scale unconventional conflict. However, casualty numbers in large-scale combat operations have brought into focus the critical need for modernized casualty receiving and convalescence: Role 4 definitive care (R4DC). Historically, World War II was the most recent conflict in which the United States fought in multiple operational theaters, with hundreds of thousands of combat casualties returned to the continental United States. These numbers necessitated the establishment of a "Zone of the Interior" which integrated military and civilian healthcare networks for definitive treatment and rehabilitation of casualties. Current security threats demand refocusing and bolstering the Military Health System's definitive care capabilities to maximize its force regeneration capacity in a similar fashion. Medical force generation, medical force sustainment and readiness, and integrated casualty care capabilities are three pillars that must be developed for MHS readiness of Role 4 definitive care in future large-scale contingencies against near-peer/peer adversaries.

Clinical Readiness Program: Refocusing the Military Health System.

INTRODUCTION: The Military Health System serves to globally provide health services and trained medical forces. Military providers possess variable levels of deployment preparedness. The aim of the Clinical Readiness Program is to develop and assess the knowledge, skills, and abilities (KSAs) needed for combat casualty care. METHODS: The Clinical Readiness Program developed a KSA metric for general and orthopedic surgery. The KSA methodology underwent a proof of concept in six medical treatment facilities. RESULTS: The KSA metric feasibly quantifies the combat relevance of surgical practice. Orthopedic surgeons are more likely than general surgeons to meet the threshold. Medical treatment facilities do not provide enough demand for general surgery services to achieve readiness. CONCLUSION: The Clinical Readiness Program identifies imbalances between the health care delivery and readiness missions. To close the readiness gap, the Military Health System needs to recapture high KSA value procedures, expand access to care, and/or partner with civilian institutions.

Achieving Mastery of General Surgery Operative Skill in the Army Healthcare System.

INTRODUCTION: Operative case volumes for military surgeons are reported to be significantly lower than civilian counterparts. Among the concern that this raises is an inability of military surgeons to achieve mastery of their craft. MATERIAL AND METHODS: Annual surgical case reports were obtained from seven Army military treatment facilities (MTF) for 2012-2016. Operative case volume and cumulative operative time were calculated for active duty general surgeons and for individual MTFs. Subgroup analyses were also performed based upon rank. Results were extrapolated to calculate the amount of time it would take to reach a cumulative of 10,000 hours of operative time (the a priori definition for achieving mastery). RESULTS: One hundred and two active duty general surgeons operated at the seven MTFs during the study period and met the inclusion criteria. The average surgeon performed 108 ± 68 cases/year. The average surgeon operated 122 ± 82 hours/year. At this rate, it would take over 80 years to reach mastery of surgery. When stratified based upon rank, Majors averaged 113 ± 75 hours/year, Lieutenant Colonels averaged 170 ± 100 hours/year, and Colonels averaged 136 ± 101 hours/year (p < 0.05). When stratified based upon individual MTF, surgeons at the busiest facility averaged 187 ± 103 hours/year and those at the least busy facility averaged 85 ± 56 hours/year (p < 0.05). CONCLUSIONS: Obtaining mastery of general surgery is a nearly impossible proposition given the current care models at Army MTFs. Alternative staffing and patient care models should be developed if Army surgeons are to be masters at their craft.

Effects of hyperglycemia and continuous intravenous insulin on outcomes of surgical patients.

BACKGROUND: Hyperglycemia in critically ill patients has been associated with increased morbidity and mortality. It is unclear to what degree hyperglycemia should be regulated in a mixed surgical population. STUDY DESIGN: A retrospective chart review of 210 surgical patients in the intensive care unit (ICU) was performed. All patients were placed on an intravenous insulin protocol targeted to a blood glucose (BG) of 80-140 mg/dL. Outcomes were compared between surgical patients with controlled BG levels (80-140 mg/dL) versus uncontrolled levels (>140 mg/dL). RESULTS: The mortality rate of this population was 12%, 5% in the controlled BG group compared with 18% in the uncontrolled BG group (P < 0.01). After adjusting for covariates, the mortality rate of the uncontrolled blood glucose group was significantly greater (OR = 4.8, 95% CI 1.4-20; P = 0.02). The overall hypoglycemic rate was <1%, and was not associated with a higher mortality, P = 0.60. A greater mortality rate was associated with patients who spent a greater time with blood glucose values >181 mg/dL (OR = 1.3, 95% CI 1.1-1.6; P = 0.01). CONCLUSIONS: Increased mortality was associated with surgical patients in the uncontrolled blood glucose group compared with patients who were well controlled with insulin therapy. These results are comparable to previous studies and indicate that surgical patients are a population who may benefit from tighter glycemic control. Further investigations through prospective randomized studies are needed to fully evaluate the effects of hyperglycemia in a diverse surgical population as well as specific surgical subspecialties.

Effect of diabetes mellitus on outcomes of hyperglycemia in a mixed medical surgical intensive care unit.

