BACKGROUND:Despite two large randomized controlled trials (RCT) designed to assess tranexamic acid (TXA) for traumatic brain injury (TBI) patients, its use and optimal dosing strategy in TBI remains uncertain. We sought to assess functional and mortality outcomes associated with prehospital TXA administration for TBI patients using Bayesian techniques. METHODS:We performed a post hoc analysis of the prehospital TXA for TBI RCT where TBI patients received TXA as a 1-g bolus followed by a 1-g infusion (standard), 2-g bolus (bolus), or placebo. Bayesian regression models were created to assess the association of early prehospital TXA administration in TBI patients using posterior probabilities for 6-month functional outcomes, as well as 28-day and 6-month mortality. RESULTS:Patients receiving prehospital TXA (standard or bolus) displayed a 78.1% probability of having improved functional neurologic outcomes at 6 months compared with placebo. When compared with placebo, the Bolus cohort displayed a 95.3% probability of improved functional neurologic outcomes at 6 months, a 95.3% probability of decreased mortality at 28 days, and a 70.7% probability of decreased mortality at 6 months. The Standard cohort displayed a less than 50% probability of benefit compared with placebo for all outcomes measured. CONCLUSION:A prehospital 2 g TXA bolus dosing strategy demonstrated a high probability of benefit compared with both placebo and Standard cohorts for functional neurologic and mortality outcomes in patients with moderate to severe TBI. ( J Trauma Acute Care Surg . 2026;100: 879-885. © 2026 American Association for the Surgery of Trauma.). LEVEL OF EVIDENCE:Therapeutic; Level III.

INTRODUCTION:This manuscript provides a comprehensive overview of modern Pararescue (PJ) medical experiences and capabilities, focusing on the period from 2012 to 2024. Pararescues, unique within the Department of Defense, are specifically trained for personnel recovery and provide rapid medical response in adverse conditions. Their extensive training pipeline equips them to handle a wide range of medical emergencies as advanced-scope paramedics that are also equipped with a broad scope of rescue skills. MATERIALS AND METHODS:This retrospective review analyzes data from the Air Combat Command's Lessons Learned Repository, encompassing 197 human PJ-patient encounters spanning from 2012 to 2024. After-action reports and patient care reports available for this time were utilized to generate a patient registry. Relevant data was then collated and utilized for this manuscript. RESULTS:Key findings include a 12.2% case fatality rate, with 86% of cases involving trauma. Missions occurred within the continental United States, in combat zones overseas, Alaska, and at sea, highlighting the diverse operational environments PJs encounter. Mechanisms of injury varied significantly, including hiking/climbing injuries, plane crashes, gunshot wounds, and improvised explosive devices. Pararescue interventions included tourniquet placement, wound packing, cricothyrotomies, and blood product transfusions. Non-standardized methods of documentation was a noted problem that made depth of patient documentation inconsistent. CONCLUSIONS:Despite the challenges, PJs' unique skill set and rapid response capabilities make them invaluable in both combat and non-combat scenarios. The survival rate for patients alive at PJ contact was 97.2%, underscoring the effectiveness of their training and procedures. However, documentation practices were inconsistent, with limited standardization for patient care documentation. The manuscript emphasizes the need for improved data capture to enhance medical planning and operational effectiveness.

