Adopting a culture of remote damage control resuscitation in the military: Insights from the Israel defense forces decade of experience

Background

Remote damage control resuscitation (RDCR) aims to apply the principles of damage control resuscitation to prehospital and austere care, emphasizing early control of compressible hemorrhage, balanced volume resuscitation, and the prevention or correction of coagulopathy, acidosis, hypothermia, and hypocalcemia. Over the past decades, the Israel Defense Forces Medical Corps (IDF-MC) has made significant efforts to integrate the principles of RDCR into prehospital trauma care in the military.

Study Design and Methods

In this article, we reflect on the implementation of RDCR in the prehospital setting by the IDF-MC, sharing successes, challenges, considerations on guideline changes, and their assessment over time.

Results

The implementation of RDCR has resulted in changes in clinical practice guidelines and training programs, with increased awareness and adoption of RDCR principles among both medical and non-medical military personnel. The implementation of these principles and adherence to guideline changes have been analyzed using the Israel Defense Forces Trauma Registry.

Discussion

By sharing our experiences, we hope to provide valuable insights for other military and civilian organizations seeking to adopt similar protocols for prehospital care. Continuous evaluation and refinement of guidelines and training programs will be essential for ongoing implementation and advancement of RDCR in the prehospital setting.     

Differential impact of missed initial wound clinic visit on 6-month wound healing by race/ethnicity among patients with chronic limb-threatening ischemia

Chronic limb-threatening ischemia (CLTI) is associated with significant morbidity, including major limb amputation, and mortality. Healing ischemic wounds is necessary to optimise vascular outcomes and can be facilitated by dedicated appointments at a wound clinic. This study aimed to estimate the association between successful wound care initiation and 6-month wound healing, with specific attention to differences by race/ethnicity. This retrospective study included 398 patients with CLTI and at least one ischaemic wound who scheduled an appointment at our wound clinic between January 2015 and July 2020. The exposure was the completion status of patients' first scheduled wound care appointment (complete/not complete) and the primary outcome was 6-month wound healing (healed/not healed). The analysis focused on how this association was modified by race/ethnicity. We used Aalen–Johansen estimators to produce cumulative incidence curves and calculated risk ratios within strata of race/ethnicity. The final adjustment set included age, revascularization, and initial wound size. Patients had a mean age of 67 ± 14 years, were 41% female, 46% non-White and had 517 total wounds. In the overall cohort, 70% of patients completed their first visit and 34% of wounds healed within 6-months. There was no significant difference in 6-month healing based on first visit completion status for White/non-Hispanic individuals (RR [95% CI] = 1.18 [0.91, 1.45]; p-value = 0.130), while non-White individuals were roughly 3 times more likely to heal their wounds if they completed their first appointment (RR [95% CI] = 2.89 [2.66, 3.11]; p-value < 0.001). In conclusion, non-White patients were approximately three times more likely to heal their wound in 6 months if they completed their first scheduled wound care appointment while White/non-Hispanic individuals' risk of healing was similar regardless of first visit completion status. Future efforts should focus on providing additional resources to ensure minority groups with wounds have the support they need to access and successfully initiate wound care.     

Adaptive closed-loop resuscitation controllers for hemorrhagic shock resuscitation

Background

After hemorrhage control, fluid resuscitation is the most important intervention for hemorrhage. Even skilled providers can find resuscitation challenging to manage, especially when multiple patients require care. In the future, attention-demanding medical tasks like fluid resuscitation for hemorrhage patients may be reassigned to autonomous medical systems when availability of skilled human providers is limited, such as in austere military settings and mass casualty incidents. Central to this endeavor is the development and optimization of control architectures for physiological closed-loop control systems (PCLCs). PCLCs can take many forms, from simple table look-up methods to widely used proportional–integral–derivative or fuzzy-logic control theory. Here, we describe the design and optimization of multiple adaptive resuscitation controllers (ARCs) that we have purpose-built for the resuscitation of hemorrhaging patients.

Study Design and Methods

Three ARC designs were evaluated that measured pressure–volume responsiveness using different methodologies during resuscitation from which adapted infusion rates were calculated. These controllers were adaptive in that they estimated required infusion flow rates based on measured volume responsiveness. A previously developed hardware-in-loop test platform was used to evaluate the ARCs implementations across several hemorrhage scenarios.

Results

After optimization, we found that our purpose-built controllers outperformed traditional control system architecture as embodied in our previously developed dual-input fuzzy-logic controller.

Discussion

Future efforts will focus on engineering our purpose-built control systems to be robust to noise in the physiological signal coming to the controller from the patient as well as testing controller performance across a range of test scenarios and in vivo.