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Aryankalayil J, Shields M, Baird M, Gunasingha RMKD, Pullen WM, Johnson M, Fitch J, Uber I, Worlton T. Evaluation of a Military Global Health Engagement Mission for Critical Wartime Surgical Specialty Readiness. Mil Med 2024:usae242. [PMID: 38758070 DOI: 10.1093/milmed/usae242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Revised: 03/29/2024] [Accepted: 04/23/2024] [Indexed: 05/18/2024] Open
Abstract
INTRODUCTION Surgical volume at Military Treatment Facilities (MTFs) has been gradually decreasing for roughly the past 2 decades. The Knowledge, Skills, and Abilities (KSA) Clinical Readiness Program linked surgical volume and readiness using a tool known as the KSA metric. However, the extent to which military medical missions contribute to the readiness of critical wartime specialties has not been evaluated using this metric. METHODS In this study, a retrospective analysis was conducted using the surgical case logs from the US Naval Ship (USNS) Comfort missions in 2018 and 2019. The comprehensive case log data were categorized by year, surgeon, procedure, and location. The analysis focused on providing detailed descriptive statistics, including percentages pertaining to the types of procedures performed during these missions. The 2018 mission was 11 weeks in duration, and supported activities in Ecuador, Peru, Colombia, and Honduras. The USNS Comfort mission in 2019 lasted 6 months (June-November 2019), and visited 12 countries in Central America, South America, and the Caribbean. RESULTS The 2019 mission case log, spanning 6 months, was evaluated using the KSA score in order to assess readiness and compare against 6 months of MTF KSA values within the same calendar year. In 2019, the orthopedic surgeon aboard the USNS Comfort had a total KSA score of 44,006, but the 6-month USNS Comfort mission only contributed 5,364 points (12% of the annual score). The general surgery practice aboard the USNS Comfort produced lower KSA scores compared to each surgeon's respective MTF practice (Table III). Analyzing the cases logged by general surgeons also highlights minimal surgical diversity during these missions, with more than 90% of cases being hernia repairs or laparoscopic cholecystectomies (Table I). In addition, 35% of total procedures performed in 2018 and 2019 were performed laparoscopically. CONCLUSIONS The analysis of operative data from the 2019 USNS Comfort mission, in comparison with the surgeons' work at their respective MTFs, reveals limited benefit in the ability of hospital-ship missions to bolster surgical readiness as measured by the KSA score. However, this is not a reflection on the value of Global Health Engagement (GHE) itself but a review of the way in which it is leveraged to support surgical readiness. Military surgeons participate in GHE as part of a larger strategy to strengthen relationships with partner nations, improve military medical force interoperability, and bolster partner nation medical capacity and capabilities. The KSA score offers an excellent tool to compare readiness metrics across significantly different GHE missions, and facilitates the opportunity for future prospective studies to improve case volume, diversity, and ultimately readiness.
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Affiliation(s)
- Joseph Aryankalayil
- General Surgery Department, Walter Reed National Military Medical Center, Bethesda, MD 20889, USA
- Department of Surgery, Uniformed Services University, Bethesda, MD 20889, USA
| | - Margaret Shields
- Department of Surgery, Uniformed Services University, Bethesda, MD 20889, USA
| | - Michael Baird
- Department of Surgery, Uniformed Services University, Bethesda, MD 20889, USA
- Orthopedic Surgery Department, Walter Reed National Military Medical Center, Bethesda, MD 20889, USA
| | | | - W Michael Pullen
- Orthopedic Surgery Department, Medical University of South Carolina, Charleston, SC 29425, USA
| | - Mark Johnson
- Fleet Surgical Team Four, Portsmouth, VA 23708, USA
| | - Jamie Fitch
- General Surgery Department, Naval Medical Center Camp Lejeune, Jacksonville, NC 28542, USA
| | - Ian Uber
- Eyes, Ear, Nose, and Throat Department, Naval Medicine Readiness and Training Command, Portsmouth, VA 28542, USA
| | - Tamara Worlton
- General Surgery Department, Walter Reed National Military Medical Center, Bethesda, MD 20889, USA
- Department of Surgery, Uniformed Services University, Bethesda, MD 20889, USA
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Pfister G, Aries P, de Lesquen H, Mathieu L. Nine years of surgical activity in the deployed French military role 2 medical treatment facility in Mali. BMJ Mil Health 2023:e002553. [PMID: 37879647 DOI: 10.1136/military-2023-002553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Accepted: 10/03/2023] [Indexed: 10/27/2023]
