Implementing and preserving the advances in combat casualty care from Iraq and Afghanistan throughout the US Military:

Implementing Tourniquet Conversion Guidelines for Civilian EMS and Prehospital Organizations : A Case Report and Review

Since the first documented use of a tourniquet in 1674, the popularity of tourniquets has waxed and waned. During recent wars and more recently in Emergency Medical Services systems, the tourniquet has been proven to be a valuable tool in the treatment of life-threatening hemorrhage. However, tourniquet use is not without risk, and several studies have demonstrated adverse events and morbidity associated with tourniquet use in the prehospital setting, particularly when left in place for more than 2 h. Consequently, the US military's Committee on Tactical Combat Casualty Care has recommended guidelines for prehospital tourniquet conversion to reduce the risk of adverse events associated with tourniquets once the initial hemorrhage has been controlled. Emergency Medical Services systems that operate in rural, frontier, and austere environments, especially those with transport times to definitive care that routinely exceed 2 h, may consider implementing similar tourniquet conversion guidelines.

Microwave assisted preparation of a hemostatic gauze with mesoporous silica through in-situ synthesis

The medical disinfection cotton gauze is the most frequently used medical consumables for wound care. Here this ordinary commercial gauze was upgraded to a hemostatic gauze, which was loaded with mesoporous silica through in-situ synthesis and further microwave treatment. The original cotton gauze was pretreated with NaOH solutions for surface activation, soaked in double-silica source precursor solution for moderate in-situ synthesis, treated with microwave for quick template removement and dehydration. The final obtained hemostatic gauze (MS-G₁) showed superior physical, biocompatible and hemostatic advantages. The newborn mesoporous silica was firmly anchored onto the cotton fiber surface with <20% leaching after 10 min of sonication. The microwave treatment not only shortened the time for template removal but also promotes the formation of mesoporous structure. The clotting blood time (CBT) of MS-G₁ were only (62.00 ± 5.56 s), which was 23.14% shorter than that of original medical gauze, and even 3.6% shorter than Combat Gauze (CG). MS-G₁ also showed excellent biocompatibility in cytotoxicity tests of L-929 cells, with a 116% proliferation rate at the concentration of 5 mg/mL. Furthermore, the hemostatic performance was explored on a rabbit wound model of hemorrhagic liver injury, and MS-G₁ showed both shorter hemostasis time (113.75 s) and less blood loss (1.69 g) than that of CG (180.00 s, 5.13 g). The hemostatic gauze anchored with mesoporous silica was expected to be an excellent prehospital hemostatic dressing for field first aid.

General Perspective on the U.S. Military Conflicts in Iraq and Afghanistan After 20 Years

It has been 20 years since the September 11, 2001 terrorist attacks on America. The ongoing military conflicts in this region are the longest sustained conflicts in U.S. history. Almost 3 million military personnel have deployed, with over 7,000 fatalities and more than 53,000 wounded in action. The most common psychological health condition associated with combat deployments is PTSD. No data exist to compare the prevalence of PTSD across war eras. Therefore, a potential proxy for PTSD risk is the number of combat-related deaths, because this figure has been consistently tracked across U.S. military conflicts. This commentary includes a table of death statistics from major military conflicts, which shows that fewer military personnel have deployed, been killed, sustained wounds, and, one might conclude, suffered from PTSD than any other major U.S. military conflict in history. Advances in the military equipment, tactics, and healthcare programs perhaps mitigated casualties and suffering among Iraq/Afghanistan veterans compared to previous wars. The estimated causality differences across various military conflicts are not meant to minimize the significant contributions and sacrifices made by this new generation of military warriors but to help us gain perspective on military conflicts over the past century as we recognize the 20th anniversary of 9/11.

