The US military health systems (MHS) is now facing the possibility of future peer or near-peer warfare. This requires reevaluation of tactics, techniques, and procedures forged in the conflicts of the first two decades of the 21stcentury, mainly Afghanistan and Iraq. Many practices developed on the Global War on Terrorism (GWOT) battlefield have since made their way into civilian medical practice, including pre-hospital tourniquet use. The war in Ukraine has forced a reassessment of some of these very practices that had become standard in the post-9/11 wars, largely due to new and unique challenges including the lack of air superiority resulting in prolonged ground evacuation times. Such challenges are also expected to be significant for the US and its allies in potential future conflicts and large-scale combat operations.
During the wars in Afghanistan and Iraq, Tactical Combat Casualty Care (TCCC) was promulgated with great success, reducing preventable deaths, compared to past wars, from uncontrolled extremity hemorrhage by increasing tourniquet use and training. Complications associated with tourniquet use were less common, largely due to rapid evacuation times to surgical care, facilitated by air transport and forward placement of surgical assets. The safety of tourniquet use is now largely accepted when limb perfusion can be returned within 2 hours. Though proper application, reassessment, and conversion of tourniquets has always been a part of TCCC training, the latter steps of this algorithm were often performed by receiving practitioners at the next echelon of care. As military medical personnel in Ukraine continue to be trained using TCCC principles, it has become clear that there is need to improve the teaching of tourniquet use with a goal of preventing complications related to prolonged application and inappropriate use.
This article is a review of patients arriving to a forward surgical facility in Ukraine after prolonged tourniquet application and evaluates the use of an ischemia-reperfusion algorithm to reduce systemic effects during attempted limb salvage. Lukiianchuk et al sought to assess the systemic effects of limb reperfusion after 4 or more hours of tourniquet time in patients with isolated extremity injuries treated at a facility equivalent to a US Role 2 forward surgical team (FST). Patients with contraindications to limb salvage or confounding injuries were excluded. Outcomes included survival, limb salvage, organ failure, duration of dialysis when needed, and the presence of compartment syndrome. The closest higher level of care was a Role 3 equivalent facility 2.5 hours away by ground.
Patients eligible for tourniquet removal were prepared for surgery, including peripheral nerve block and IV sedation and analgesia. Preparation for reperfusion was begun with medication and fluids to mitigate the anticipated cardiac instability resulting from systemic return of ischemic metabolites and redistribution of blood to the extremity. Complete fasciotomy was performed before reperfusion with assessment of muscle tissue viability. Mannitol and crystalloid were given with reperfusion to reduce nephropathy. Ligation or shunting of vascular injuries was performed as indicated. Only damage control procedures were performed at the Role 2 facility. Urine output was replaced to maintain net even balance until transfer to the Role 3. Dialysis was done at the Role 3 if needed.
Over 9 months, 90 patients met inclusion criteria with a tourniquet in place for more than 4 hours. 16 were excluded, leaving 74 in the analysis. Arterial injury was identified as the source of bleeding in only 25% of patients, meaning 75% of tourniquet applications were not indicated. All patients had compartment syndrome and required fasciotomy. The incidence of multiple complications increased with increasing tourniquet time with the need for dialysis, delayed amputation, and death more common in those with tourniquet times longer than 6 hours. During Role 3 treatment, 70% of patients required acute hemodialysis (with an average requirement of 3 sessions before renal recovery), 36% required limb amputation, and 7% died.
This article demonstrates again the urgent need to improve TCCC training with an emphasis on indicated tourniquet application, frequent reevaluation, and timely conversion when appropriate. This is essential in Ukraine now and it should give impetus to the US MHS to take corrective action before any potential future peer or near-peer conflict where rapid evacuation to surgical care may not be as readily available as it was during the GWOT. Limitations of the study include lack of long-term data regarding limb function and other outcomes, related to classification of casualty data. It is a single-center retrospective study and generalizability is limited by exclusion of patients with other significant injuries. However, the preliminary results using this treatment algorithm indicate that survival rates are high, renal function can be expected to recover with limited use of dialysis, and limb salvage is possible in the majority of cases.
This article reviews the key findings of the panel session held during the 2022 Excelsior Surgical Society Symposium at the American College of Surgeons Clinical Congress exploring military-civilian partnerships (MCPs) as a potential way to overcome the peacetime effect confronting the US Military Health System (MHS). Recognizing that current geopolitical events reinforce the need for a posture of strength and deterrence which must include a ready medical force, the panel discussed possible strategies and changes to overcome the Walker dip. The panel addressed four topics: training and education of combat-ready surgical leaders, simulation and research to drive innovation, impact of military health policy on medical readiness, and the role of civilian advocacy and legislative efforts to mitigate the peacetime effect.
To produce combat-ready surgeons, a focus on military-specific medical skills and knowledge must begin early, in the Undergraduate Medical Education (UME) portion of surgical training, continue through residency and fellowship (GME), and be part of lifelong learning (CME). To that end, the Uniformed Services University (USU) School of Medicine has developed a knowledge, skills, and abilities (KSA) blueprint so that graduates will start their GME training with a baseline set of knowledge and skills relevant to military medicine, particularly in the deployed environment. These skills need further development during GME training and should be refreshed during pre-deployment training and CME. The next step is to scale these KSA initiatives and expand them to the other 75% of physicians entering the military system in addition to USU graduates, including Health Profession Scholarship Program (HPSP) students. Avenues for improvement at the UME level exist such as greater collaboration and integration of HSPS programs at civilian medical schools with the USU School of Medicine.