Abstract
INTRODUCTION In January 2013, France launched a military operation in Mali, which ended in August 2022. This study aimed to analyse the global activity performed by a surgical team within the role 2 medical treatment facility (MTF) deployed in Gao during this period, in order to adapt medical battlefield support and combat casualty care teaching. METHODS A retrospective study was conducted using the French surgical database OpEX (French Military Health Service) from January 2013 to August 2022. All patients operated on were included. RESULTS During this period, 1298 patients with a median age of 29 (range: 23-38) years were included. Among them, 229 (17.6%) underwent a combat-related trauma surgery (CRTS), 234 (18.0%) underwent a non-CRTS, 167 (12.9%) underwent a non-trauma-related surgery and 668 (51.5%) underwent a scheduled surgery in the context of medical supply to the population.Among the CRTS group, 195 (85.2%) patients underwent an orthopaedic procedure, 73 (31.8%) required a general surgery. Finally, 15 (6.6%) wounded required a specialised surgery. CONCLUSIONS In line with the activity described in the role 2 MTF deployed in other contemporary asymmetric conflicts, this activity is moderate, especially if only combat-related injuries are considered; medical support to the population occupied most of the surgical activity. For CRTS, most of the traumas are limb traumas. Other traumas are composed of various lesions, which are often life-threatening. This fact imposes the presence of an orthopaedic surgeon with the appropriate equipment, as well as a general surgeon with a wide range of skills, in asymmetric conflicts.
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Affiliation(s)
- Georges Pfister
- Department of Orthopaedic, Trauma and Reconstrucive Surgery, HIA Percy, Clamart, France
| | - P Aries
- Department of Anesthesia and Surgical Intensive Care, HIA Clermont-Tonnerre, Brest, Bretagne, France
| | - H de Lesquen
- Thoracic and Vascular Surgery, HIA Sainte Anne, Toulon, France
| | - L Mathieu
- Department of Orthopaedic, Trauma and Reconstrucive Surgery, HIA Percy, Clamart, France
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Ruggero JM, Farnand AW, Roach PB, Starr F, Tadlock MD, Bokhari F. Initial Assessment of a Regional Military-Civilian Partnership on Trauma Surgery Skills Sustainment. Mil Med 2023; 188:e2462-e2466. [PMID: 35880592 DOI: 10.1093/milmed/usac229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 07/01/2022] [Accepted: 07/21/2022] [Indexed: 11/12/2022] Open
Abstract
INTRODUCTION Trauma surgery skills sustainment and maintenance of combat readiness present a major problem for military general surgeons. The Military Health System (MHS) utilizes the knowledge, skills, and abilities (KSA) threshold score of 14,000 as a measure of annual deployment readiness. Only 9% of military surgeons meet this threshold. Most military-civilian partnerships (MCPs) utilize just-in-time training models before deployment rather than clinical experiences in trauma at regular intervals (skills sustainment model). Our aim is to evaluate an established skills sustainment MCP utilizing KSAs and established military metrics. MATERIALS AND METHODS Three U.S. Navy active duty general surgeons were embedded into an urban level-1 trauma center taking supervised trauma call at regular intervals prior to deployment. Operative density (procedures/call), KSA scores, trauma resuscitation exposure, and combat casualty care relevant cases (CCC-RCs) were reviewed. RESULTS During call shifts with a Navy surgeon present an average 16.4 trauma activations occurred; 32.1% were category-1, 27.6% were penetrating, 72.4% were blunt, and 33.8% were admitted to the intensive care unit. Over 24 call shifts of 24 hours in length, 3 surgeons performed 39 operative trauma cases (operative density of 1.625), generating 11,683 total KSA points. Surgeons 1, 2, and 3 generated 5109, 3167, and 3407 KSA points, respectively. The three surgeons produced a total of 11,683 KSA points, yielding an average of 3,894 KSA points/surgeon. In total, 64.1% of operations fulfilled CCC-RC criteria. CONCLUSIONS Based on this initial evaluation, a military surgeon taking two calls/month over 12 months through our regional skills sustainment MCP can generate more than 80% of the KSA points required to meet the MHS KSA threshold for deployment readiness, with the majority being CCC-RCs. Intangible advantages of this model include exposure to multiple trauma resuscitations while possibly eliminating just-in-time training and decreasing pre-deployment requirements.