Multifunctional dopamine modification of green antibacterial hemostatic sponge

A novel hemostatic nanocomposite (OBC-PDA/PDA-MMT/Ag NPs) was prepared. As Functional hemostatic particles, hydrochloric acid modified montmorillonite coated with dopamine (PDA-MMT) doped into oxidized bacterial cellulose (OBC). In the presence of carboxyl and dopamine, silver ions (Ag⁺) were reduced into Ag nanoparticles (Ag NPs) distributed homogeneously on the matrix of PDA-MMT and OBC. Then, dopamine was grafted onto the oxidized bacterial cellulose under the crosslinking effect of 1-ethyl-3-(3-dimethylaminopropyl)-carbodiimide (EDC). After dopamine was grafted onto the oxidized bacterial cellulose, the interaction between PDA-MMT and the whole material was enhanced, and the flexibility was also improved. OBC-PDA/PDA-MMT/Ag NPs hemostatic sponge have appropriate mechanical strength, broad-spectrum antibacterial properties and excellent biodegradability. The hemostatic sponge with addition of PDA-MMT and Ag NPs is expected to provide functional properties such as rapid hemostasis, bacteriostasis and wound healing. In addition, the hemostatic effect of the compound was confirmed in vivo. The hemostatic sponge showed greater coagulation capacity, higher adherent red blood cells and platelets, and lower blood loss. The results show that hemostatic sponge is a rapid and effective coagulant with good antibacterial properties.

Potential Concussive Event Narratives of Post-9/11 Combat Veterans: Chronic Effects of Neurotrauma Consortium Study

INTRODUCTION

Deployment-related mild traumatic brain injury (mTBI) affects a significant proportion of those who served in Post-9/11 combat operations. The prevalence of head injuries, including those that lead to mTBI, is often reported quantitatively. However, service member (SM) and Veteran firsthand accounts of their potential concussive events (PCEs) and mTBIs can serve as a rich resource for better understanding the nuances and context of these exposures.

MATERIALS AND METHODS

Post-9/11 SMs and Veterans with a history of combat deployment were recruited through the Chronic Effects of Neurotrauma Consortium's observational study of deployment-related mTBI. During a comprehensive assessment, participants completed the Virginia Commonwealth University retrospective Concussion Diagnostic Interview, a specialized validated interview measure which obtains detailed narratives of deployment-incurred blast and non-blast-related PCEs. Qualitative thematic analysis was used to identify and code recurring themes within the narratives.

RESULTS

Among the sample of 106 SMs and Veterans, deployment-related mTBI was highly prevalent (67.0%). Over half (50.9%) of the participants identified a blast as the cause of their worst PCE, frequently with accompanying themes of self-reported acute neurological symptoms, intense physical blast forces, and tertiary head impact. Exposure to blast at close range, such as driving directly over an improvised explosive device, occurred in 24.7% of all blast-related narratives and in 59.3% of narratives where blast was identified as causing the worst PCE. Themes of potentially preventable head impacts experienced during noncombat circumstances were also frequent, accounting for 35% of all non-blast-related head injuries in the sample.

CONCLUSIONS

Prevalence of deployment-related close-range blast exposure, non-blast impact PCEs, and mTBIs among this Post-9/11 combatant sample was substantial, and in many cases potentially preventable. The use of detailed semi-structured interviews may help health care providers and policymakers to better understand the context and circumstances of deployment-related PCEs and mTBIs.

Preliminary Data on Trauma Knowledge, Confidence, and Stress During Navy Trauma Training

INTRODUCTION

The Navy Trauma Training Center (NTTC) is a military-civilian partnership that provides advanced trauma training for application across the range of military operations while exposing military medical personnel to high-volume and high-acuity trauma. Few published data evaluate the outcomes of military-civilian partnerships, including NTTC. The purpose of this study is to evaluate the knowledge, confidence, and stress of NTTC participants before, at mid-point, and after completion of the program. Participants include corpsmen (HM), nurses (RNs), physician assistants (PAs), and physicians (MDs).

MATERIALS AND METHODS

These are preliminary data from an ongoing prospective, observational study with repeated measures. Included are participants that complete NTTC training. Pre-training measures include a demographic questionnaire, trauma knowledge test, Confidence survey, and the Perceived Stress Scale. These same instruments are completed at mid-training and at the conclusion of the NTTC curriculum. Data were analyzed using paired t-tests and linear mixed models.

