Military Medicine最新文献

Introduction: More than 90% of children in military families attend civilian schools that may lack understanding of the unique experiences and stressors of military life. School success in children of military families has important implications on future academic achievement, health outcomes, and military groups; yet there has not been an examination of challenges of school success among children of military families in the United States using nationally representative data.

Materials and methods: Data captured in the 2021-2022 National Survey of Children's Health, limited to children aged 6 to 17 years, were used to examine the association between child's caregiver military status and challenges of school success: lack of school engagement measured through caring about school and completing schoolwork, school absenteeism, and grade repetition (n = 60,599). Weighted to be nationally representative, bivariate analyses used chi-squared tests to examine estimates between selected variables and caregiver military status. Multivariable regression analyses were used to examine the association between caregiver military status and challenges of school success measures.

Results: In both unadjusted and adjusted analyses, we found that children of military families were more likely to not be engaged in school (adjusted odds ratios 1.35; 95% CI 1.19-1.53) and more likely to repeat a grade (adjusted odds ratios 1.33; 95% CI 1.09-1.64) than their civilian counterparts. There were no statistically significant differences in school absenteeism between children of military families and of civilian families.

Conclusions: This study extends beyond previous research findings that have focused primarily on academic achievement by including school engagement, attendance, and grade repetition for a more holistic and complete understanding of school success of children in military families. Our findings can be informational for school systems and policymakers to create educational and connective interventions for children in military families to improve school success.

Introduction: Military Interprofessional Health care Teams (MIHTs) are the backbone of modern military medicine. However, these teams face distinct operational challenges, including frequent personnel rotation, diverse work environments, and the constant possibility of rapid deployment. Serving in dynamic teams that deploy for both military and humanitarian missions, MIHTs face the unique challenge of constant restructuring and reorganization. Consequently, preparing MIHT members to function effectively as a team presents a significant hurdle. This difficulty highlights the limited applicability of existing literature focused on training civilian interprofessional health care teams. To address this gap, we conducted interviews with MIHT members to understand specific training elements that equip MIHT members to effectively collaborate. By gaining a deeper understanding of their needs, we can improve training programs and ultimately optimize MIHT performance, readiness, and patient care.

Methods: We conducted individual semi-structured interviews with military health care professionals. We employed purposeful sampling to ensure a diverse range of perspectives from individuals with direct experience working in or leading MIHTs. The 30 participants interviewed represented a broad spectrum of MIHT professions. The data used for this study stems from a broader research program on MIHTs conducted between 2017 and 2019. We conducted a secondary analysis focusing specifically on interview data related to education and training. Using Braun and Clarke's 6-step approach to Thematic Analysis, we identified themes from the data to build an understanding of MIHT perspectives on training effectiveness.

Results: The participants' insights allowed us to identify 3 critical themes related to the training elements they considered most beneficial for fostering collaboration within MIHTs: (1) MIHT members rely on their own predeployment readiness; (2) MIHT contexts require unique, adaptive communication skills; and (3) MIHT training is an ongoing endeavor.

Discussion: We need our MIHTs to be ready to deploy and effectively collaborate, which involves being clinically, emotionally, physically, and operationally ready. MIHT members describe 3 aspects of specific training elements as having significant potential to equip them to effectively collaborate: (1) MIHT members rely on their own predeployment readiness; (2) MIHT contexts require unique, adaptive communication skills; and (3) MIHT training is an ongoing endeavor at both the individual and team levels. By investing in tailored training programs that address these areas, we can empower MIHTs to continuously adapt, excel, and ultimately, positively impact patient outcomes in diverse military health care settings.