BACKGROUND:Military trauma/surgical critical care (T/SCC) surgeons perform both clinical "inside-the-tent" (ITT) and leadership/administrative "outside-the-tent" (OTT) responsibilities during forward deployments. Despite these demands, fellowship programs lack a standardized curriculum addressing the full spectrum of military-specific requirements. This study evaluates military T/SCC surgeons' perceptions of training quality, satisfaction, and confidence in managing deployment trauma situations, and readiness to assume leadership roles. METHODS:A survey was distributed to all current military T/SCC fellows and attendings to evaluate their perception of ITT and OTT skill training during fellowship. Respondents reported their satisfaction with fellowship training, as well as their confidence, satisfaction, and frequency with which they practiced on ITT and OTT skills. Attendings were additionally asked how often they utilized OTT skills and assumed key OTT leadership positions, such as unit commander or deputy commander, trauma director, or chief medical officer, during deployments. RESULTS:Ninety-four military T/SCC surgeons (80% attendings and 20% fellows) participated; 68% had deployed after fellowship. Confidence in core ITT skills, such as damage control surgery and resuscitation, was high (99% for both), but confidence was low for thoracic (58%) and complex liver trauma procedures (53%). Exposure to OTT domains-triage, systems, and tactical leadership-was limited; fewer than one-third of respondents reported frequent exposure or satisfaction with OTT training during fellowship. However, 84% of attendings frequently performed OTT functions during deployment. Previously deployed surgeons showed significantly greater confidence in disaster management (69% vs. 42%; p <0.05) and tactical decision-making (75% vs. 46%; p <0.05) OTT skills. CONCLUSIONS:While operative training was viewed favorably, many surgeons felt clinically confident but underprepared for deployment leadership roles. Greater OTT confidence among previously deployed surgeons suggests that operational experience-not fellowship training-currently drives proficiency. A military-specific curriculum is needed to prepare surgeons for leadership responsibilities in combat settings. (J Trauma Acute Care Surg. 2026;101: 258-267. Copyright © 2026 Wolters Kluwer Health, Inc. All rights reserved.). LEVEL OF EVIDENCE:Prognostic/Epidemiological, Level IV.

ABSTRACT:Routine tourniquet use has significantly improved early survival in both military and civilian settings for extremity hemorrhage in trauma patients. However, most supporting evidence revolves around short-duration tourniquet use stemming from trauma systems with rapid evacuation and early surgical care. Emerging military operations and austere civilian settings risk prolonged prehospital times, introducing uncertainty in the management of prolonged tourniquet application. These scenarios present high-risk situations for medical providers and potentially life-threatening complications for patients. Despite this, management strategies during these scenarios remain poorly defined. This review synthesizes current military and civilian literature to address key challenges in prolonged ischemia, including tourniquet conversion, decision-making surrounding limb salvage versus early amputation, and the pathophysiology and management of ischemia reperfusion injury.

BACKGROUND:Hemorrhage remains the leading cause of preventable traumatic deaths, with many fatalities occurring before hospital arrival. Although geographic differences in prehospital time (PHT) are recognized, contemporary national estimates and their implications for resuscitation readiness are not well defined. This study aimed to characterize geographic variation in PHT among trauma patients at risk of hemorrhagic shock to inform strategies for earlier intervention. STUDY DESIGN AND METHODS:We analyzed 2020-2023 data from the National Emergency Medical Services (EMS) Information System (NEMSIS) and included trauma patients aged ≥16 years at risk of hemorrhagic shock, defined as shock index (heart rate/systolic blood pressure) ≥1 at the scene. PHT was defined as the interval from dispatch to hospital arrival and compared across urbanicity (urban, suburban, rural, wilderness) and transport mode (ground or air). RESULTS:Among 939,335 eligible encounters, the median prehospital time (PHT) differed significantly across urbanicity categories, increasing progressively from urban to wilderness regions (urban 39 min [IQR 30-51], suburban 45 [32-63], rural 50 [34-71], wilderness 56 [37-78]; p < .001). All three components of PHT-system response, scene, and transport time-were longer in rural and wilderness. Total PHTs remained stable, with only minor year-to-year variation. Air PHT was consistently longer than ground PHT (p < .001) and showed no temporal improvement across 2020-2023. DISCUSSION:National EMS data show persistently prolonged prehospital times for trauma patients at risk of hemorrhagic shock, especially in rural and wilderness areas. Bringing transfusion capability closer to patients through prehospital blood programs may be critical to reducing time-dependent mortality.