RESULTS

The sample was composed of 83 participants (49 HM, 18 RNs, 4 PAs, and 12 MDs. Knowledge and confidence increased from baseline to post-NTTC for each clinical role (P < .05). Stress for all roles was low and stable over time (P > .05).

CONCLUSIONS

These preliminary data suggest that, as expected, trauma-related knowledge and confidence increase significantly with training at NTTC. Stress was low and stable over time. These data from a small sample of participants indicate NTTC training is increasing participants' trauma knowledge and confidence to care for trauma casualties. Continued collection of data in the ongoing study will allow us to determine whether these early findings persist in the overall study sample and may help inform the optimal length of training needed.

Implementation and Evaluation of Tactical Combat Casualty Care for Army Aviators

INTRODUCTION

The importance of developing military strategies to decrease preventable death by mitigating hemorrhage and reducing time between the point of injury and surgical intervention on the battlefield is highlighted in previous studies. Successful implementation of Tactical Combat Casualty Care (TCCC) throughout elements of the USA and allied militaries begins to address this need. However, TCCC implementation is neither even nor complete in the larger, conventional force. Army Aviators are at risk for preventable death as they do not receive prehospital care training and are challenged to render prehospital care in the austere environment of helicopter operations. Army aviators are at risk for preventable death due to the challenges to render prehospital care in the austere environment of helicopter operations. Helicopters often fly at low altitudes, engage in direct action in support of ground troops, operate at a great distance from medical facilities, typically do not have medical personnel onboard, and can have long wait times for medical evacuation services due to the far forward nature of helicopter operations.

MATERIALS AND METHODS

This is a quality improvement pre-post-intervention design study evaluating the implementation of a combat casualty care training program for Army aviators using well-established evidence-based guidelines for providing care to casualties on the battlefield. The evaluation consisted of participants' self-perceived confidence in providing care to a casualty and change in knowledge level in combat casualty care in a pre/post-intervention design. Clinical skills of tourniquet application, nasopharyngeal airway placement, and needle chest decompression were assessed on a pass/fail grading standard.

RESULTS

A total of 18 participants completed the pre- and post-education surveys. A paired t-test showed a statistically significant increase in total composite scores from pre (M = 24.67, SD = 5.06) to post-education self-efficacy (M = 37.94, SD = 2.10), t (17) = -11.29, p < 0.001. A paired t-test revealed a significant increase in exam scores from pre (M = 70.22, SD = 9.43) to post (M = 87.78, SD = 7.19), t (17) = -7.31, p < 0.001. There was no pre-intervention skills assessment, however, all participants (n = 18, 100%) passed the tourniquet application, needle chest compression, and insertion of nasopharyngeal airway.

CONCLUSION

TCCC for Army Aviators is easily implemented, demonstrates an increase in knowledge and confidence in providing prehospital care, and provides effective scenario-based training of necessary psychomotor skills needed to reduce preventable death on the battlefield. TCCC for Army Aviators effectively takes the TCCC for All Combatants curriculum and modifies it to address the unique considerations in treating wounded aviators and passengers, both in flight and after crashes. This project demonstrates on a small scale how TCCC can be tailored to specific military jobs in order to successfully meet the intent of the upcoming All Service Member TCCC course mandated in DoD 1322.24. Beyond Army aviation, this program is easily modifiable for aviators throughout the military and civilian sector.

Progress on combat damage control resuscitation/surgery and its application in the Chinese People's Liberation Army

Damage control resuscitation (DCR) and damage control surgery (DCS) has now been developed as a well-established standard of care for severely injured civilian patients worldwide. On the other hand, the application of combat DCR/DCS has saved the lives of thousands of severely injured casualties in several wars during the last two decades. This article describes the great progress on DCR/DCS in the last two decades and its application in the Chinese People's Liberation Army (PLA). The main development of the advanced theories of combat DCR/DCS including the global integration of DCR/DCS, application of remote battlefield DCR, balanced hemostatic resuscitation in combat hospitals and enhancement of en route DCR. There are two key factors that determine the feasibility of combat DCR: one is the availability of resources and supplies to implement the advanced theories of combat DCR/DCS, the other is the availability of qualified personnel who master the skills needed for the implementation of DCR/DCS. In the PLA, the advanced theories of combat DCR/DCS have now been widely accepted, and some of related advanced products, such as fresh-frozen plasma, packed red blood cells, and platelets, have been available in Level III medical facilities. In conclusion, great progress in combat DCR/DCS has been achieved in recent years, and the Chinese PLA is keeping good pace with this development, although there is still room for improvement.