BACKGROUND: Intensive insulin therapy and degree of glycemic control in critically ill patients remains controversial, particularly in patients with diabetes mellitus. We hypothesized that diabetic patients who achieved tight glucose control with continuous insulin therapy would have less morbidity and lower mortality than diabetic patients with uncontrolled blood glucose. METHOD: A retrospective chart review was performed on 395 intensive care unit (ICU) patients that included 235 diabetic patients. All patients received an intravenous insulin protocol targeted to a blood glucose (BG) level of 80-140 mg/dl. Outcomes were compared between (a) nondiabetic and diabetic patients, (b) diabetic patients with controlled BG levels (80-140 mg/dl) versus uncontrolled levels (>140 mg/dl), and (c) diabetic survivors and nonsurvivors. RESULTS: Diabetic patients had a shorter ICU stay compared to nondiabetic patients (10 ± 0.7 vs 13 ± 1.1, p = .01). The mean BG of the diabetic patients was 25% higher on average in the uncontrolled group than in the controlled (166 ± 26 vs 130 ± 9.4 mg/dl, p < .01). There was no difference in ICU and hospital length of stay (LOS) between diabetic patients who were well controlled compared to those who were uncontrolled. Diabetic nonsurvivors had a significantly higher incidence of hypoglycemia (BG <60 mg/dl) compared to diabetic survivors. CONCLUSION: The results showed that a diagnosis of diabetes was not an independent predictor of mortality, and that diabetic patients who were uncontrolled did not have worse outcomes. Diabetic nonsurvivors were associated with a greater amount of hypoglycemic episodes, suggesting these patients may benefit from a more lenient blood glucose protocol.

Effects of combination dobutamine and vasopressin therapy on microcirculatory blood flow in a porcine model of severe endotoxic shock.

BACKGROUND: Dobutamine (DB) has been recommended in combination with vasopressor therapy in septic shock, given its reported ability to improve mesenteric and microcirculatory perfusion. Vasopressin (VP) is typically reserved as a second-line agent due to the concern of ischemia. The purpose of our study was to determine whether combination DB and VP therapy improved microcirculatory blood flow in severe endotoxic shock. METHODS: Septic shock was induced in 20 anesthetized piglets with injection of E. coli endotoxin. DB (10 µg/kg/min, n = 5) and VP (0.04 units/min, n = 10) were administered alone and in combination (n = 15). Measurements were compared at baseline, following endotoxin administration, and following treatment. Microcirculatory blood flow was determined via the injection of colored microspheres. RESULTS: VP completely reversed endotoxin-mediated hypotension with a mean arterial pressure (MAP) of 85 ± 4.5 mm Hg, which was not significantly altered with the addition of DB (77 ± 4.9 mm Hg). Endotoxin uniformly depressed cardiac output (CO) from baseline (227 ± 10.7 versus 174 ± 12.4 mL/min/kg) despite treatment with VP alone or in combination with DB. The addition of DB did not improve the CO in this severe septic shock model. VP was found to shunt microcirculatory flow from the skin and GI tract to vital organs such as the brain, liver, and kidneys, which was not altered with the addition of DB. CONCLUSIONS: Results indicate that DB is ineffective in increasing CO or improving mesenteric blood flow when used with physiologic replacement doses of VP. In combination, DB is unable to overcome the blood flow distribution achieved with VP administration alone in severe endotoxic shock.

Thoracoscopic decortication for advanced pediatric empyema.

BACKGROUND: Although tube thoracostomy with fibrinolytic agents and video-assisted thoracoscopic (VATS) decortication are relatively equivalent in the treatment of empyema with regard to time to patient defervescence and hospital discharge, the potential for greater benefit with VATS decortication in the setting of advanced empyema has not been explored fully. This paper describes our transition from a policy of drainage and antibiotics to primary operative management with VATS. We wanted to assess the safety and efficacy of primary operative management as a first-line treatment for advanced disease. METHODS: A retrospective review was conducted of 25 patients treated for stage 3 or 4 empyema. The primary endpoints were morbidity and death. The secondary endpoints were conversion to an open procedure, time to defervescence, and length of hospital stay. RESULTS: The morbidity rate was 16% with no deaths. No patient required conversion to open decortication. The mean time to defervescence was 3.2 days, and on average, patients were discharged on postoperative day 9. Patients were discharged home earlier when managed primarily with VATS. CONCLUSIONS: Video-assisted thoracoscopic decortication is a safe and effective treatment for pediatric stage 3 or 4 empyema.

Burnout in medical students: examining the prevalence and associated factors.

OBJECTIVE: Burnout has been described as a syndrome of emotional exhaustion, depersonalization, and decreased personal accomplishment, and may originate during medical school. The objective of this study is to determine the prevalence of burnout and contributing factors in medical students. METHODS: A survey was administered to 249 medical students using a modified Maslach Burnout Inventory Human Services Survey (MBI-HSS) and scales of stressors, assessment of workload, relaxation, control, accomplishment, support systems, and demographics. RESULTS: Moderate or high degree of burnout was seen in 21% of the first year class, 41% of the second year class, 43% of the third year class, and 31% of the fourth year class (P < 0.05). Lower support, higher stress, and lack of control over one's life were significantly related to burnout using multivariate analysis. CONCLUSIONS: Burnout progressively develops over the course of medical education, while a high level of support and low stress decreased burnout.