BACKGROUND:Special Operations Forces (SOF) undergo significantly more rigorous selection and training than conventional military units, which can have an impact on body composition. The aim of this study was to determine whether SOF exhibit distinct body composition characteristics compared to conventional military personnel. METHODS:A total of 500 Belgian male soldiers, aged 20-30 years, participated in this study. Participants were recruited from six military units: 182 noncommissioned officers (NCOs), 85 officers, 122 paratroopers, 32 SOF, 24 physical training instructors (PTIs), and 55 sailors serving on a frigate (Navy personnel). Multifrequency bioelectrical impedance analysis assessed anthropometric measurements. RESULTS:Mean body weight ranged from a minimum of 75.4 (SD 9.4) kg in NCOs to a maximum of 83.2 (SD 12.5) kg in Navy personnel. Body fat percent was lowest in PTI (13.7% [SD 3.6%]) and highest in Navy personnel (19.7% [SD 5.8%]). Fat mass index (FMI) in SOF was comparable to other units, with 3.6 (SD 0.8) kg/m2. Fat-free mass index (FFMI) was lowest for officers, and highest for SOF, at 19.6 (SD 1.4) kg/m2 and 21.0 (SD 0.9) kg/m2, respectively. A low FMI coupled with a high FFMI was most prevalent in SOF with 53.1%. CONCLUSION:SOF demonstrated the highest FFMI, likely as a result of the rigorous selection process, daily physical training, and operational demands. This finding underscores the importance of body composition assessment in evaluating candidates' potential for success in SOF selection.
BACKGROUND:Testosterone may assist in traumatic hemostasis given its well-established role in erythropoiesis, platelet activation, and vasoconstriction; however, whether exogenous testosterone improves acute outcomes in traumatic hemorrhage is unknown. METHODS:Following PRISMA 2020, we registered the protocol in PROSPERO (CRD42024617294; 12 October 2024). MEDLINE, EMBASE (both via Ovid), and PubMed were searched from inception to November 2024 for studies that investigated the acute effects of testosterone administration in adults with hemorrhage. Two reviewers independently screened citations and full texts using prespecified eligibility criteria. Independent and duplicate data extraction by two reviewers, and GRADE certainty assessments were prespecified. RESULTS:Of the 215 records identified, 197 were excluded at title/abstract and 18 underwent full-text review. No study met the inclusion criteria. Consequently, no planned data extraction and GRADE assessments were performed. CONCLUSIONS:No eligible human studies evaluate exogenous testosterone as an acute intervention in traumatic hemorrhage. The literature gap persists despite a clear clinical rationale and predefined outcome set. High-quality translational and clinical studies using rigorous dosing/timing definitions and standard coagulation and patient-centred endpoints are needed to determine whether testosterone confers benefit or harm in this setting.
Unconventional warfare medicine operates in contested, resource-limited, and nonpermissive environments that challenge traditional models of combat care. Characterized by irregular forces, proxy engagements, and disrupted medical evacuation pathways, it requires clinicians to deliver prolonged, adaptable care with limited command, control, and logistics. Despite its operational significance, the field remains poorly defined, with knowledge dispersed across classified reports, practitioner experience, and fragmented literature. This gap constrains doctrine development, training, interoperability, and innovation. Emerging studies highlight themes, such as distributed treatment nodes, autonomous resuscitation, and adaptive medical structures, yet evaluative research and outcome data remain scarce. As modern conflict increasingly reflects irregular and hybrid characteristics, advancing unconventional warfare medicine is essential for future readiness. A scoping review of existing evidence can provide the first structured foundation for establishing this discipline, fostering collaboration between practitioners and researchers, and guiding capability development without compromising operational security.
BACKGROUND:This study compared point-of-care ultrasound (POCUS) accuracy in identifying a standard bougie (SB) versus a wire-core bougie (WCB) placed in the trachea or esophagus of cadaveric models. Using a trans-tracheal approach at the suprasternal notch, we assessed whether the WCB improves POCUS identification. METHODS:In this double-blind, randomized crossover trial, 31 emergency medicine and general surgery residents and faculty evaluated bougie placement in a controlled cadaveric lab. Participants were blinded to bougie type and location and interpreted real-time POCUS images as tracheal, esophageal, or indeterminate. The primary outcome was identification accuracy; secondary outcomes included sensitivity, specificity, accuracy, likelihood ratios, and time to identification. RESULTS:After excluding indeterminate responses, 112 matched pairs were analyzed. Identification accuracy was higher with the WCB (98%; 110/112) than the SB (89%; 100/112). Although this 9% difference was statistically significant (P=.006), it did not meet the predetermined 20% threshold for clinical significance. The WCB showed superior sensitivity (96%) and specificity (100%) compared with the SB (92% and 86%, respectively). Median time to identification was similar: 3.3 seconds (IQR 2.4-6.4s) for the SB and 3.4 seconds (IQR 2.6-5.0s) for the WCB (P=.16). CONCLUSIONS:POCUS accurately detects placement of both bougie types in cadaveric models. Although the WCB demonstrated higher diagnostic accuracy, the difference was not clinically meaningful based on the a priori threshold. Participants rapidly identified both devices, supporting POCUS as a feasible adjunct for airway confirmation. Additional studies are needed to evaluate POCUS detection of bougie placement during live intubations.