The effect of prehospital transport time, injury severity, and blood transfusion on survival of US military casualties in Iraq

BACKGROUND

Reducing time from injury to care can optimize trauma patient outcomes. A previous study of prehospital transport of US military casualties during the Afghanistan conflict demonstrated the importance of time and treatment capability for combat casualty survival.

METHODS

A retrospective descriptive analysis was conducted to analyze battlefield data collected on US military combat casualties during the Iraq conflict from March 19, 2003, to August 31, 2010. All casualties were analyzed by mortality outcome (killed in action, died of wounds, case fatality rate) and compared with Afghanistan conflict. Detailed data for those who underwent prehospital transport were analyzed for effects of transport time, injury severity, and blood transfusion on survival.

RESULTS

For the total population, percent killed in action (16.6% vs. 11.1%), percent died of wounds (5.9% vs. 4.3%), and case fatality rate (10.0 vs. 8.6) were higher for Iraq versus Afghanistan (p < 0.001). Among 1,692 casualties (mean New Injury Severity Score, 22.5; mortality, 17.6%) with detailed data, the injury mechanism included 77.7% from explosions and 22.1% from gunshot wounds. For prehospital transport, 67.6% of casualties were transported within 60 minutes, and 32.4% of casualties were transported in greater than 60 minutes. Although 97.0% of deaths occurred in critical casualties (New Injury Severity Score, 25-75), 52.7% of critical casualties survived. Critical casualties were transported more rapidly (p < 0.01) and more frequently within 60 minutes (p < 0.01) than other casualties. Critical casualties had lower mortality when blood was received (p < 0.01). Among critical casualties, blood transfusion was associated with survival irrespective of transport time within or greater than 60 minutes (p < 0.01).

CONCLUSION

Although data were limited, early blood transfusion was associated with battlefield survival in Iraq as it was in Afghanistan.

LEVEL OF EVIDENCE

Performance improvement and epidemiological, level IV.

Timely completion of multiple life-saving interventions for traumatic haemorrhagic shock: a retrospective cohort study

Background

Early control of haemorrhage and optimisation of physiology are guiding principles of resuscitation after injury. Improved outcomes have been previously associated with single, timely interventions. The aim of this study was to assess the association between multiple timely life-saving interventions (LSIs) and outcomes of traumatic haemorrhagic shock patients.

Methods

A retrospective cohort study was undertaken of injured patients with haemorrhagic shock who presented to Alfered Emergency & Trauma Centre between July 01, 2010 and July 31, 2014. LSIs studied included chest decompression, control of external haemorrhage, pelvic binder application, transfusion of red cells and coagulation products and surgical control of bleeding through angio-embolisation or operative intervention. The primary exposure variable was timely initiation of ≥ 50% of the indicated interventions. The association between the primary exposure variable and outcome of death at hospital discharge was adjusted for potential confounders using multivariable logistic regression analysis. The association between total pre-hospital times and pre-hospital care times (time from ambulance at scene to trauma centre), in-hospital mortality and timely initiation of ≥ 50% of the indicated interventions were assessed.

Results

Of the 168 patients, 54 (32.1%) patients had ≥ 50% of indicated LSI completed within the specified time period. Timely delivery of LSI was independently associated with improved survival to hospital discharge (adjusted odds ratio (OR) for in-hospital death 0.17; 95% confidence interval (CI) 0.03–0.83; p = 0.028). This association was independent of patient age, pre-hospital care time, injury severity score, initial serum lactate levels and coagulopathy. Among patients with pre-hospital time of ≥ 2 h, 2 (3.6%) received timely LSIs. Pre-hospital care times of ≥ 2 h were associated with delayed LSIs and with in-hospital death (unadjusted OR 4.3; 95% CI 1.4–13.0).