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Affiliation(s)
- John M Ruggero
- Department of Trauma, Cook County Health, Chicago, IL 60612, USA
- Navy Medicine Readiness and Training Command Great Lakes, North Chicago, IL 60064, USA
| | - Alex W Farnand
- Navy Medicine Readiness and Training Command Great Lakes, North Chicago, IL 60064, USA
| | - Paul B Roach
- Navy Medicine Readiness and Training Command Great Lakes, North Chicago, IL 60064, USA
| | - Frederic Starr
- Department of Trauma, Cook County Health, Chicago, IL 60612, USA
| | - Matthew D Tadlock
- 1st Medical Battalion, 1st Marine Logistics Group, Camp Pendleton, CA 92055, USA
| | - Faran Bokhari
- Department of Trauma, Cook County Health, Chicago, IL 60612, USA
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Vasquez M, Edson TD, Lucas DJ, Hall AB, Tadlock MD. The Impact of the Maritime Deployment Cycle on the Surgeon's Knowledge, Skills, and Abilities. Mil Med 2023; 188:e1382-e1388. [PMID: 36260423 DOI: 10.1093/milmed/usac316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 08/30/2022] [Accepted: 09/30/2022] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION The U.S. Navy routinely deploys aircraft carriers and amphibious assault ships throughout the world in support of U.S. strategic interests, each with an embarked single surgeon team. Surgeons and their teams are required to participate in lengthy pre-deployment shipboard certifications before each deployment. Given the well-established relationship of surgeon volume to patient outcome, we aim to compare the impact of land vs. maritime deployments on Navy general surgeon practice patterns. MATERIALS AND METHODS Case logs and pre-deployment training initiation of land-based (n = 8) vs. maritime-based (n = 7) U.S. Navy general surgeons over a 3-year period (2017-2020) were compared. Average cases per week were plotted over 26 weeks before deployment. Student's t-test was utilized for all comparisons. RESULTS Cases declined for both groups in the weeks before deployment. At 6 months (26 weeks) before deployment, land-based surgeons performed significantly more cases than their maritime colleagues (50.3 vs. 14.0, P = .009). This difference persisted at 16 weeks (13.1 vs. 1.9, P = .011) and 12 weeks (13.1 vs. 1.9, P = .011). Overall, surgeon operative volume fell off earlier for maritime surgeons (16 weeks) than land-based surgeons (8 weeks). Within 8 weeks of deployment, both groups performed a similarly low number of cases as they completed final deployment preparations. CONCLUSIONS Surgeons are a critical component of combat causality care teams. In this analysis, we have demonstrated that both land- and maritime-based U.S. Navy surgeons have prolonged periods away from clinical care before and during deployments; for shipboard surgeons, this deficit is large and may negatively impact patient outcomes in the deployed maritime environment. The authors describe this discrepancy and provide practical doctrinal solutions to close this readiness gap.
