The Joint Trauma System and Armed Services Blood Program have collaborated to develop a Clinical Practice Guideline for the use of Type A Whole Blood to expand the availability of whole blood in the operational environment. This MPO Minute discusses the rationale, key considerations, and recommendations outlined in the CPG.
As healthcare systems evolve to integrate digital technologies, the Military Health System (MHS) faces unique challenges requiring specialized expertise in health informatics. Health informatics enables the optimization of workflows, enhances patient safety, and supports operational readiness by transforming data into actionable insights. This manuscript discusses the critical role informaticists play in supporting the mission of the MHS by improving clinical outcomes, facilitating health data interoperability, and advancing medical research. Despite their pivotal role, the informatics workforce across the military services is inconsistently tracked, leading to significant gaps in resource allocation and strategic planning. Quantitative estimates suggest that while the Navy and Air Force have recognized informaticists through specific qualification designators and special experience identifiers, formal designation and dedicated billets remain limited, particularly in the Army. Barriers such as budget constraints, reliance on collateral duties, and lack of unified policy frameworks impede progress. To address these challenges, this article recommends establishing formal informatics subspecialties, developing standardized education pathways, and designating specific billets across the Services. It also proposes a vision where informaticists are embedded throughout the MHS, enabling predictive health models, interoperability with Veterans Affairs systems, and real-time decision support in deployed environments. Investing in a robust informatics workforce is not merely a technological enhancement but a strategic imperative essential for maintaining force health, medical readiness, and national security.
Introduction: In deployed military settings, ensuring consistent access to durable medical equipment (DME) remains a significant challenge due to logistical and supply chain limitations. This study retrospectively reviews the clinical use of 3D-printed upper extremity orthoses fabricated out of necessity at Al Udeid Air Base (AUAB), Qatar, in response to such shortages. Devices were implemented during routine care and assessed through provider documentation and photographic evidence. Although representative of logistics-supported Role 2s, the results may not fully extend to forward combat Role 2s without adaptations.
Materials and methods: A retrospective chart review was conducted for patients treated with 3D-printed orthotic splints between March and July 2024 at AUAB. Printers included a FormLabs 3B+ SLA and Creality CR-6 MAX FDM device, using Formlabs Draft V2 resin and Overture PLA filament. Devices were fabricated using an open-source design to meet immediate clinical needs, with print times of 1-2 h per splint. Variables extracted included splint type, application site, patient tolerance, and clinical utility as documented in the medical record.
Results: Multiple splint designs were fabricated, including an en bloc thumb spica, a heat-moldable flat PLA splint, and a series of DIP extension splints for mallet finger injuries. The en bloc splint, printed using SLA resin, provided satisfactory fit and comfort with a stockinette liner and adjustable securing mechanisms (Figure 1). A flat PLA-based splint was customized at bedside through heat molding (Figure 2 and 3). Finger extension splints were printed in batch-scaled sizes and used for 8-week immobilization in 1 patient with a soft tissue mallet deformity (Figure 4). All splints were well tolerated, functionally effective, and enabled continuity of duty with minimal limitation. Compared to plaster, 3D prints offered better ventilation and durability.
Conclusions: 3D printing enabled the timely fabrication of upper extremity orthoses during a period of equipment shortage at a deployed military medical facility. These devices were created to fulfill immediate clinical needs and were retrospectively evaluated using documentation from routine patient care. This study highlights the real-world feasibility of using 3D printing in constrained settings to deliver personalized orthopedic support when conventional DME is unavailable. Printers are moderately robust but sensitive to dust, temperature, and motion; ruggedized models and IP-compliant designs are recommended for austere use. Costs may exceed traditional initially but offer logistics savings. Multi-specialty applications justify deployment. Although limited by its retrospective design and absence of formal outcome tracking, the findings demonstrate the potential for 3D printing to reduce supply chain dependence, support operational autonomy, and enhanc
Introduction: Glucose dysregulation is a significant obesity-related comorbidity known to impair both mental and physical performance. Glycated hemoglobin (HbA1c), a measure of average glucose regulation over 2-3 months, is elevated in over a third of American adults, indicating prediabetes (5.7-6.4%) or type 2 diabetes mellitus (≥ 6.5%). However, the 'fit-fat' concept suggests that physical activity may mitigate the adverse effects of adiposity on metabolic health.
Materials and methods: This study investigated the relationship between relative body fat (%BF), HbA1c, and maximal oxygen uptake (V.O2max) as a surrogate measure of physical activity, in 216 physically active military personnel (188 men, 28 women).