The TASER™ T10® (T10) is a new generation of conducted electrical weapon (CEW) introduced in 2023. T10 has significant new technology enhancements related to the deployed darts. These darts are thin-diameter, low-profile projectiles launched by primer-ignited black-powder instead of compressed nitrogen used in previous model launch platforms. They are also launched at higher muzzle velocity (62.5±9.1m/s or 205±30 feet/s) than previous CEW darts, to assist with enhanced target adherence. We retrospectively examined digital images of human tissue that had 40 T10 darts fired into it at measured velocities between 186 feet per second and 273 feet per second (56.7- 83.2m/s). Target sites included bare skin on the lower abdomen, mid-thigh, and buttocks. The T10 darts were fired via an adjustable velocity, compressed air cannon through a ballistic chronograph to record accurate projectile velocities. The images were evaluated for evidence of over-penetration. Even at the fastest velocities, no over-penetration of human tissue was noted. We conclude that the new CEW darts operate with a significant margin of safety in terms of muzzle velocity and risk of human tissue penetration when fired as intended into recommended target areas.
Melioidosis, caused by the gram-negative bacillus Burkholderia pseudomallei - a Tier 1 Select Biological agent - remains a significant cause of severe community-acquired infection in tropical regions, but with recent expanding recognition in temperate climates, including the United States. Pulmonary involvement is the most frequent clinical manifestation, ranging from subclinical nodules to fulminant necrotizing pneumonia and acute respiratory distress syndrome. Despite its clinical severity, melioidosis remains underdiagnosed due to its radiologic mimicry of tuberculosis, broad clinical manifestations, and limited laboratory capacity in many endemic areas. Special Operations Forces (SOF) participating in field exercises or operations in B. pseudomallei endemic countries are at significantly increased risk of infection. Accordingly, SOF medical providers should maintain a high index of suspicion for melioidosis and be familiar with its clinical recognition, diagnosis, and management.
Modern individual first aid kits (IFAKs) were designed to stabilize a single casualty during short evacuation timelines, an increasingly invalid assumption in large-scale combat operations. Sustained exposure to artillery, mortars, and dronedelivered munitions produces multiple simultaneous casualties with complex polytrauma and prolonged evacuation delays. This article uses a firsthand account from a trench engagement in Ukraine to examine how contemporary injury patterns rapidly overwhelm standard IFAK contents. Through structured interviews with a combat-experienced Soldier, the narrative illustrates repeated depletion and physical destruction of individual medical kits during ongoing contact, despite appropriate hemorrhage control techniques. Adaptations in medical loadouts observed in this environment emphasize distributed supplies, redundancy, and forward shifting of traditionally medic-held equipment to individual Soldiers. These observations highlight a critical mismatch between currently issued IFAKs and the realities of modern high-intensity conflict, underscoring the need to reassess individual medical loadout doctrine for future battlefields.
BACKGROUND:Point-of-care ultrasound (POCUS) enhances combat survivability, yet civilian standards often fail to address battlefield constraints. This scoping review delineates Expeditionary POCUS (E-POCUS) as a distinct capability. METHODS:A systematic scoping review following PRISMA-ScR guidelines searched PubMed, Embase, Web of Science, and Google Scholar through November 2025. Inclusion criteria targeted terrestrial austere and combat environments, strictly excluding hospital-based studies. We assessed quality using a modified GRADE framework. RESULTS:Fifty-three studies met the inclusion criteria. Data originated largely from civilian, resource-limited settings (34%) rather than from military zones (26%). Methodological quality was polarized: high-quality randomized trials supported artificial intelligence-assisted acquisition, while trauma protocols relied on very low-quality animal models. Analysis identified critical gaps in military-relevant POCUS standardization in equipment acquisition, training, and the application of ultrasound in austere and combat environments. CONCLUSION:E-POCUS requires a doctrine distinct from civilian standards. We propose a Best, Better, Minimum competency matrix to standardize training and justify the allocation of ultrasound equipment. We argue that to ensure the sustainability of standardized training in E-POCUS as a diagnostic capability, future research must validate these frameworks along with systemic quality improvement initiatives.