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Affiliation(s)
- Matthew Vasquez
- 1st Medical Battalion, 1st Marine Logistics Group, Camp Pendleton, CA 92058, USA
- Department of Surgery, Navy Medicine Readiness and Training Command, San Diego, CA 92134, USA
| | - Theodore D Edson
- 1st Medical Battalion, 1st Marine Logistics Group, Camp Pendleton, CA 92058, USA
| | - Donald J Lucas
- Department of Surgery, Navy Medicine Readiness and Training Command, San Diego, CA 92134, USA
| | - Andrew B Hall
- Department of Surgery, Navy Medicine Readiness and Training Command, CENTCOM, CA 33621, USA
| | - Matthew D Tadlock
- 1st Medical Battalion, 1st Marine Logistics Group, Camp Pendleton, CA 92058, USA
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Beck EC, Rider D, Nadig N, Moreland C, Rushford P, Wolfley C, Brown S, Shaw KA, Waterman BR. Senior Military Rank Is Associated With Higher Rates of Return to Running and Unrestricted Activity Among Military Servicemembers After Surgical Repair of Patellar Tendon Rupture at 1-Year Follow-up. Arthrosc Sports Med Rehabil 2022; 4:e2019-e2024. [PMID: 36579040 PMCID: PMC9791865 DOI: 10.1016/j.asmr.2022.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Accepted: 09/02/2022] [Indexed: 11/09/2022] Open
Abstract
Purpose To evaluate 1-year outcomes in active-duty servicemembers who underwent patellar tendon rupture repair and to identify baseline variables associated with return to activity. Methods We performed a retrospective review of all active-duty servicemembers undergoing primary patellar tendon rupture repair between 2009 and 2014. All patients had a minimum 12-month follow-up. Demographic variables were recorded, as well as ability to return to impact activities and remain on active-duty status. Rates of recurrent rupture and revision surgery were identified. Univariate analysis was performed to assess relations between outcomes and baseline variables. Results A total of 123 patients met the inclusion criteria (average age, 33.5 ± 6.6 years; 99% male patients) with a mean follow-up period of 4.3 ± 2.2 years. Whereas 67.4% of patients returned to running at an average of 8.3 months from index surgery, only 42.4% of patients resumed unrestricted occupational function. Higher rates of return to running were observed among patients with senior military rank (P = .046). Senior military rank was also associated with a higher rate of return to unrestricted active-duty status (P = .006). Logistic regression analysis showed an association between postoperative pain (odds ratio [OR], 0.684; 95% confidence interval [CI], 0.56-0.84; P < .001) and return to running, between postoperative pain (OR, 0.77; 95% CI, 0.60-0.98; P = .033) and return to active duty, and between rank (OR, 2.06; 95% CI, 1.04-4.07; P = .037) and return to active duty. Patients who sustained injuries during deployment had a higher rate of recurrent rupture (26.1% vs 9.3%, P = .028). Conclusions At 1-year follow-up, approximately two-thirds of military servicemembers undergoing primary patellar tendon repair had returned to running after surgery, whereas fewer than one-half returned to full military duty. Younger age and more senior military rank were associated with higher rates of return to running. Additionally, servicemembers of higher rank, particularly officers, had statistically higher rates of return to unrestricted activity. Level of Evidence Level IV, therapeutic case series.
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Affiliation(s)
- Edward C. Beck
- Department of Orthopaedic Surgery, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina, USA,Address correspondence to Edward C. Beck, M.D., M.P.H., Department of Orthopaedic Surgery, Wake Forest Baptist Health, 1 Medical Center Blvd, Winston-Salem, NC 27157, USA.