Results: In men, fat mass (FM) was significantly, but weakly, inversely associated with HbA1c (β = -0.008, 95% CI [-0.015 to 0.000], SE = 0.004, P = 0.048), a finding that warrants further investigation. Maximal oxygen uptake was not significantly associated with HbA1c in either men or women. The variance explained by these models was low. Cluster analysis identified 3 distinct clusters with differing profiles of adiposity and fitness, but no significant differences in HbA1c were observed between them (F(2, 213) = 0.72, P = 0.488).
Conclusions: In this physically active military population, normal mean HbA1c levels (5.2%) suggest that regular physical activity may mitigate the adverse effects of adiposity on glucose homeostasis. These findings support the 'fit-fat' concept and suggest that current fitness standards may be sufficient to maintain metabolic health. Therefore, inclusion of HbA1c testing in annual physical readiness standards may not be warranted in young, physically active service members.
Introduction: Traumatic brain injuries (TBIs) are associated with substantial morbidity and mortality. We examined characteristics and outcomes among military personnel with battlefield-related penetrating TBI (pTBI) compared to closed TBI (cTBI) and non-head injuries (without cranial injuries).
Materials and methods: Military personnel admitted to participating U.S. military hospitals (2009-2014) were classified based on injury patterns: pTBI, cTBI (head Abbreviated Injury Scale [AIS] ≥3), and non-head (≥1 non-head injury AIS ≥3). Propensity score and inverse probability of treatment weighting (IPTW) were used to assess associations with mortality, hospital stay, and infection burden.
Results: The study population included 106 pTBI patients, 259 cTBI patients, and 715 patients with non-head injuries. Patients with pTBIs were more severely injured with differing injury mechanisms compared to the other 2 groups. Patients with pTBIs had more critical care requirements versus both cTBI and non-head injury patients (P < .05) and longer hospitalization (median 27 days vs. 22; P = .041) compared to cTBI patients. More central nervous system (CNS) infections were diagnosed among patients with pTBIs (11.3%) versus cTBIs (1.2%) and non-head injuries (0.7%; P < .001). Although the overall proportion of patients who developed non-CNS infections was not significantly different between the TBI groups, there was a higher proportion among pTBI versus non-head injury patients (53.8% vs. 40.8%; P = .012). Patients with pTBIs also had less skin and soft-tissue infections and more pneumonia compared to non-head injury patients (P < .05). There was no significant difference in the proportion of mortality between the pTBI and cTBI patients (7.6% vs. 3.1%); however, it was higher compared to patients with non-head injuries (1.0%; P < .001). Sustaining any TBI (penetrating or closed) was associated with greater risk of mortality compared to non-head injuries (risk ratio: 3.71; 95% CI, 1.83-7.55).
Conclusions: Patients with pTBIs are critically injured with substantial critical care requirements and morbidity. Between patients with pTBIs and cTBIs, there was not a significant difference in non-CNS infection burden or mortality, but pTBI patients did have longer hospitalization. When compared to severely injured military personnel with non-head injuries using propensity scores and IPTW analysis, sustaining a TBI (penetrating or closed) was not associated with having more non-CNS infections or a longer hospital stay. This may be a result of the high injury severity (median of 26) and relative occurrence of polytrauma in the total population. Patients with TBIs (penetrating or closed) did have a greater risk of mortality compared to patients with non-head injuries.
Introduction: Military plastic surgeons play a critical role in the care and rehabilitation of wounded servicemembers. However, the ability of military plastic surgeons to maintain a robust reconstructive skill set within military treatment facilities (MTFs) is often hampered by a narrow case mix and low case volume. We conducted this study to evaluate how integration of a targeted military-civilian partnership (MCP) impacted an MTF-based plastic surgery practice.
Materials and methods: Beginning in March 2020, MTF-assigned plastic surgeons expanded their practice through a targeted MCP with a civilian cancer center, whereby military plastic surgeons provided reconstructive care to civilian patients. We obtained clinical workload data through the billing offices at the MCP and comparable offices within the MTF. The primary outcomes measured were the volume of operative procedures and the Joint Knowledge, Skills, and Ability (JKSA) scores related to the clinical workload. Outcomes were standardized to surgeon-months to adjust for variations in surgeon assignment time and then compared between the pre-intervention period (October 2016-February 2020) and the post-intervention period (March 2020-December 2022).
