Article 1
Comparison of military and civilian surgeon outcomes with emergent trauma laparotomy in a mature military-civilian partnership. Lammers D, Uhlich R, Rokayak O, Manley N, Betzold RD, Hu P. Trauma Surg. Acute Care Open. 2024 Mar 1;9(1):e001332.
Active-duty surgeons must remain operationally and medically prepared for the next mission. Dwindling surgical case volume at military treatment facilities (MTFs) threaten surgical readiness not only for surgeons, but also for surgical techs, nurses, and other MTF personnel. Military-civilian partnerships (MCP) serve a key role in active-duty readiness training. This study aimed to evaluate the rate of complications in emergency trauma laparotomies (ETL) between Special Operations Surgical Team (SOST) non-fellowship trained surgeons and full-time faculty civilian surgeons (CIV).
This retrospective review of a single center, level 1 trauma database from November 2019 through December 2022 looked at trauma patients requiring ETL. Included patients were separated into two cohorts for comparison based on initial operating surgeon – those performed by SOST surgeons and those performed by a CIV surgeon. The main outcomes were rates of mortality during operation and within 6 hours, 24 hours, and hospitalization. Intraoperative blood products transfused and rates of damage control laparotomy (DCL) were compared, as were median times in the ED and of operation. 647 laparotomies were performed during the period and 514 were defined as ETL and included in final analysis.
SOST surgeons performed only 8.4% of included ETL overall with the rest being performed by the CIV cohort. There were no differences in patient demographics, mechanism of injury, or presenting vital signs between the cohorts. Mortality rates for the population requiring ETL overall were as follows: 2.5% intraoperative, 3.3% within 6 hours; 4.7% within 24 hours, 8.0% during hospitalization. There were no differences in mortality rates between SOST and CIV surgeons at any time point in initial bivariate analysis. Operative duration was significantly long in the SOST group, and this could be due to a multitude of reasons, but the clinical implications remain unclear. Interestingly, the SOST cohort was more likely to use resuscitative endovascular balloon occlusion of the aorta (REBOA), but this did not increase their time to the operating room significantly. The SOST cohort did utilize the backup attending surgeons more. Limitations of the study include small SOST sample size and a focus on early mortality data. Additional data on postoperative complications and unplanned return to OR may be helpful to provide a more detailed comparison.
This analysis offers the first objective outcomes-based assessment of surgeons operating at a single MCP. This highlights the utility and safety of incorporating military non-fellowship trained surgeons at high-volume level 1 trauma centers. For the military, this provides a vital readiness training opportunity and for civilian centers, this represents a safe model for patient care while including military teams in a high-volume trauma setting. This could be expanded to a wider breadth of surgical team members. It also allows for cross-training military knowledge to civilian surgeons and institutions especially as the next large-scale combat operations loom in the future.
Article 2
Concurrent Surgical Care in an Austere Military Setting: A Preparation for Mass Casualty Events. Benham L, Brocuglio T, Maxwell D, Becerra D. Mil Med. 2025 Sep 1;190(9-10):e1806-e1810.
The U.S. military consistently utilizes small forward surgical teams (FST) to care for casualties prior to medical evacuation to a higher level of care. In austere environments where personnel and supplies can be limited, time is the greatest asset. In recent and anticipated future conflicts, concurrent casualty care is anticipated, and austere FST must provide it. In this paper, a Navy FST lays out a proof-of-concept to utilize two operating rooms (OR) with one FST on an amphibious warship – one surgeon, one certified registered nurse anesthetist (CRNA), one perioperative nurse, one critical care nurse, and 3 surgical technicians.
One FST on an amphibious warship selected four elective surgical cases and staggered them in two ORs – one hemorrhoidectomy, two pilonidal resections, and one inclusion cyst excision (6 cm). In times of war, military members may expand their skills to assist in other areas and that occurred here too. On the warship, the FST is augmented with 2 additional surgical technicians and one additional corpsman. The corpsman in this setting expands the scope and was used as a surgical technician. Each OR was staffed with 3 surgical techs for room set up and turnover. The CRNA was available to initiate anesthesia for each operation, but depending on the needs of the concurrent OR, the FST critical care RN aided in the maintenance of and recovery from anesthesia. The surgeon was present from operative timeout until end of procedure in each case without exception.
No adverse events occurred in the perioperative period or in clinical follow-up. The average surgical care overlap time during the three turnover periods was 33 min. The total time saved over the entire day, factoring in both surgical care overlap time and natural turnover time was 2 hours and 33 minutes. The four surgical cases were performed in less than 5 hours but utilizing the concurrent OR setup.
