Shared Science
Combat-Related Orthopedic Trauma in the Russo-Ukrainian War: A Systematic Review
Spring 2026
Garcia-Canas R, Navarro-Suay R
Abstract
Introduction: The Russo-Ukrainian conflict has produced large numbers of military and civilian casualties, with orthopedic and musculoskeletal trauma representing a major proportion of combat injuries. Explosions, gunshots, and blast mechanisms frequently generate complex wounds that demand specialized surgical and rehabilitative management. This review summarizes injury types, mechanisms, severity, clinical responses, and gaps in current knowledge. Methods: Following PRISMA guidelines, a comprehensive search of PubMed, Scopus, Web of Science, and MEDLINE via WoS was conducted in February 2025. Eligible studies published from 2014 to 2024 included case reports, case series, cohort studies, and observational research describing orthopedic injuries in military or civilian populations affected by the conflict. Two reviewers independently screened studies, performed quality assessments using Joanna Briggs Institute tools and STROBE criteria, and synthesized data qualitatively with descriptive statistics when available. Results: Thirty-one studies were included, primarily case reports and retrospective analyses from Ukrainian military hospitals and frontline facilities. Explosive and ballistic trauma produced high-energy fractures, traumatic amputations, severe soft-tissue loss, and neurovascular damage. Management strategies included external and internal fixation, bone grafting, microsurgical reconstruction, distraction osteogenesis, and the progressive use of 3D-printed implants to support limb salvage. Rehabilitation, including pain control, physiotherapy, and prosthetic training, was essential for functional recovery. Long-term complications included neuromas, phantom pain, stump morbidity, and psychological trauma. Telemedicine enabled remote consultation and continuity of care under resource-limited conditions. Conclusions: Combat-related orthopedic injuries in this conflict require advanced surgical techniques, coordinated multidisciplinary support, and prolonged rehabilitation. Expanded data collection, standardized reporting, and long-term follow-up are essential to improve functional outcomes and reintegration.
Keywords: war-related injuries; Ukraine conflict; military medicine; casualty; surgical management; combat trauma
AI-Assisted Lung Sliding Detection in Point-of-Care Ultrasound by Marine Corps Corpsmen: A Multi-Reader Study
Spring 2026
Cote M, Prager R, Tran K, Orozco N, Smith D, Holliday Z, Arntfield R
Abstract
Background: Artificial intelligence (AI) has the potential to address training limitations and inter-operator variability that constrain the use of lung ultrasound (LUS) in austere and prehospital settings. This pilot study evaluated whether AI-based decision support could improve the diagnostic accuracy and confidence of United States Marine Corps Corpsmen in identifying absent lung sliding, a key indicator of pneumothorax, during LUS interpretation. Methods: This pilot-prospective multi-reader, multi-case study involved five military medics, all novices in point-of-care ultrasound, each interpreting 50 de-identified LUS video clips twice, once without AI assistance (control) and once with AI assistance (ATLAS, Deep Breathe Inc., London, Canada), in randomized order with at least a 2-hour washout between sessions. Expert consensus served as a reference standard. Diagnostic performance was assessed using area under the receiver operating characteristic curve (AUROC), sensitivity, specificity, and accuracy. Differences were analyzed using the Random-Reader Random-Case method. Per-clip reader confidence ratings were compared using the Stuart-Maxwell test. Results: AI assistance significantly improved diagnostic performance across all measured outcomes. The mean AUROC increased from 0.72 (SD 0.16) without AI to 0.93 (SD 0.04) with AI (P=.03). Sensitivity rose from 0.63 (SD 0.14) to 0.90 (SD 0.09), specificity from 0.70 (SD 0.15) to 0.86 (SD 0.10), and overall accuracy from 0.67 (SD 0.10) to 0.88 (0.06) (McNemar’s test, P<.001). Reader confidence also improved, with high-confidence ratings nearly doubling from 20% to 37%, and low-confidence ratings decreasing from 38% to 33%. These distributional changes were statistically significant (Stuart-Maxwell χ², P<.001). Conclusion: AI support markedly improved the diagnostic accuracy and confidence of novice LUS interpretation for detecting absent lung sliding. These findings suggest that real-time AI-based decision support may help improve access to high-quality LUS in military and other resource-limited care settings.
