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Background: The global burden of trauma disproportionately affects low-income countries and middle-income countries (LMIC), with variability in trauma systems between countries. Military and civilian healthcare systems have a shared interest in building trauma capacity for use during peace and war. However, in LMICs it is largely unknown if and how these entities work together. Understanding the successful integration of these systems can inform partnerships that can strengthen trauma care. This scoping review aims to identify examples of military-civilian trauma systems integration and describe the methods, domains, and indicators associated with integration including barriers and facilitators., Methods: A scoping review of all appropriate databases was performed to identify papers with evidence of military and civilian trauma systems integration. After manuscripts were selected for inclusion, relevant data was extracted and coded into methods of integration, domains of integration, and collected information regarding indicators of integration, which were further categorized into facilitators or barriers., Results: Seventy-four studies were included with authors from 18 countries describing experiences in 23 countries. There was a predominance of authorship and experiences from High-Income Countries (91.9 and 75.7%, respectively). Five key domains of integration were identified; Academic Integration was the most common (45.9%). Among indicators, the most common facilitator was administrative support and the lack of this was the most common barrier. The most common method of integration was Collaboration (50%)., Conclusion: Current evidence demonstrates the existence of military and civilian trauma systems integration in several countries. High-income country data dominates the literature, and thus a more robust understanding of trauma systems integration, inclusive of all geographic locations and income statuses, is necessary prior to development of a framework to guide integration. Nonetheless, the facilitators identified in this study describe the factors and environment in which integration is feasible and highlight optimal indicators of entry., (Copyright © 2024 The Author(s). Published by Wolters Kluwer Health, Inc.)

Global surgery and anesthesia is an emerging field in global health and academic medicine. Promoting the education of global surgery and anesthesia among uniformed medical students is imperative and will prepare the next generation of uniformed physicians for global surgical missions through both the DoD and civilian opportunities., (Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2023. This work is written by (a) US Government employee(s) and is in the public domain in the US.)

Mini abstract Typical preoperative markers of a difficult laparoscopic cholecystectomy did not apply during the US Naval ShipComfort Deployment in 2019. This prospective study reveals the importance of preparedness for short-term surgical missions, the impact of health care disparities on the severity of disease, and the need for deliberate and thoughtful engagement with host-nation partners., (Copyright © 2024 The Author(s). Published by Wolters Kluwer Health, Inc.)

Introduction: Trauma burden is one of the leading causes of young human life and economic loss in low- and middle-income countries. Improved emergency and trauma care systems may save up to 2 million lives in these countries., Method: This is a comprehensive expert opinion participated by 4 experts analyzing 6 Asian countries compiling the most pressing trauma care issues in Asia as well as goal directed solutions for uplifting of trauma care in these countries., Result: Lack of legislation, stable funding under a dedicated lead agency is a major deterrent to development and sustainment of trauma systems in most Asian countries. While advocating trauma, critical care as a specialty is a key event in the system establishment, Trauma specialized training is challenging in low resource settings and can be circumvented by regional cooperation in creating trauma specialized academic centers of excellence. Trauma quality improvement process is integral to the system maturity but acquisition and analysis of quality data through trauma specific registries is the least developed in the Asian setting., (© 2024. The Author(s).)