Extracorporeal life support (ECLS) is the most advanced form of life support in existence for patients experiencing acute cardiac and/or pulmonary failure. However, major limitations for the use of ECLS, in both far-forward and transport environments, are the difficulty of its initiation, the need for adjunctive imaging to avoid damage to the heart and great vessels, and difficulty confirming correct cannula placement. We hypothesize that a dual-lumen cannula (DLC) modified for femoral vein placement will make cannula placement by an individual feasible and will overcome constraints of large imaging adjuncts and limited personnel experience. This type of design may lead to a faster, safer, and more reliable delivery of ECLS to the patient. Herein, our objective is to create recommendations for the design of a DLC for femoral vein placement. We present findings from the placement of a femoral DLC using a simulation mannequin and subsequent interviews with hospital, military, and academic personnel.
The term tactical athlete is being used prolifically in the tactical environment, originally coined to highlight the significant physical demand faced by many in tactical professions. While the use of this phrase had positive intentions, there are substantial and important differences between the privileges afforded to professional athletes and the challenges faced by tactical professionals. This review highlights the similarities and differences between the two and describes how the term tactical athlete may not be the best nomenclature for these personnel. By challenging the 'tactical athlete' label, this review highlights the risk of misaligned training and support strategies that may compromise operational readiness and increase injury risk.
BACKGROUND:We investigated factors associated with military personnel success in Special Operations courses (course pass or fail). METHODS:A systematic search was conducted across eight databases using the keywords "Special Operations" and "attrition." Sample size and profile data, course characteristics, predictive factors, follow-up, and results were extracted from the studies. We compared the means of the variables associated with success between the groups that completed and did not complete the courses. A meta-analysis was conducted for factors assessed by two or more studies, pooling standardized or weighted mean differences using fixedor random-effects models. RESULTS:A total of 23 studies were included. They were published between 1990 and 2022, included samples from 10 nations, lasted between 5 days and 12 months, and ranged from 11 to 1,138 individuals. VO2max, pull-ups, push-ups, and marching performance showed consistent positive associations with course success, while body fat percentage and sit-up performance did not. Certainty of evidence was rated as low to very low using the Grading of Recommendations Assessment, Development, and Evaluation. CONCLUSION:The factors that increased the probability of success in Special Operations courses were character strengths, recidivism in the course, anthropometric data, performance on physical assessment tests, psychological dissociation, psychosocial resources, blood markers, smoking/alcohol consumption, personality, and psychological strength. These findings support the inclusion of aerobic capacity, muscular endurance, and psychological resilience in early screening and preparatory selection processes.
BACKGROUND:Telemedicine is a critical military medicine capability in austere, remote, and denied environments where prolonged casualty care and knowledge gaps exist. Despite significant military investment in telemedicine, the literature lacks detailed lessons from real-world cases. METHODS:U.S. Air Force Pararescue missions between 1 January 2010 and 31 December 2020 that included telemedicine consultation were reviewed. Participating flight surgeons (FS) and Pararescuemen (PJ) were interviewed, and available after-action reports were analyzed. Mission parameters, outcomes, and technical or human factors affecting communication were evaluated. RESULTS:Across 13 telemedicine consultations, the 28 patients experienced: cave entrapment (13), trauma (7), burns (4), and illness (4). Consultations were from PJ to FS (11), U.S. Coast Guard to FS (1), and FS to neurosurgery (1). Secondary consultations (7) were from FS to dental (1), dermatology, burn/critical care, orthopedics (2), pediatric anesthesiology, and thoracic surgery specialists. Missions used voice over mobile or satellite phone, text, and email. Recommendations commonly involved medication selection (6), advisement against mission launch (3), and burn care (2). Consultation effectiveness was impacted by unclear directions (3) and degraded communications (2). CONCLUSION:Telemedicine is valuable to PJs during complicated cases and rarely performed procedures, but cannot replace pre-deployment medical exposure and training. Rehearsals may optimize telemedicine, and training should focus on synchronizing a shared mental model of the patient using well-understood patient report and evaluation tools (ATMIST and MARCH PAWS). Telemedicine may reduce human error, give medics the confidence to take action, and limit the psychological impact of difficult care decisions.