Results: Throughout the study period, five plastic surgeons contributed 187 surgeon-months at the MTF, spanning before (103 surgeon-months) and after (84 surgeon-months) the intervention. After MCP integration, military plastic surgeons demonstrated a significant increase in procedural volume, with an average of 33.3 procedures per surgeon-month compared to 16.3 before intervention (P < .001). Additionally, there was a substantial rise in the readiness value of the work being performed, as reflected by the JKSA points generated per surgeon-month (108.0 points vs 374.0 points, P < .001). The proportion of operative procedures yielding JKSA points also improved, increasing from 75.2% to 92.4% (P < .001). Notably, several lessons learned were identified to better support MCP integration into MTF based practices including the need for local infrastructure to support these advancements.
Conclusions: Military-civilian partnerships are essential for military plastic surgeons to sustain the advanced reconstructive skills necessary to treat our nation's wounded service members. Further efforts are necessary to identify best practices in MCP oversight and execution.
Introduction: Large-scale combat operations in multi-domain environments are projected to result in patient care volumes and complexities that exceed historical en route critical care (ERCC) capabilities. Multimodal assessments in field environments are needed to evaluate and optimize ERCC team performance and identify solutions that assist teams in maintaining care standards in difficult operational environments. Recent advances in sensors enable audio-video data for detailed measures of technical performance, such as efficiency and accuracy, and nontechnical performance, such as cognitive load management and communication. These metrics enable insights into drivers of team effectiveness for optimizing care in challenging operational environments. Our primary aim was to evaluate the association between nontechnical team performance and time to critical action in simulated multi-provider, multi-patient usual care ERCC missions. This is a critical first step to exploring threats and protective factors toward teamworking and cognition in more stressful and/or resource-limited settings.
Materials and methods: We conducted simulations with n = 14 ERCC teams comprising a physician, nurse, and respiratory therapist or a second nurse, each transporting 2 casualties in a static aircraft. The San Antonio Institutional Review Board approved the study procedures. Participants completed a NASA Task Load Index (NASA-TLX) after the simulation. Independent raters reviewed audio and video recordings to assess nontechnical team performance using the Assessment of Combat Casualty Non-Technical Skills (AC2ENTS) Rubric and technical performance by assessing time to critical action completion. We calculated Pearson's correlations and R2 values among the AC2ENTS scores and time to critical action.
Results: We analyzed 14 teams. Higher team nontechnical skills scores were significantly associated with shorter time to critical actions. The median cumulative time to critical action for 2 events was 169.0 seconds (IQR 114.8-299.5 seconds). Mean global team nontechnical score (1-100 scale) was 56.3 (SD 12.7). Higher global nontechnical scores were associated with shorter time to critical action (r = -0.60, P = .0222). Higher situational awareness (r = -0.70, P = .0053) and decision making (r = -0.63, P = .0153) scores reflect the AC2ENTS domains that were most predictive of better technical performance. The median NASA-TLX reported workload (1-100 scale) was 32.6 (IQR 26.2-43.4). Reduced NASA-TLX workload was associated with improved gathering information (r = -0.54) and anticipating (r = -0.61) among AC2ENTS elements.
Conclusions: Improved nontechnical team performance was associated with superior technical performance in multi-provider, multi-casualty simulated ERCC missions. This provides important validity evidence for the impact of nontechnical skills on team performance in ERCC o
Introduction: Military medical training marries the challenges of medical education and military operations. Military Graduate Medical Education (GME) programs rely heavily on civilian healthcare training, often leaving military physicians with gaps in operational leadership skills during their first deployments. Hands-on, operational experiences are essential in preparing these physicians for their dual roles as medical and military leaders.
Materials and methods: This assessment evaluated the educational program offered to GME trainees who participated in a medical augmentation mission aboard the USNS Mercy during Pacific Partnership FY24. To evaluate the educational program, GME trainee physicians from various specialties were surveyed on pre- and post-mission comfort in 6 global health-relevant domains using a 5-point Likert scale. Due to the small sample size, Monte Carlo simulation and bootstrap resampling with replacement were also performed.
Results: Seven of 11 participants completed both pre- and post-assessments. The greatest increases in self-reported confidence were in international medical knowledge exchange, practicing across language barriers and practicing limited-resource medicine. Each increased by a mean of more than one point, which was consistent across both statistical modeling simulations. Comfort with culturally sensitive practice also showed borderline improvement among individuals.
Conclusions: This hands-on training demonstrated significant educational benefits for military GME trainees via their self-assessed readiness for dual roles as clinicians and military leaders. Although the sample size was small, these surveys highlight the value of integrating such educational experiences into military medical curricula. Future efforts should include the development and implementation of tangible skill assessments and longitudinal evaluation to assess clinician perceptions later in their careers, once out of the training environment.
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