On the GME level, discussion centered around developing selection criteria for civilian residencies seeking to train military-committed residents. Criteria would aim to identify residencies where military trainees could count on combat-relevant clinical exposures in line with relevant KSAs. The panel emphasized the importance of supporting and sustaining existing MHS GME programs while also working to improve the value of training provided at civilian residencies. A need for more mentorship was identified to help maintain connection to the MHS, both for military-obligated residents training at civilian centers and for military staff surgeons assigned to civilian centers through MCP programs.
Military-civilian collaboration and true integration between the MHS and US civilian health system was discussed as a goal given the current state of often siloed and fragmented partnership efforts. Legislative advocacy supporting MCPs was identified as an opportunity, with recommendations to better document and demonstrate value through KSA tracking and other metrics. The importance of combat-related research utilizing the DoD Trauma Registry to drive innovation was stressed in the discussions. The use of simulation and team training for disaster or mass casualty scenarios led by military treatment facilities (MTFs) was noted as a path to mitigate the KSA gap and augment clinical experiences and training.
As the possibility of future large scale combat operations looms, it is timely to consider how best to create and maintain a military health system prepared to triage and treat a high volume of combat-injured patients. These skills fade during peacetime and the maintenance of a combat-ready medical force is a continuous struggle that requires constant attention and innovation. Looking to potential future conflicts also calls attention to the possibility of US civilian hospitals receiving large numbers of combat-injured casualties from abroad. The call for greater integration and collaboration between the MHS and the US civilian health system is urgent and existing MCP relationships provide a framework for the needed bidirectional knowledge exchange that can make this transition successful. Joint clinical research between military and civilian academic centers using both military and civilian databanks can advance knowledge and enhance collaboration. A more detailed discussion of how to quantify and track MCP exposures and productivity by nonphysician members of military teams and suggested strategies to start undoing the siloing of MCP efforts would be welcome additions to the article. Overall, this is an important reminder of the work that remains to stave off the peacetime effect and maintain military medical readiness in the current geopolitical environment.
This prospective laboratory study evaluated the safety and hemostatic function of non-leukoreduced whole blood stored at room temperature (+22°C) for up to 5 days. Ten units of group O or A RhD-positive whole blood were assessed daily for bacterial growth, hematologic indices, metabolic markers, platelet function, coagulation factors, thrombin generation, and viscoelastic parameters. Results showed that blood cell counts remained stable, most coagulation factors—including FV, FVIII, and FX—remained within physiologic range despite slight declines, and clot strength was maintained. Platelet function declined, particularly ADP-mediated aggregation by day 3, but von Willebrand factor levels stayed normal. No bacterial growth was detected. Metabolic changes mirrored those in cold-stored products. The authors concluded that whole blood stored at room temperature for up to 5 days retained most hemostatic properties and was bacteriologically safe, suggesting potential extension beyond the current 24-hour transfusion window.
This study suggests the potential to reduce logistical burdens for whole blood use in EMS, austere civilian care, and military operations where cold storage is limited. EAST’sWhole Blood Resuscitation for Injured Patients Requiring Transfusionguideline supports whole blood use as an effective resuscitation product, and reducing reliance on cold storage could facilitate wider availability while decreasing wastage. The study’s extensive use of thromboelastography to document functional clotting capacity highlights that these room-temperature stored products are not only safe, but potentially effective. While thorough, this study is only a proof-of-concept, limited by small donor pool and absence of in vivo transfusion outcomes. The observed bacteriological safety may not be reproducible in a forward environment as fresh whole blood collection is at times performed with suboptimal cleanliness. Further, without patient-centered endpoints such as bleeding control or survival, clinical impact remains uncertain, but the results hold promise and warrant further investigation.
Recognizing high rates of unnecessary or improperly applied tourniquets—particularly notable due to the high overall tourniquet use in the Ukraine conflict—the NATO Science and Technology Organization’s Human Factors and Medicine Panel developed a simplified Tourniquet Reassessment Algorithm for nonmedical military personnel. The team reviewed military and civilian literature, analyzed battlefield case series, and incorporated expert consensus to address complications from not medically indicated use, incorrect application, and ischemic injury from prolonged (>2 hours) application. The algorithm defines key procedural terms, stratifies actions by time since application (>2 h, 2–6 h, >6 h), incorporates telemedicine consultation when available, and removes shock assessment as a prerequisite for reassessment to streamline decision-making. It emphasizes conversion to pressure dressings when feasible, safe reassessment timing, and redundancy strategies such as a second tourniquet for anticipated >12-hour use.
Widespread enthusiasm for tourniquet use in both military and civilian settings has given rise to frequent misuse. This working group has generated an actionable tool to guide nonmedical providers in tourniquet reassessment and conversion—offering a concrete solution to minimize negative consequences from tourniquet utilization as it is currently practiced. The proposed algorithm is written in straightforward language to maximize intelligibility to a wide audience and was informed by recent large-scale combat operations. Notably, this is a proposed solution without validation. The algorithm relied on limited-quality evidence and expert opinion—especially concerning the 2–6-hour conversion window. The authors acknowledge that the algorithm’s use of telemedicine during this same window is often not feasible in austere scenarios where this algorithm may be most applicable. Nevertheless, this pragmatic design has the potential to improve survival and limb salvage. Future studies should evaluate training outcomes, real-world feasibility, and potential unintended harms from premature conversion attempts.
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