BACKGROUND:The U.S. Army Forward Resuscitative Surgical Detachment (FRSD) provides rapid damage control resuscitation and surgery near the point of injury within combat zones. To improve team performance and operational readiness within two FRSD units preparing for combat deployment, we developed a systematic, evidence-informed standard operating procedure (SOP) to address the unique challenges of far-forward trauma resuscitation. METHODS:This project was conducted under unit-level authority as an internal readiness optimization effort, consistent with every FRSD's responsibility to develop its own SOPs. We created a theoretical framework for team performance optimization based on literature and interdisciplinary expert input. The prototype SOP was refined through simulation training and real-world trauma resuscitations during two FRSD deployments. Performance feedback and after-action reviews were used to iteratively optimize the "STEP" system. RESULTS:The STEP method is a framework for optimizing Army FRSD team performance, based on four crucial elements: Skill, Team organization, Equipment, and Process. "Skill" emphasizes proficiency in performing trauma resuscitation procedures and cross-training of team members for adaptability in mass casualty scenarios. "Team organization" includes clear roles and responsibilities, and a communication standard to avoid miscommunication and confusion. "Equipment" includes equipment maintenance, positioning, and familiarization. "Process" refers to the "game plan," a structured sequence of diagnostic and therapeutic steps that supports organization and efficiency. CONCLUSION:The STEP method introduces a standardized approach to traumaresus-citation by Army FRSDs, offering a replicable SOP template with broad applicability across Army medical units. It holds potential beyond trauma resuscitation, offering a versatile framework for optimizing team performance in high-stress, high-stakes environments.
INTRODUCTION:The focused assessment with sonography in trauma (FAST) is the most important ultrasound exam in the operational environment, yet its sensitivity for diagnosis of solid organ injury is limited. Contrast-enhanced FAST (cFAST) augments the diagnostic power of the FAST exam of parenchymal and vascular injuries, and it rivals CT. Studies on cFAST have not used handheld ultrasound systems found in the combat environment. METHODS:As part of a methodsdesign process for a cFAST study, the authors tested six hand-held and portable ultrasound systems for their ability to visualize contrast enhancement: Philips Lumify, Butterfly IQ3, GE Vscan Air, Fujifilm Sonosite Edge II, Fujifilm Sonosite M-Turbo, and GE Venue (cart-based comparator). None had dedicated "contrast" settings. Device settings were adjusted to minimize gain and maintain a mechanical index below .3. Three standardized patients received .02mL to .11mL intravenous boluses of perflutren (Definity) followed by a 10mL saline flush. The right upper quadrant was scanned to assess contrast visualization in the kidney. RESULTS:Contrast enhancement was visualized on only one handheld device (GE Vscan Air) and the GE Venue (cart-based comparator). No enhancement was seen with the others. CONCLUSIONS:Most handheld and portable ultrasound systems currently used in deployed medical settings failed to visualize contrast. While the GE Vscan Air shows promise, further investigation is necessary to determine whether system modifications, software upgrades, or dosing adjustments can enable cFAST capability in the far-forward environment. Reliable handheld-based cFAST methods will advance research and implementation of this technology in military trauma care.
BACKGROUND:Hypothermia is a major driver of trauma-induced coagulopathy on the battlefield. Several portable blood warmers have been developed for use in forward-deployed prehospital environments; however, end-user preferences for device use have not previously been investigated. METHODS:A convenience sample of Naval Special Warfare (NSW) Corpsmen (HMs, n=35) were surveyed regarding their perceived usability of five blood warmer devices: the QinFlow®, M Warmer, Buddy Lite®, Thermal Angel™, and the North American Rescue (NAR) Quantum®. The Likert-based survey was built around evaluating three domains: ease of use, device ruggedness, and perceived device efficacy. Responses were quantified and compared using the Kruskal-Wallis test and the chi-square test, as appropriate. Statistical significance was defined as P<.05. Qualitative responses were summarized into major themes. RESULTS:The M Warmer received the highest overall scores in all three domains with statistically significant differences identified across most comparisons to other warmers. Qualitative analysis reinforced these findings, emphasizing the importance of compactness, intuitive deployment, and device reliability in austere environments. The M Warmer was the most frequently preferred device (45%, P=.0067), with users citing portability, rapid setup, and compatibility with existing gear as key advantages. CONCLUSION:In this cohort of NSW HMs, user-centered evaluation of field blood warmers identified the M Warmer as the most operationally favorable device. Preferences were shaped not only by perceived effectiveness but by factors directly relevant to forward-deployed settings: portability, intuitive operation, and logistical simplicity. These findings underscore the importance of integrating end-user feedback into medical equipment acquisition.