| | - Danielle Rider
- Department of Orthopaedic Surgery, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina, USA
| | - Nischal Nadig
- Department of Orthopaedic Surgery, Dwight D. Eisenhower Army Medical Center, Fort Gordon, Georgia, USA
| | - Colleen Moreland
- Department of Orthopaedics & Rehabilitation, Womack Army Medical Center, Fort Bragg, North Carolina, USA
| | - Patrick Rushford
- Department of Orthopaedic Surgery, Dwight D. Eisenhower Army Medical Center, Fort Gordon, Georgia, USA
| | - Cortney Wolfley
- Department of Orthopaedic Surgery, Dwight D. Eisenhower Army Medical Center, Fort Gordon, Georgia, USA
| | - Scott Brown
- Department of Orthopaedic Surgery, Dwight D. Eisenhower Army Medical Center, Fort Gordon, Georgia, USA
| | - K. Aaron Shaw
- Department of Orthopaedic Surgery, Dwight D. Eisenhower Army Medical Center, Fort Gordon, Georgia, USA
| | - Brian R. Waterman
- Department of Orthopaedic Surgery, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina, USA
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Lee JJ, Hall AB, Carr MJ, MacDonald AG, Edson TD, Tadlock MD. Integrated military and civilian partnerships are necessary for effective trauma-related training and skills sustainment during the inter-war period. J Trauma Acute Care Surg 2022; 92:e57-e76. [PMID: 34797811 DOI: 10.1097/ta.0000000000003477] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Joseph J Lee
- From the Department of Surgery (J.J.L., M.J.C., M.D.T.), Navy Medicine Readiness & Training Command, San Diego, California; 96th Medical Group (A.B.H.), US Air Force Regional Hospital, Eglin AFB, Florida; Uniformed Services University of the Health Sciences (A.G.M.), Bethesda, Maryland; and 1st Medical Battalion (T.D.E.), 1st Marine Logistics Group, Camp Pendleton, California
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Dalton MK, Remick KN, Mathias M, Trinh QD, Cooper Z, Elster EA, Weissman JS. Analysis of Surgical Volume in Military Medical Treatment Facilities and Clinical Combat Readiness of US Military Surgeons. JAMA Surg 2021; 157:43-50. [PMID: 34705038 DOI: 10.1001/jamasurg.2021.5331] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Low surgical volume in the US Military Health System (MHS) has been identified as a challenge to military surgeon readiness. The Uniformed Services University of Health Sciences, in partnership with the American College of Surgeons, developed the Knowledge, Skills, and Abilities (KSA) Clinical Readiness Program that includes a tool for quantifying the clinical readiness value of surgeon workload, known as the KSA metric. Objective To describe changes in US military general surgeon procedural volume and readiness using the KSA metric. Design, Setting, and Participants This cohort study analyzed general surgery workload performed across the MHS, including military and civilian facilities, between fiscal year 2015 and 2019 and the calculated KSA metric value. The surgeon-level readiness among military general surgeons was calculated based on the KSA metric readiness threshold. Data were obtained from TRICARE, the US Department of Defense health insurance product. Main Outcomes and Measures The main outcomes were general surgery procedural volumes and the KSA metric point value of those procedures across the MHS as well as the number of military general surgeons meeting the KSA metric readiness threshold. Aggregate facility and regional market-level claims data were used to calculate the procedural volumes and KSA metric readiness value of those procedures. Annual adjusted KSA metric points earned were used to determine the number of individual US military general surgeons meeting the readiness threshold. Results The number of general surgery procedures generating KSAs in military hospitals decreased 25.6%, from 128 377 in 2015 to 95 461 in 2019, with a 19.1% decrease in the number of general surgeon KSA points (from 7 155 563 to 5 790 001). From 2015 to 2019, there was a 3.2% increase in both the number of procedures (from 419 980 to 433 495) and KSA points (from 21 071 033 to 21 748 984) in civilian care settings. The proportion of military general surgeons meeting the KSA metric readiness threshold decreased from 16.7% (n = 97) in 2015 to 10.1% (n = 68) in 2019. Conclusions and Relevance This study noted that the number of KSA metric points and procedural volume in military hospitals has been decreasing since 2015, whereas both measures have increased in civilian facilities. The findings suggest that loss of surgical workload has resulted in further decreases in military surgeon readiness and may require substantial changes in patient care flow in the MHS to reverse the change.
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Affiliation(s)
- Michael K Dalton
- Center for Surgery and Public Health, Harvard Medical School, Harvard T. H. Chan School of Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts.,Department of Surgery, Rutgers New Jersey Medical School, Newark, New Jersey
| | - Kyle N Remick
- Department of Surgery, Uniformed Services University of the Health Sciences, Walter Reed National Military Medical Center, Bethesda, Maryland
| | | | - Quoc-Dien Trinh
- Center for Surgery and Public Health, Harvard Medical School, Harvard T. H. Chan School of Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Zara Cooper
- Center for Surgery and Public Health, Harvard Medical School, Harvard T. H. Chan School of Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Eric A Elster
- Department of Surgery, Uniformed Services University of the Health Sciences, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Joel S Weissman
- Center for Surgery and Public Health, Harvard Medical School, Harvard T. H. Chan School of Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
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