Operative time is an asset and in an active warzone or large area of responsibility (AOR) like the Indo-Pacific, concurrent polytrauma casualties will be commonplace. As discussed in the paper, austere medicine requires providers and medical personnel to leave their comfort zone to provide the best care with the limited resources and personnel available. Role sharing allows team members to cross train, adapt, and expand their clinical volume. This requires additional communication, situational awareness, and debriefing to ensure it is done safely to deliver the best care possible. Although this paper uses four relatively quick and easy elective cases, it is a starting point on which to base further expansion and exercises. In a civilian setting, concurrent OR cases are commonplace, but this is difficult with a FST in an austere environment. Surgeon and CRNA time is the critical resource along with surgical instruments and consumables. With potentially limited logistics and blood product resupply in a contested airspace conflict, FSTs will have to do more with less. Medical evacuation will also be limited in these situations. This is a good first step to proving that austere concurrent OR utilization is not only safe and feasible but will be necessary in the next large scale combat operation.
Article 3
Hypobaric Conditions in Cabin Altitude Restricted Aeromedical Evacuation Induce Systemic Inflammation Following Porcine Traumatic Brain Injury. Price AD, Becker ER, Baucom MR, Archdeacon CM, Smith MP, Schuster R, Caskey C, Blakeman TC, Strilka RJ, Pritts TA, Goodman MD. Mil Med. 2025 Nov 1;190(11-12):e2355-e2361.
Traumatic brain injury during aeromedical evacuation exposes patients to hypobaric hypoxia, a known driver of secondary neural injury. The CAR (Cabin Altitude Restriction) protocol targets lower cabin pressures (~5000 ft equivalent) to mitigate hypoxic stress, yet the optimal altitude threshold after brain trauma remains uncertain.
The article summarizes a controlled porcine experiment comparing TBI vs sham across ground level and simulated cabin pressures of 8000 ft (standard) and 5000 ft (CAR), with oxygen saturation modulated to match both normoxic and relative hypoxic states. Results demonstrate that both 8000 ft and 5000 ft hypobaria significantly elevated systemic inflammatory cytokines (IL-1β and IL-6) at 90-min and 6-h post-injury, and TNF-α acutely increased post-flight at both altitudes. Notably, cytokine elevation persisted despite supplemental oxygen restoring SpO2 to >97%, indicating an inflammation pathway triggered by hypobaric stress itself—not simply hypoxia. Authors conclude that 5000-ft CAR may not adequately blunt the inflammatory cascade and suggest that delaying evacuation may warrant reassessment.
Critique of the article centers on translational constraints of the model: use of only female Yorkshire pigs may limit generalizability; Controlled Cortical Impact produces a reproducible lesion but fails to represent the heterogeneity of blunt TBI; pulse-ox probe adaptation to the tongue introduces physiologic differences vs digital readings in humans; and absence of neurocognitive or imaging outcomes leaves uncertainty in true functional impact of the cytokine surge. The study duration (6 h) captures early systemic inflammation but not delayed neuroinflammatory or behavioral sequelae.
The key takeaway is that even altitude-restricted cabin profiles can provoke early systemic inflammation after TBI via hypobaria-dominant mechanisms that oxygen supplementation alone cannot reverse. This supports broader consideration of evacuation timing and barometric exposures beyond SpO2 targets and highlights that CAR altitudes may require further lowering or that post-injury stabilization time prior to flight should be investigated.
Article 4
Civilian Evacuation During War: Evidence from Ukraine. Martinez SK, Pompeo M, Sheremeta RM, Vakhitov V, Weber M, Zaika N. The Economic Journal. August 23 2025.
TBI evacuation and civilian-movement decisions during modern wars balance life-threat reduction against severe uncertainty, disruption, and perceived agency. In Ukraine after the 2022 invasion, rapid digital alerts created new scope to test how messaging design can influence evacuation willingness of civilians under real threat, where displacement may be prolonged or permanent.
The article reports a controlled survey experiment (N=2,006 Ukrainians, July 2022) comparing evacuation messages with varied framing and the inclusion of an operational evacuation plan. Findings show that adding a clear plan (e.g., organized transport points) increased perceived message effectiveness by 5%, while gain/loss or military-support framing produced no significant differences. Observational regressions further indicate that being offered transport by others correlated with 10–18% higher actual evacuation rates, particularly among non-evacuees and women, motivating the experimental test of plan provision. The study concludes that actionable logistics information, not emotional framing, matters most in war evacuation contexts.
Critically, the paper’s strengths are its timely wartime sample and causal test of plan provision, yet its evidence is perception-based rather than behavior-tracked, limiting certainty of real uptake. There are modest gender-sample imbalances likely due to military-age men’s service, and the study excludes fully occupied areas (e.g., Donetsk, Luhansk, Kherson), which may reduce applicability to the most trapped populations. All additional transport correlations are non-causal, and the rapid 5-day data-collection window captures a relatively stable combat period, which might not reflect responses during intense escalations.
As discussions surround planning for potential LSCO (Large Scale Combat Operations), government and relief organizations must evaluate how to anticipate and care for civilians, and other non-combatants, involved in future combat areas. The landscape of the war in Ukriane provides a look into what the battlefield may look like in the current theatres of operations. The core takeaway is that in real war environments, civilians are not blind to danger, but many doubt their ability to leave. Evacuation communication should therefore prioritize concrete, stepwise, and operational transport guidance, potentially reducing “felt-entrapment” barriers and meaningfully improving evacuation response, while reframing emotional appeals yields limited added value.