In the community of Army Nurse Anesthetists, there is an underutilized potential for Combat-Relevant Fellowship training that, if enthusiastically encouraged and taken advantage of, would proffer many benefits to the Military Health System and the beneficiaries of its care. Most importantly, increased access to and encouragement for participation in these fellowships for Nurse Anesthetists would act as a tool for skill sustainment, denying any potential for skill degradation or readiness gaps in preparation for the next-generation war. These fellowships would also augment the already robust breadth, quality, and safety of Army Nurse Anesthetists' combat and noncombat anesthesia care, potentially increase Return-To-Duty rates, potentially expedite casualty clearance of the battlefield, increase the often-limited access to advanced pain management care for chronic pain patients in Military Treatment Facilities, increase the retention rates of Nurse Anesthetists, augment the military anesthesia community's knowledge-base, and help to advance the art of anesthesia as a whole. To triumph against the anticipated rigors of the future war's multidomain operational environment, we are duty bound to continually improve and strive to be the best versions of ourselves as soldiers, as professionals, and as communities. This paper will explore the untapped utility of Combat-Relevant Fellowships for Army Nurse Anesthetists.

Intravascular shrapnel or bullet embolization after a gunshot injury is rare, with fewer than 200 cases reported over the past century. Military injuries typically have high energy transfer, making this phenomenon less prevalent. A 22-year-old military personnel presented with chronic leg ischemia resulting from arterial bullet embolization. Before 4 months, he had sustained a military injury and subsequently required hospitalization for pneumohemothorax. A 21-mm bullet obstructing the popliteal artery caused chronic leg ischemia and was scheduled for elective vascular surgery. Physicians should be aware of potential bullet embolization indications in gunshot wound patients to prevent complications, ensuring early detection and appropriate treatment for successful management.

Introduction: Disease and non-battle injuries (DNBIs) cause substantial losses among military personnel. NATO has monitored DNBIs among its personnel since 1996 using multiple versions of a tool now called EpiNATO-2, but the surveillance system has never been systematically evaluated. Following a request from NATO to the CDC, the objective of this study was to assess surveillance system attributes of EpiNATO-2 using CDC's updated guidelines for evaluating public health surveillance systems.

Materials and methods: Between June and October 2022, a literature review and key informant interviews were conducted to assess the following attributes: usefulness, simplicity, flexibility, data quality, acceptability, sensitivity, positive predictive value, representativeness, timeliness, stability, informatics system quality, informatics service quality, and informatics interoperability. Key informant interviews were conducted in Kosovo, Germany, and remotely with EpiNATO-2 users spanning three levels: clinical and data entry personnel (tactical level); regional medical and public health officers (operational level); and senior commanders and other governmental entities (strategic level).

Results: Fourteen EpiNATO-2 users participated in interviews, representing 3 of the 5 major NATO missions, 3 partner entities, and 7 nationalities. All users (100%) reported that the system did not meet their needs, with most users noting the following challenges: lack of clearly defined system objectives; poor data quality due to ambiguous case definitions and frequently unsubmitted reports (37% missing during January to June 2022); long delay between the occurrence of health events and the availability of corresponding data (≥2 weeks); and an antiquated and inflexible data management system. Overall, performance was deemed unsatisfactory on 11 of the 13 attributes.

Conclusions: This multinational sample of EpiNATO-2 users at all military levels reported that the system is currently not useful with respect to its stated objectives. Opportunities exist to improve the performance and usefulness of EpiNATO-2: improve case definitions, modernize data infrastructure, and regularly evaluate the surveillance system.

Introduction: A dilation and evacuation (D&E) is a safe and effective option for patients undergoing a second trimester abortion. Recent legislation and geographic restrictions threaten patients' access to this surgical procedure, prompting a call to action to strengthen abortion training. This quality improvement project aimed to assess if a standardized lecture and checklist would improve military trainee knowledge and comfort with performing D&Es.

Materials and methods: Using society recommendations and incorporating available level I to III evidence, a standardized checklist for D&Es was created to include necessary equipment, procedural steps, perioperative considerations, and potential complications. The checklist and associated lecture were presented to gynecology residents from seven of the nine military training programs. Residents completed a six-question assessment regarding comfort and knowledge in performing D&Es prior to and following the intervention. Responses were ranked on a five-point Likert scale and analyzed with the Wilcoxon sign-rank test. This project was deemed exempt by the Institutional Review Board. The standard Plan, Do, Study, Act (PDSA) methodology was used for ongoing assessment of the efficacy of this quality improvement project.