Conclusions

Timely completion of LSI when indicated was completed in a small proportion of patients and reflects previous research demonstrating delayed processes and errors even in advanced trauma systems. Timely delivery of a high proportion of LSIs was associated with improved outcomes among patients presenting with haemorrhagic shock after injury. Provision of LSIs in the pre-hospital phase of trauma care has the potential to improve outcomes.

From the battlefield to main street: Tourniquet acceptance, use, and translation from the military to civilian settings

Throughout history, battlefield medicine has led to advancements in civilian trauma care. In the most recent conflicts of Operation Enduring Freedom in Afghanistan/Operation Iraqi Freedom, one of the most important advances is increasing use of point-of-injury hemorrhage control with tourniquets. Tourniquets are gradually gaining acceptance in the civilian medical world-in both the prehospital setting and trauma centers. An analysis of Emergency Medical Services (EMS) data shows an increase of prehospital tourniquet utilization from 0 to nearly 4,000 between 2008 and 2016. Additionally, bystander educational campaigns such as the Stop the Bleed program is expanding, now with over 125,000 trained on tourniquet placement. Because the medical community and the population at large has broader acceptance and training on the use of tourniquets, there is greater potential for saving lives from preventable hemorrhagic deaths.

Specific stretchers enhance rapid extraction by tactical medical support teams in mass casualty incidents

OBJECTIVE

In mass casualty incidents where the threat is on-going, victim evacuation remains a challenge: fast extraction while respecting spinal immobilisation and haemorrhage control. Different devices can be used but their suitability has not been compared.

METHODS

We conducted a simulation study comparing eight extraction devices with a randomisation of the order of testing. Five teams, consisting of four officers, evacuated a single victim in five steps: device's deployment, loading the victim, carrying the victim along a corridor, negotiating a corner passage and a descent by staircase. Primary outcome was the emergency extraction time, from deployment to the first obstacle. Secondary outcomes included ease of transport and victim's stability, rated from 1 (worst) to 10 (best).

RESULTS

One hundred and sixty simulations were carried out. The median emergency extraction time was 16.7 [IQR: 11.6-24.9] seconds. The three speediest devices were the "firefighters' worn", "snogg" and "flexible tarp", taking 9.7 [8.1-11.0], 11.7 [10.9-15.4] and 12.2 [11.2-17.9] seconds respectively (p < 0.0001). Regarding the ease of transport, the three best-evaluated devices were the "firefighters' worn", "strap" and "flexible tarp" with 10 [9-10], 9 [8-9] and 8 [8-9] respectively (p < 0.0001). Considering stability reported by simulated victims, the three best-evaluated devices were the "inflated stretcher", "flexible tarp" and "firefighters' worn" with 8.0 [7.8-9.0], 8.0[7.0-8.0] and 6.5 [6.0-7.0] respectively.

CONCLUSION

Devices were not equivalent in terms of extraction time and suitability criteria. For rapid extraction of victims from danger zones, the "firefighter's worn" and "flexible tarp", as very simple stretchers, seem to be the most appropriate devices.

En Route Critical Care Transfer From a Role 2 to a Role 3 Medical Treatment Facility in Afghanistan

BACKGROUND

En route care is the transfer of patients requiring combat casualty care within the US military evacuation system. No reports have been published about en route care of patients during transfer from a forward surgical facility (role 2) to a combat support hospital (role 3) for comprehensive care.

OBJECTIVE

To describe patients transferred from a role 2 to a role 3 US military treatment facility in Afghanistan.

METHODS

A retrospective review of data from the Joint Trauma System Role 2 Database was conducted. Patient characteristics were described by en route care medical attendants.

RESULTS

More than one-fourth of patients were intubated at transfer (26.9%), although at transfer fewer than 10% of patients had a base deficit of more than 5 (3.5%), a pH of less than 7.3 (5.2%), an international normalized ratio of more than 2 (0.8%), or temporary abdominal or chest closure (7.4%). The en route care medical attendant was most often a nurse (35.5%), followed by technicians (14.1%) and physicians (10.0%). Most patients (75.3%) were transported by medical evacuation (on rotary-wing aircraft).