Introduction: The U.S. Naval Ship COMFORT has performed six humanitarian assistance and disaster relief mission since 2007. This paper describes the surgical volume per surgical specialty for five missions spanning 19 countries., Materials and Methods: Raw surgical case logs were analyzed for total case volume, total operating days, unanticipated return to operating room, and percentage of pediatric cases (<18 years old) for each country visited., Results: Total surgical volume for the five missions was 5,142. The countries most frequently visited were Columbia and Haiti with seven and five visits, respectively. General surgery, ophthalmology, and plastic surgery have had consistent volume over time. Orthopedic surgery volume has steadily decreased with the exception of the 2018 mission., Conclusion: As volume in military treatment facilities declines, alternative sources of surgical volume for military surgeons are being examined. This paper highlights the historical volume which can inform future personnel planning requirements of U.S. Naval Ship COMFORT missions. With the exception of orthopedic surgery, surgical volume has remained consistent over the last decade. For future best practice, historical case data should be used to determine staffing needs on hospital ships and case logs and operating procedures and follow-up protocols should be standardized., (© The Association of Military Surgeons of the United States 2022. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Introduction: Traumatic injury is a leading cause of morbidity globally, particularly in low-income and middle-income countries (LMICs). In high-income countries (HICs), it is well documented that military and civilian integration can positively impact trauma care in both healthcare systems, but it is unknown if this synergy could benefit LMICs. This case series examines the variety of integration between the civilian and military systems of various countries and international partnerships to elucidate if there are commonalities in facilitators and barriers., Methods: A convenience sampling method was utilized to identify subject matter experts on civilian and military trauma system integration. Data were collected and coded through an iterative process, focusing on the historical impetuses and subsequent outcomes of civilian and military trauma care collaboration., Results: Eight total case studies were completed, five addressing specific countries and three addressing international partnerships. Themes which emerged as drivers for integration included history of conflict, geography, and skill maintenance for military physicians. High-level government support was a central theme for successful integration, and financial issues were often seen as the greatest barrier., Conclusions: Various approaches in civilian-military integration exist throughout the world, and the studied nations and international partnerships demonstrated similar motivators and barriers to integration. This study highlights the need for further investigation, particularly in LMICs, where less is known about integration strategies., (Published by Elsevier Inc.)

Objective: For more than half a century, surgeons who managed vascular injuries were guided by a 6-hour maximum ischaemic time dogma in their decision to proceed with vascular reconstruction or not. Contemporary large animal survival model experiments aimed at redefining the critical ischaemic time threshold concluded this to be less than 5 hours. Our clinical experience from recent combat vascular trauma contradicts this dogma with limb salvage following vascular reconstruction with an average ischaemic time of 6 hours., Methods: During an 8-month period of the Sri Lankan Civil War, all patients with penetrating extremity vascular injuries were prospectively recorded by a single surgeon and retrospectively analysed. A total of 76 arterial injuries was analysed for demography, injury anatomy and physiology, treatment and outcomes. Subsequent statistical analysis was performed to evaluate the impact of independent variables to include; injury anatomy, concomitant venous, skeletal trauma, shock at presentation and time delay from injury to reconstruction., Results: In this study, the 76 extremity arterial injuries had a median ischaemic time of 290 (IQR 225-375) min. Segmental arterial injury (p=0.02), skeletal trauma (p=0.05) and fasciotomy (p=0.03) were found to have a stronger correlation to subsequent amputation than ischaemic time., Conclusions: Multiple factors affect limb viability following compromised distal circulation and our data show a trend towards various subsets of limbs that are more vulnerable due to inherent or acquired paucity of collateral circulation. Early identification and prioritisation of these limbs could achieve functional limb salvage if recognised. Further prospective research should look into the clinical, biochemical and morphological markers to facilitate selection and prioritisation of limb revascularisation., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.)

Purpose of Review: The US Navy has a long history of responding to disasters around the globe. US Navy ships have unique characteristics and capabilities that determine their capacity for a disaster response. This paper discusses common considerations and lessons learned from three distinct disaster missions., Recent Findings: The 2010 earthquake in Haiti had a robust response with multiple US Navy ship platforms. It was best assessed in three phases: an initial mass casualty response, a subacute response, and a humanitarian response. The 2017 response to Hurricane Maria had a significant focus on treating patients with acute needs secondary to chronic illnesses to decrease the burden on the local healthcare system. The COVID-19 response brought distinctive challenges as it was the first mission where hospital ships were utilized in an infectious disease deployment., Summary: The first ships to respond to a disaster will need to focus on triage and acute traumatic injury. After this first phase, the ship's medical assets will need to focus on providing care in a disrupted health care system which most often includes acute exacerbations of chronic disease. Surgeons must be ready to be flexible in their responsibilities, be competent with end-of-life care, and negotiate technical and cultural communication challenges., Competing Interests: Conflict of InterestThe authors declare no competing interests., (© This is a U.S. government work and not under copyright protection in the U.S.; foreign copyright protection may apply 2022.)

Ethical issues can arise when planning for direct patient care surgical missions. Based on the lessons learned from the USNS COMFORT Deployment 2019, the authors present concise considerations and recommendations for future hospital ship surgical mission planning., (Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2020. This work is written by (a) US Government employee(s) and is in the public domain in the US.)