Results: There were 67 trainees that completed the pre-intervention assessment and 44 who completed it post-intervention, with 27 responses paired for statistical analysis. All trainees self-reported improved comfort and knowledge in all procedural aspects of D&Es, with the largest improvement observed in equipment knowledge (mean difference 1.44, P <0.001), performing procedural steps (mean difference 1.26, P <0.001), and managing complications (mean difference 1.33, P <0.001).

Conclusions: Use of an evidence-based checklist significantly improves resident knowledge and comfort with performing second trimester D&Es. In a post Dobbs environment, the military is an appropriate proxy for larger society and training programs need to develop alternatives and adjuncts to clinical training.

Introduction: Military-Civilian Partnerships (MCPs) are vital for maintaining the deployment readiness of military health care physicians. However, tracking their clinical activity has proven to be challenging. In this study, we introduce a locally driven process aimed at the passive collection of external clinical workload data. This process is designed to facilitate an assessment of MCP physicians' deployment readiness and the effectiveness of individual MCPs.

Materials and methods: From March 2020 to February 2023, we conducted a series of quality improvement projects at the Wright Patterson Medical Center (WPMC) to enhance our data collection efforts for MCP physicians. Our methodology encompassed several steps. First, we assessed our existing data collection processes and their outcomes to identify improvement areas. Next, we tested various data collection methods, including self-reporting, a web-based smart phone application, and an automated process based on billing or electronic health record data. Following this, we refined our data collection process, incorporating the identified improvements and systematically tracking outcomes. Finally, we evaluated the refined process in 2 different MCPs, with our primary outcome measure being the collection of monthly health care data.

Results: Our examination at the WPMC initially identified several weaknesses in our established data collection efforts. These included unclear responsibility for data collection within the Medical Group, an inadequate roster of participating MCP physicians, and underutilization of military and community resources for data collection. To address these issues, we implemented revisions to our data collection process. These revisions included establishing clear responsibility for data collection through the Office of Military-Civilian Partnerships, introducing a regular "roll call" to match physicians to MCP agreements, passively collecting data each month through civilian partner billing or information technology offices, and integrating Office of Military-Civilian Partnership efforts into regular executive committee meetings. As a result, we observed a 4-fold increase in monthly data capture at WPMC, with similar gains when the refined process was implemented at an Air Force Center for the Sustainment of Trauma and Readiness Skills site.

Conclusions: The Military-Civilian Partnership Quality Improvement Program concept is an effective, locally driven process for enhancing the capture of external clinical workload data for military providers engaged in MCPs. Further examination of the Military-Civilian Partnership Quality Improvement Program process is needed at other institutions to validate its effectiveness and build a community of MCP champions.

Introduction: This study aimed to examine the relationships between dissociative and somatic symptoms and how they might contribute to PTSD severity among ex-soldiers who sought help from the IDF Combat Stress Reaction Unit (CSRU).

Materials and methods: This cross-sectional study included 1,305 former compulsory, career, and reserve soldiers, who filled out self-report questionnaires on admission for evaluation at the CSRU. The study's dependent variables included two posttraumatic stress disorder measures (CAPS and PCL-5). The independent variables were the Dissociative Experience Scale and Brief Symptom Inventory. Background and service-related variables were also examined.

Results: Spearman correlation revealed that the higher the level of somatization is, the higher the level of PTSD via PCL and CAPS. A significant positive association was found between somatization and dissociation (r = 0.544; P < 0.001). The higher the somatization level, the more severe the dissociation. A multivariate logistic regression analysis to predict severe PTSD revealed that the longer the time elapsed from the traumatic event (OR = 1.019, P = 0.015), the higher the risk for severe PTSD. The most prominent variables were dissociation (OR = 6.420, P < 0.001) and somatization (OR = 4.792, P < 0.001). The entire model reached 40.8% of the shared variance in the regression.

Conclusions: While there is direct reference to dissociation in the clinical assessment by PCL or CAPS, there is no such reference to somatization. Highly functioning combatants sometimes express their distress somatically. Our findings suggest regarding severe somatic symptoms as diagnostic criteria for PTSD.