ABSTRACT

In the third installment of the "Lest We Forget" series, the authors discuss a critical advance-vascular repair, pioneered by Dr. Carl Hughes-in the care of the war-wounded during the Korean War. This article reviews the management of large vessel injuries in wartime, the challenges and advances in military medicine during the Korean War, and the application of these lessons to current practices.

Prolonged Care for Presumed Typhoid Encephalitis in Indonesia

Berrios I, Carius BM, Vaughn NA, Dobbe L. 24(3). 79 - 83. (Journal Article)

Despite advancements in military medical treatment and evacuation, soldiers in austere environments remain vulnerable to disease and non-battle injury and may face prolonged evacuation before receiving definitive care. In particular, arranging care for a soldier presenting with a conditions that has a wide differential diagnosis, such as acute altered mental status (AMS), can be especially challenging. We highlight the case of an otherwise young, healthy U.S. Soldier serving in Indonesia, who presented with acute AMS concerning for undifferentiated infection. Subsequent workup at the receiving hospital following evacuation revealed Salmonella enterica infection, more commonly known as typhoid. However, even with clinical findings of typhoid encephalitis and initiation of empiric treatment, medical care proved challenging in the resource-limited local facilities, despite multiple escalations of care. Ultimately, the patient was evacuated to a tertiary facility in Singapore, where his condition improved, and 4 days after initial presentation the patient had no definitive findings of infections on lumbar puncture. This case not only highlights the threat of typhoid and other infectious diseases in modern operations but also the challenges of suboptimal medical care in both the prehospital and hospital settings when utilizing host nation facilities.



ABSTRACT

Introduction: Mass casualty events (MASCALs) in the combat environment, which involve large numbers of casualties that overwhelm immediately available resources, are fundamentally chaotic and dynamic and inherently dangerous. Formal triage systems use diagnostic algorithms, colored markers, and four or more named categories. We hypothesized that formal triage systems are inadequately trained and practiced and too complex to successfully implement in true MASCAL events. This retrospective analysis evaluates the real-world application of triage systems in prehospital military MASCALs and other aspects of MASCAL management. Methods: We surveyed Special Operations Forces (SOF) medics known to us who have participated in military prehospital MASCALs and analyzed them. Aggregated data describing the scope of the incidents, the use of formal triage algorithms and colored markers, the number of categories, and the interventions on scene were analyzed using descriptive statistics, and lessons learned were consolidated. Results: From 1996 to 2022 we identified 29 MASCALs that were managed by military medics in the prehospital setting. There was a median of three providers (range 1-85) and 15 casualties (range 6-519) per event. Four or more formal triage categories were used in only one event. Colored markers and formal algorithms were not used. Life-saving interventions were performed in 27 of 29 (93%) missions and blood transfusions were performed in four (17%) MASCALs. The top lessons learned were: 1) security and accountability are cornerstones of MASCAL management; 2) casualty movement is a priority; 3) intuitive triage categories are the default; 4)life-saving interventions are performed as time and tactics permit. Conclusion: Formal triage systems requiring the use of diagnostic algorithms, colored tags, and four or five categories are seldom implemented in real-world military prehospital MASCAL management. The training of field triage should be simplified and pragmatic, as exemplified by these instances.

Keywords: mass casualty management; triage; MASCAL; survey; SOF medics

The JSOM podcast digs deeper into the articles and subjects that matter to our readers. Our podcast hosts, Captains Alex Merkle and Josh Randles, tackle articles from the journal based on merit, interest, and application for operators in the field. The Summer 24 episode is here! We have also uploaded a bonus episode for our listeners featuring a special interview with Jeff Butler, co-author of Tell Them Yourself: It's Not Your Day to Die."

Current Episode

Our JSOM podcast team will be reviewing the following articles for our Summer podcast: 

Advancing Combat Casualty Care Statistics and Other Battlefield Care Metrics by Jud C. Janak, Russ S. Kotwal, Jeffrey T. Howard, Jennifer M. Gurney, Brian J. Eastridge, John B. Holcomb, Stacy S. Shackelford, Robert A. De Lorenzo, Ian J. Stewart, and Edward L. Mazuchowsk (https://www.jsomonline.org/FeatureArticle/2024211Janak.pdf)

Evaluation of a Rebreathing System for use with Portable Mechanical Ventilators by Thomas Blakeman, Maia Smith, and Richard Branson (https://www.jsomonline.org/FeatureArticle/2024234Blakeman.pdf)

The Effect of Critical Task Auto-failure Criteria on Medical Evaluation Methods in the Pararescue Schoolhouse by Ian Richardson, Michael Lauria, Brian Gravano, Jeffrey Swenson, and Stephen Rush (https://www.jsomonline.org/FeatureArticle/2024267Richardson.pdf)

JSOM Guest Author

Advancing Combat Casualty Care Statistics and Other Battlefield Care Metrics author Jud C. Janak will be interviewed by our podcaster team about the article. 

Jud C. Janak, PhD, has over 10 years of experience as an epidemiologist and applied biostatistician in the private sector, public sector, and academia. He has published over 50 peer-reviewed studies on topics related to traumatic injury, accelerated aging, chronic disease, and real-world pharmacoepidemiology. He completed a post-doctoral fellowship at the U.S. Army Institute for Surgical Research where he focused on traumatic brain and genitourinary injuries. He was Director of Epidemiology and Biostatistics for the Department of Defense Joint Trauma System from 2017 to 2020. He also served as the lead epidemiologist for the Military Trauma Preventable Death Working Group. He was an Associate Director of Epidemiology at CorEvitas from 2020 to 2023. His current responsibilities focus on leveraging real-world patient and clinical registry data to study the safety and effectiveness of FDA-approved therapies as a Principal Epidemiologist in the Real-World Data Research and Analytics group at Merative. Dr. Janak received his master’s and doctoral degrees in Epidemiology from the University of Texas Health Science Center School of Public Health.

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