CONCLUSION

This is the first comprehensive review of patients transported from a forward surgical facility to a more robust combat support hospital in Afghanistan. Understanding the epidemiology of these patients will inform provider training and the appropriate skill mix for the transfer of postsurgical patients within a combat setting.

Bleeding Control With Limb Tourniquet Use in the Wilderness Setting: Review of Science

The purpose of this review is to summarize tourniquet science for possible translation to wilderness settings. Much combat casualty data has been studied since 2005, and use of tourniquets in the military has changed from a last resort to first aid. The US Government has made use of tourniquets a health policy aimed to improve public access to bleeding control items. International authorities believe that education in first aid should be universal, as all can and should learn first aid. The safety record of tourniquet use is mixed, but users are reliably safe if trained well. Well-designed tourniquets can reliably attain bleeding control, may mitigate risk of shock progression, and may improve survival rates, but conclusive proof of a survival benefit remains unclear in civilian settings. Even a war setting has a bias toward survivorship by sampling mostly survivors in hospitals. Improvised tourniquets are less reliable than well-designed tourniquets but may be better than none. The tourniquet model used most often in 2016 by the US military is the Combat Application Tourniquet (C-A-T), and civilians use an array of various models, including C-A-T. Evidence on tourniquet use to date indicates that most uses are safe and effective in civilian settings. Future directions for study relevant to the wilderness setting include consideration of research priorities, study of the burdens of injury or capability gaps in caregiving for various wilderness settings, determination of the skill needs of outdoor enthusiasts and wilderness caregivers, and survey of wilderness medicine stewards regarding bleeding control.

Leadership and a casualty response system for eliminating preventable death

Combat casualties who die from their injuries do so primarily in the prehospital setting. Although most of these deaths result from injuries that are nonsurvivable, some are potentially survivable. Of injuries that are potentially survivable, most are from hemorrhage. Thus, military organizations should direct efforts toward prehospital care, particularly through early hemorrhage control and remote damage control resuscitation, to eliminate preventable death on the battlefield. A systems-based approach and priority of effort for institutionalizing such care was developed and maintained by medical personnel and command-directed by nonmedical combatant leaders within the 75th Ranger Regiment, U.S. Army Special Operations Command. The objective of this article is to describe the key components of this prehospital casualty response system, emphasize the importance of leadership, underscore the synergy achieved through collaboration between medical and nonmedical leaders, and provide an example to other organizations and communities striving to achieve success in trauma as measured through improved casualty survival.

Ten Years of En Route Critical Care Training

OBJECTIVE

The French Military Health Service (FMHS) has developed a training program for medical evacuation (MEDEVAC) of critical care patients on fixed wing aircraft.

METHODS

We conducted a 10-year retrospective analysis (2006-2015) of the data from the FMHS Academy. The number of trainees was listed according to the different courses and medical specialties. The number of MEDEVACs recorded during the period was described.

RESULTS

Since 2006, the FMHS has developed training courses designed for MEDEVAC of critical care patients. Forty-five collective strategic MEDEVAC courses were delivered to 91 intensivists, 130 anesthetic nurses, 79 flight surgeons, 55 flight nurses, and 89 nurses. Five sessions of tactical MEDEVAC courses were performed for 14 flight surgeons, 6 flight nurses, and 17 other nurses. Ten sessions of individual strategic MEDEVAC courses were delivered to 17 intensivists, 10 flight surgeons, 21 flight nurses, and 7 other nurses. Between 2006 and 2015, 818 (± 68) individual strategic MEDEVACs were performed per year. Thirty-three (± 19) concerned critical care patients. Five missions of collective strategic MEDEVAC were performed for 56 patients.

CONCLUSION

The FMHS has developed specific courses for the MEDEVAC of critical care patients, allowing the training of numerous MEDEVAC teams.

The state of the union: Nationwide absence of uniform guidelines for the prehospital use of tourniquets to control extremity exsanguination

BACKGROUND

After the Sandy Hook shootings and the resulting Hartford Consensus, as well as the recent Boston Marathon bombing, the need for a uniform, detailed, and aggressive prehospital extremity exsanguination control protocol became clear. We hypothesized that most states within the United States lack a detailed uniform protocol.