Keywords: lung ultrasound; point-of-care ultrasound; pneumothorax detection; artificial intelligence; eFAST; combat casualty care
High-Altitude Pulmonary Edema Management in a Special Operator
Spring 2026
Rodriguez JO, Shumway D, Tubbs P, Leek M, Nettlow D
Abstract
This case report delves into the challenges in diagnosis and management of a 30-year-old Army Special Forces officer who experienced respiratory distress during high-altitude training in Nepal, where he gained 3,000m in elevation over 3 days. Notably, the patient was prophylactically treated with acetazolamide but did not receive nifedipine or tadalafil. At an elevation of 13,550 feet (4,130m), the patient developed classic high-altitude pulmonary edema (HAPE) symptoms as well as concomitant respiratory symptomatology of breathlessness and worsening productive cough. The complexity of this case lay in managing HAPE in a remote, resource-limited environment with a small rescue window. We analyze the treatment alternatives used and ones not used, such as the portable hyperbaric chamber, and emphasize the necessity for standard-ized HAPE prophylaxis in appropriate personnel to prevent disruption to mission and loss of operational capabilities.
Keywords: high-altitude pulmonary edema (HAPE); Pararescuemen; rapid ascent; military operations; altitude-related illnesses; austere environment; remote environments; wilderness medicine; mountain medicine
Tourniquet Management Beyond the Golden Hour: A Call for Doctrinal Change in TCCC
Winter 2025
Beerbaum M, White J, Henderson J
Abstract
Tourniquets have proven lifesaving in modern combat, particularly during the Global War on Terror, where rapid evacuation often mitigated the risks of prolonged and non-medically indicated application. However, in future large scale combat operations (LSCOs), prolonged field care and delayed evacuation will be common. Without timely reassessment, medically unnecessary or ineffective tourniquets may lead to avoidable morbidity, including limb loss, rhabdomyolysis, and compartment syndrome. Data from U.S. and Ukrainian surgical teams reveal tourniquet reassessment, conversion, and optimization are not being practiced in the field to effectively control hemorrhage. Despite this, current TCCC doctrine lacks sufficient emphasis on tourniquet reassessment, conversion (TC), and optimization (TO)-especially among non-medical personnel. This paper calls for doctrinal change to classify tourniquet reassessment, TC, and TO as Tier 1 (All Service Member) skills. We recommend updating TCCC training, emphasizing reassessment within 2 hours of application, incorporating TC/TO into training lanes, and revising the DD1380 TCCC card to document these interventions. Preparing for LSCOs requires shifting from the “fire-and-forget” mindset. Equipping all service members with the skills to reassess and manage tourniquets appropriately can reduce preventable morbidity and preserve lives in prolonged care environments without compromising the proven benefits of rapid hemorrhage control.
Keywords: military medicine; medicine; trauma; tourniquets; TCCC; LSCO
Maritime Applications of Prolonged Casualty Care Training Scenario: Burn Injury on a Destroyer During Distributed Maritime Operations
Winter 2025
Adams D, Tripp MS, Damin VH, Chambers J, Brower JJ, Aydelotte JD, Gurney JM, Cancio LC, Tadlock MD
Abstract
As the U.S. Navy further develops the concept of distributed maritime operations (DMOs), where individual components of the naval force will be more geographically dispersed, smaller vessels may be operating at a significant time and distance from more advanced medical capabilities. Therefore, Role 1 maritime caregivers will need to manage injured and disease non-battle injury patients for prolonged periods during current and future contested DMOs. We developed a hypothetical burn injury patient scenario to present an innovative approach to teaching complex operational medicine concepts including austere burn resuscitation, wound care, and Prolonged Casualty Care (PCC) to austere Role 1 maritime caregivers using the Joint Trauma System PCC and Tactical Combat Casualty Care clinical practice guidelines (CPGs) and other standard references. The format includes basic epidemiology of burn injury in the operational maritime environment. The scenario includes a stem clinical vignette, followed by expected clinical changes for the affected patient at specific time points (e.g., time 0, 1 hour, 2 hours, and 48 hours) with expected interventions based on the PCC CPG, appropriate guidelines, and available standard shipboard equipment. Through this process, opportunities to improve both training, clinical skills sustainment, and standard shipboard medical supplies are identified.