The USNS Mercy (T-AH 19) on Pacific Partnership 2018 was the first mobile, expeditionary platform to utilize the da Vinci Surgical System. Using a de-identified, web-based survey, the impact of this new technology on Pacific Partnership 2018 on the attitudes of host nation surgeons was examined., (Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2020. This work is written by (a) US Government employee(s) and is in the public domain in the US.)

What started as a cluster of patients with a mysterious respiratory illness in Wuhan, China, in December 2019, was later determined to be coronavirus disease 2019 (COVID-19). The pathogen severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), a novel Betacoronavirus , was subsequently isolated as the causative agent. SARS-CoV-2 is transmitted by respiratory droplets and fomites and presents clinically with fever, fatigue, myalgias, conjunctivitis, anosmia, dysgeusia, sore throat, nasal congestion, cough, dyspnea, nausea, vomiting, and/or diarrhea. In most critical cases, symptoms can escalate into acute respiratory distress syndrome accompanied by a runaway inflammatory cytokine response and multiorgan failure. As of this article's publication date, COVID-19 has spread to approximately 200 countries and territories, with over 4.3 million infections and more than 290,000 deaths as it has escalated into a global pandemic. Public health concerns mount as the situation evolves with an increasing number of infection hotspots around the globe. New information about the virus is emerging just as rapidly. This has led to the prompt development of clinical patient risk stratification tools to aid in determining the need for testing, isolation, monitoring, ventilator support, and disposition. COVID-19 spread is rapid, including imported cases in travelers, cases among close contacts of known infected individuals, and community-acquired cases without a readily identifiable source of infection. Critical shortages of personal protective equipment and ventilators are compounding the stress on overburdened healthcare systems. The continued challenges of social distancing, containment, isolation, and surge capacity in already stressed hospitals, clinics, and emergency departments have led to a swell in technologically-assisted care delivery strategies, such as telemedicine and web-based triage. As the race to develop an effective vaccine intensifies, several clinical trials of antivirals and immune modulators are underway, though no reliable COVID-19-specific therapeutics (inclusive of some potentially effective single and multi-drug regimens) have been identified as of yet. With many nations and regions declaring a state of emergency, unprecedented quarantine, social distancing, and border closing efforts are underway. Implementation of social and physical isolation measures has caused sudden and profound economic hardship, with marked decreases in global trade and local small business activity alike, and full ramifications likely yet to be felt. Current state-of-science, mitigation strategies, possible therapies, ethical considerations for healthcare workers and policymakers, as well as lessons learned for this evolving global threat and the eventual return to a "new normal" are discussed in this article., Competing Interests: There are no conflicts of interest., (Copyright: © 2020 Journal of Global Infectious Diseases.)

Background: In extremity vascular trauma, early complications occur at a rate of 13% to 44%. The most common of which are infection, dehiscence, thrombosis, and stenosis. Failure of the arterial repair, also called arterial blowout, has the potential for exsanguinating hemorrhage and poses a considerable challenge for the surgeon to save limb and life., Method: All adults with extremity vascular injuries admitted in 8-month period were prospectively recorded and retrospectively analyzed. Extremity vascular injuries in this group include those in which limb salvage attempted. 5 arterial blowouts in a recorded 87 arterial repairs were analyzed for demographics, presentation, management and outcome in the context of identifying most probable causative factors., Result: 5 arterial blowouts occurred out of 87 arterial repairs for a rate of 5.75%. These occurred at a mean of 14 days post-operatively. All patients were male with the majority of the injuries, 80%, resulting from gunshot wounds. All injuries were associated with severe soft tissue injury and clinical evidence of bacterial infection. Technical error, inadequate debridement, prolonged exposed vessel and unstable skeletal injury were noted as causative factors in addition to the commonly reported causes of repair failure. At a mean follow-up of 17 days, the arterial blowout cohort had 80% limb survival rate., Conclusion: Ischemic, damaged and contaminated military wounds lead to infections of varied degree. Delay in closure due to tight distal muscle compartments or severe persistent soft tissue infections, necessitating serial irrigation and debridement (I&D) of wounds, is the common chain noted leading to arterial blowout. To break this chain of events the authors suggest early identification of at risk limbs and aggressive soft tissue cover of the newly constructed repair., Level of Evidence: Case series, level IV.