METHODS

We performed a systematic nationwide assessment of emergency medical services (EMS) prehospital extremity exsanguination control protocols. An online search (updated February 7, 2015) identified state-, region-, or county-specific EMS protocols in all 50 states. If unavailable online, protocols were retrieved directly by contacting each state's Department of Public Health (or other appropriate agency). Two investigators independently screened each extremity exsanguination control protocol. Protocols were first grouped into three categories: I, tourniquet not mentioned; II, tourniquet mentioned, without specific guidance; III, tourniquet mentioned, with specific guidance related to type, indications, application technique, and safety concerns. Each protocol was then scored on a five-point scale for comparison.

RESULTS

Forty-two states (84%) had statewide and 14 (28%) had at least one county-specific protocol. Seven states (16%) had no statewide protocol but at least one county-specific protocol (range, 1-10). Mississippi had neither statewide nor county-specific protocols. Of statewide protocols, 4 (9.5%) were in Category I, 23 (54.8%) in Category II, and 15 (35.7%) in Category III. The mean score for statewide tourniquets was 2.4/5 (SD, 1.25; range, 0-5). Thirteen (31%) statewide protocols referred to "commercial" or "approved" tourniquets; only three (7%) recommended a particular commercial device. The mean score for the county-specific protocols of states with no statewide protocol was 3.10 (SD, 1.56; range, 0-5) CONCLUSIONS: Throughout the United States, there is considerable variability in EMS protocols addressing the management of extremity exsanguination and an alarming absence of specific guidance for tourniquet use. Most states do not have a uniform, detailed, and aggressive prehospital extremity exsanguination control protocol.

LEVEL OF EVIDENCE

Epidemiologic and prognostic study, level III.

A Serious Game for Massive Training and Assessment of French Soldiers Involved in Forward Combat Casualty Care (3D-SC1): Development and Deployment

BACKGROUND

The French Military Health Service has standardized its military prehospital care policy in a ''Sauvetage au Combat'' (SC) program (Forward Combat Casualty Care). A major part of the SC training program relies on simulations, which are challenging and costly when dealing with more than 80,000 soldiers. In 2014, the French Military Health Service decided to develop and deploy 3D-SC1, a serious game (SG) intended to train and assess soldiers managing the early steps of SC.

OBJECTIVES

The purpose of this paper is to describe the creation and production of 3D-SC1 and to present its deployment.

METHODS

A group of 10 experts and the Paris Descartes University Medical Simulation Department spin-off, Medusims, coproduced 3D-SC1. Medusims are virtual medical experiences using 3D real-time videogame technology (creation of an environment and avatars in different scenarios) designed for educational purposes (training and assessment) to simulate medical situations. These virtual situations have been created based on real cases and tested on mannequins by experts. Trainees are asked to manage specific situations according to best practices recommended by SC, and receive a score and a personalized feedback regarding their performance.

RESULTS

The scenario simulated in the SG is an attack on a patrol of 3 soldiers with an improvised explosive device explosion as a result of which one soldier dies, one soldier is slightly stunned, and the third soldier experiences a leg amputation and other injuries. This scenario was first tested with mannequins in military simulation centers, before being transformed into a virtual 3D real-time scenario using a multi-support, multi-operating system platform, Unity. Processes of gamification and scoring were applied, with 2 levels of difficulty. A personalized debriefing was integrated at the end of the simulations. The design and production of the SG took 9 months. The deployment, performed in 3 months, has reached 84 of 96 (88%) French Army units, with a total of 818 hours of connection in the first 3 months.

CONCLUSIONS

The development of 3D-SC1 involved a collaborative platform with interdisciplinary actors from the French Health Service, a university, and videogame industry. Training each French soldier with simulation exercises and mannequins is challenging and costly. Implementation of SGs into the training program could offer a unique opportunity at a lower cost to improve training and subsequently the real-time performance of soldiers when managing combat casualties; ideally, these should be combined with physical simulations.