Keywords: prolonged casualty care; Tactical Combat Casualty Care; infective endocarditis; critical care; burn injury; MRSA
Medical Considerations in High-Risk Maritime Operations: A Narrative Review
Winter 2025
Granholm F, Lauria MJ, Melau J, Tin D
Abstract
Maritime operations conducted by military Special Operations Forces and civilian special weapons and tactics (SWAT) units present unique medical challenges. These missions often occur in unpredictable environments, far from immediate medical resources and with exposure to waterborne threats. This article examines the medical aspects critical to maritime operations, including hypothermia management, trauma care in confined and moving spaces, management of drowning and respiratory issues, and specialized training for maritime-specific injuries. A narrative review of literature from 2005-2024 was conducted across major databases and grey sources, with studies included by author consensus. The review identified core maritime medical challenges, hypothermia, drowning, confined-space trauma, respiratory hazards, motion sickness, and impact injuries. Medical support tailored to these environments is essential for maintaining operational effectiveness and responder safety. By examining both preventive and responsive medical approaches, this article highlights the need for maritimespecific medical protocols and training
Keywords: maritime; tactical medicine; transesophageal echocardiogram; prehospital; trauma; performance; transthoracic echocardiogram; SWAT; SOF; Special Operations
In-Theater Assessment of Resuscitative Balloon Occlusion of the Aorta (REBOA) Capabilities and Training
Fall 2025
Koo AY, Hu J, Couperus KS, Eastman J, Kwolek T, Remick KN
Abstract
Background: Resuscitative endovascular balloon occlusion of the aorta (REBOA) is an endovascular technology indicated for temporarily controlling traumatic life-threatening, noncompressible abdominal, truncal, or pelvic hemorrhage. Through percutaneous access or cut-down to the femoral artery, an intra-aortic balloon catheter is fed into the aorta and inflated, occluding distal blood flow and, thus, bleeding. To determine specific barriers to REBOA in deployed environments, we conducted a quality improvement project and survey of ER-REBOA® placement and monitoring capabilities at four medical treatment locations in Iraq and Kuwait during the spring of 2019. Methods: The primary objective was to evaluate each in-theater medical site’s ability to deploy REBOA, which was defined as having a provider capable of placing REBOA and the minimum equipment necessary. The investigators interviewed providers and through self-reported surveys, determined the personnel capable of placing a REBOA. REBOA equipment and monitoring equipment were identified through direct inspection of sites and interviews with logistical and equipment staff. Results: A total of 113 individuals participated in the evaluation and training. Three of the four sites had the minimum training and equipment requirements to complete the procedure: one REBOA-capable provider, an unexpired ER-REBOA® device, and an unexpired introducer catheter kit. Overall, 6 out of 32 physicians (18.7%) were capable of placing an ER-REBOA. Conclusion: This deployed site survey demonstrates that the minimal requirements and personnel for ER-REBOA placement were met at most studied locations in 2019. However, improvements in pre-deployment training of select medical personnel in REBOA and arterial blood pressure monitoring are recommended to ensure adequate resourcing and redundancy in training.
Keywords: REBOA; resuscitative endovascular balloon occlusion of the aorta; intra-aortic balloon; ER-REBOA; deployment; noncompressible hemorrhage
Antibiotic Concentrations After Massive Transfusion (ACME) Study: A Review of the Literature on Antibiotic Dosing During Transfusion and Study Protocol
Fall 2025
Huaman RJ, Mancha F, Anderson EL, April MD, Bebarta VS, Castaneto MS, Christians U, Darlington DN, Douin DJ, Glenn KR, Ke P, Kirkwood BJ, Long BJ, Maddry JK, Mendez J, Mireles AA, Ritter AC, Schauer KE, Schumaker AL, Smith MD, Wright FL, Ginde AA, Rizzo JA, Schauer SG
Abstract
Background: Trauma in combat or civilian settings often involves severe hemorrhage and open wounds, which carry a high risk of infection. Current clinical guidelines recommend prophylactic antibiotics for high-risk wounds. Adequate plasma antibiotic concentrations are necessary for tissue penetration, particularly into injured tissue. Blood loss from traumatic hemorrhage may impact plasma antibiotic concentrations. However, the association between blood loss, subsequent blood product transfusion, and antibiotic concentrations remains unclear. We hypothesize that antibiotic concentrations decrease in proportion to the volume of blood transfused, potentially leading to insufficient antibiotic concentrations, placing the injured patient at increased infection risk. Methods: We are conducting a prospective, multicenter study that will enroll trauma patients from two large trauma centers: Brooke Army Medical Center and the University of Colorado Hospital. We will enroll participants receiving antibiotics for wound prophylaxis and three or more units of blood products. We will also enroll a control arm comprised of participants receiving the same antibiotics who receive two or fewer units of blood. Blood samples will be collected from participants at predetermined time intervals after antibiotic infusion to assess antibiotic concentrations. Our statistical analysis will focus on the relationship between the volume of blood products administered and antibiotic concentrations. Results will inform the development of antibiotic dosing models for clinicians that adjust for the effects of blood transfusion. Conclusion: The goal of this study is to fill a significant gap in trauma care that could potentially lead to optimized antibiotic dosing and improved outcomes for trauma patients.