BACKGROUND:We evaluated pressures and tightening-system use of 3.8cm-wide, self-securing-strap/redirect-and-tightening-system X8T-T2G tourniquets (X8Ts). METHODS:Applied left/right, mid-arm and mid-thigh, 40 recipients, first completion one-click-past arterial occlusion, release 100s later. Compared to concurrent study: four 3.8cm-wide, windlass-rod-tightening-system tourniquets (n=30 each). RESULTS:All X8T reached occlusion and completion without securing struggles. Maintaining occlusion till release, 3 arms/25 thighs required additional click once, 2/2 required twice, and 1 thigh required thrice. Nineteen arms large enough for X8T pressure monitoring: occlusion median 298mmHg (minimum 188, interquartile range 262, 322, maximum 335), first completion 338mmHg (219, 310, 372, 391), pre-release 304mmHg (172, 270, 323, 342). Thigh pressures: occlusion 359mmHg (273, 334, 388, 478), first completion 393mmHg (308, 366, 426, 489), pre-release 368mmHg (289, 339, 390, 462); each< respective windlass-rod tourniquet pressures (every P<.030). Arm clicks: occlusion 5 (0, 4, 7, 10), first completion 6 (1, 5, 8, 11), pre-release 7 (1, 5, 8, 11); first completion and pre-release tightening-system rotation<windlass-rod tourniquets (every P<.0001, 10 clicks=180°). Thigh clicks: occlusion 13 (6, 10, 16, 39), first completion 14 (7, 11, 17, 40), pre-release 15 (7, 12, 18, 41); first completion and pre-release tightening-system rotation<windlass-rod tourniquets (one pre-release P=.072, all other P<.005). Clicks after first completion took 2s (1, 2, 3, 4); faster than 66 additional uses of windlass-rod tightening systems (medians 10-18s, every P<.0001). CONCLUSIONS:X8Ts were arterially occlusive with simple, self-securing, tightening-system advances. Versus windlass-rod systems, first completion and pre-release pressures and total tightening-system rotation were lower, and completion of tightening-system use after first completion was faster.
BACKGROUND:Night vision goggles (NVG) grant warfighters a tactical advantage in low-light environments. However, NVG use can negatively affect visual acuity, depth perception, and color discrimination, which impacts warfighter safety and operational performance. Therefore, the purpose of this study was to examine the biomechanical effects in the walking phase of an obstacle clearance course and prefrontal cortex (PFC) regional oxygen saturation (rScO2) during embedded marksmanship and cognitive tasks performed with and without NVGs. METHODS:Twelve participants (21 [SD 1] years) completed an obstacle avoidance course with and without NVGs, which included pistol marksmanship assessments, cognitive assessments, and ground obstacles. Gait pattern, performance tasks, and PFC activity were recorded. RESULTS:Marksmanship performance decreased by 58.2% (P<.01), but cognitive performance was not impacted with NVG use (P=.676). Toe clearance increased by 32.2% (P<.01), toe velocity decreased by 20.5% (P<.01), and ankle dorsiflexion increased by 24.0% (P=.02) with NVG. Significant reductions in rScO2 during Marksmanship 2 (P<.01) and Cognitive Assessment Task 1 (P=.01) and 2 (P=.01) were observed. CONCLUSION:Performance decrements with NVG use are hypothesized to be primarily due to altered vision perception and increased metabolic demand affecting marksmanship performance and gait patterns. NVG training may minimize the risk of musculoskeletal injuries and improve operational performance.
This case report describes treatment of a Special Operations Forces (SOF) Operator with high religiosity experiencing posttraumatic stress disorder (PTSD) and moral injury after exposure to indirect combat-related trauma via real-time audiovisual drone feed. The patient completed virtual massed cognitive processing therapy (CPT) augmented by a single spiritual counseling session to address faith-based concerns interfering with trauma processing. Initial symptom exacerbation occurred early during CPT, but following spiritual counseling, the patient engaged more fully in therapy, leading to a significant reduction in PTSD and depressive symptoms. This case highlights the importance of identifying and addressing faith-related moral injury early in treatment and suggests that integrating spiritual counseling with CPT may enhance outcomes for Operators and other Servicemembers suffering with vicarious posttraumatic stress stemming from indirect combat exposure.
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.