Keywords: antibiotic; concentration; drug; massive antibiotic; blood; blood transfusion; hemorrhage; anti-bacterial agents; wounds and injuries
Definitive Field Care: The Modern Application of a Historical Strategy
Fall 2025
Hiles JM, Hofmann LJ, Grant AA, Hardin RD
Abstract
Definitive Field Care (DFC) is a medical strategy required when evacuation is impossible due to tactical, environmental, or political constraints. Unlike Prolonged Field Care (PFC) or Prolonged Casualty Care (PCC), which assume eventual evacuation, DFC places full responsibility for definitive treatment on the initial provider. Historical examples, such as the Yugoslavian Partisans in World War II and Afghan resistance fighters during the Soviet invasion, highlight the necessity of DFC in austere, high-risk environments. Key considerations include operational constraints, risk tolerance, and provider mindset. Without evacuation, medical priorities shift, requiring difficult decisions. Providers must adapt to scarce resources, hostile conditions, and the absence of Geneva Convention protections. The mindset required demands resilience, adaptability, and acceptance of non-Western medical standards. As irregular warfare becomes more prevalent, formally recognizing, studying, and integrating DFC into military and humanitarian medical planning is essential. Training personnel for DFC will enhance operational effectiveness and improve survival rates in extreme conditions.
Keywords: field care; austere surgery; irregular warfare; PFC; PCC
Undersea and Hyperbaric Medicine Case Studies and Review
Summer 2025
Day M, Radi J
Abstract
There is a dearth of studies in undersea and hyperbaric medicine (UHM), likely due to the limited number of clinicians currently specializing in UHM. Due to the high-consequence nature of diving and the effects of pressure on the human body, medical clearance is of the utmost importance. Despite all efforts to mitigate the possibilities of dive maladies, divers occasionally succumb to the effects of prolonged submersion. This article provides an in-depth look at three individuals who suffered from separate dive-related medical events. In each example, UHM was applied and successfully mitigated short and long-term medical consequences. The manuscript then reviews common and life-threatening dive maladies, with an in-depth examination of decompression strategies and diving clearance.
Keywords: undersea and hyperbaric medicine; hyperbaric medicine; diving medicine; dive; recompression chamber; emergency evacuation hyperbaric stretchers; pulmonary overinflation syndrome; decompression sickness; decompression illness; barotrauma
“The Future of Special Operations Forces Medicine”: Review of the Paris Special Operations Forces Combat Medical Care Conference, Fall 2024
Summer 2025
Pasquier P, Mahe P, Josse F
Abstract
Keywords:
Effects of Whole Blood Donation on Physiological Responses and Physical Performance at Altitude
Spring 2025
Jones D, Roberts N, Weller RS, McClintock RJ, Buchanan C, Dunn TL
Abstract
Background: The impact of single-unit blood donation (BD) on donor physical performance at sea level is well-studied. However, no studies have evaluated the impacts of BD on warfighter performance at higher elevations. This study evaluated the effects of BD on high-altitude combat-load carry performance in acclimatized military personnel following BD. Methods: Thirteen acclimatized military personnel (age: mean 28 [SD 6] years; height mean 175 [SD 7] cm; weight: mean 78.4 [SD 9.1] kg; residence elevation 2,100m) completed two 3.2-km rucksack carries (mean 24.2 [SD 2.1] kg from 2800 to 3,050m, one without BD (control) and one after BD. Total ruck march time, heart rate (HR), oxygen saturation (SpO2), respiratory rate (RR), minute ventilation (VE), rating of perceived exertion (RPE), thermal sensation (TS), and acute mountain sickness (AMS) symptoms were analyzed. Results: There were no differences between control and BD for ruck march time (F(1,11)=2.13, P>.1, η2G=.03), HR (P>.1), RR (P>.1), VE (P>.1), RPE (P>.1), and TS (P>.07). AMS symptoms were not impacted by either condition. SpO2 was lower in the control scenario than after BD (b=-4.23 [SE 2.4], P=.007). Conclusions: A single-unit whole blood donation does not impact donor physical performance in acclimatized participants during combat-load carries at elevations up to 3,050m except with respect to SpO2
Keywords: military; blood transfusion; elevation; exercise; performance; resource-limited settings