Background: Increasing use of low-titer group O whole blood and red blood cells in trauma resuscitation has increased the likelihood that RhD-negative females of childbearing potential (FCPs) will receive RhD-positive blood products. Concurrently, national trauma data demonstrate that FCPs with traumatic hemorrhage are approximately 40% less likely to receive low-titer group O whole blood than comparable males, highlighting a trauma systems and equity concern. Evidence-based guidance for post-transfusion management remains limited. Study Design: A multidisciplinary panel representing trauma surgery, transfusion medicine, emergency medicine, critical care, obstetrics, pediatrics, and prehospital care reviewed available literature, registry data, modeling studies, existing guidance, and ethical considerations and developed consensus recommendations through an iterative process for management of RhD-negative FCPs exposed to RhD-positive blood products during trauma resuscitation. Results: Reported D-alloimmunization rates following trauma transfusion range from approximately 8%–43%. Modeling studies estimate a perinatal death risk from anti-D-mediated hemolytic disease of the fetus and newborn (HDFN) of approximately 0.04% and a combined severe HDFN/perinatal death risk of approximately 0.24% after RhD-positive transfusion. Estimated risk of any HDFN-complicated future pregnancy ranges from approximately 0.6%–6.5%. The panel concluded that RhD-positive blood products should not be withheld when RhD-negative products are unavailable and transfusion is clinically indicated. Recommended management includes selective Rh immunoglobulin prophylaxis for low-volume exposures, structured antibody surveillance, patient counseling, multidisciplinary follow-up, and institutional protocols. Conclusions: For RhD-negative FCPs with life-threatening hemorrhage, immediate survival should take precedence over potential future reproductive risk. Standardized post-transfusion pathways may support equitable access to life-saving transfusion while mitigating alloimmunization-related reproductive risks.

ABSTRACT:Future large-scale combat operations (LSCO) will invalidate core assumptions of modern trauma care. Contested movement, disrupted logistics, and prolonged or denied evacuation will make timely surgical access and fully resourced critical care the exception rather than the rule. While recent conflicts optimized early hemorrhage control, the capacity to sustain critically injured patients in LSCO environments remains poorly defined. In LSCO, trauma care shifts from episodic intervention to prolonged system endurance. Injuries routinely survivable in resource-rich settings will become functionally non-survivable under these conditions. Future combat casualty survival will depend less on maximal capability than what care can be sustained under constant constraint. Without austere-adapted critical care standards, doctrinal alignment, and operationally embedded research, the gains of modern combat casualty care will not translate to the future battlefields where they are needed the most. This review synthesizes contemporary military and civilian literature with operational experience to identify key unresolved capability gaps and examine austere surgical and critical care in LSCO, focusing on hemorrhage control, far-forward surgery, prolonged critical care, evacuation constraints, and ethical decision-making under sustained resource limitation. ( J Trauma Acute Care Surg . 2026;101: S168-S176. Copyright © 2026 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the American Association for the Surgery of Trauma.).

INTRODUCTION:Resuscitative endovascular balloon occlusion of the aorta (REBOA) has emerged as a critical tool in trauma management, particularly for elderly patients. However, its application in this population is often debated because of concerns over potential complications. This study evaluates the outcomes of REBOA compared with resuscitative thoracotomy (RT) in trauma patients 65 years or older with indications for aortic occlusion. METHODS:A retrospective cohort analysis was conducted using the Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery registry (2013-2024), including trauma patients presented pulseless or sustained cardiac arrest in the trauma bay during evaluation. Patients were divided into REBOA and RT groups based on the aortic occlusion method selected at physician discretion. Variables analyzed included demographics, injury severity, hemorrhage control procedures, transfusion needs, and clinical outcomes. Multivariate analyses accounted for confounders, such as penetrating injuries, Injury Severity Score of >15, systolic blood pressure of <90 mm Hg, heart rate of >100 beats per minute, Glasgow Coma Scale score of <9, provider type, and the need for hemorrhage control procedures. RESULTS:The study included 360 patients (RT, 162; REBOA, 198). Survival to hemorrhage control was significantly higher in the REBOA group (75.8% vs. 49.4%, p < 0.001), and overall, in-hospital mortality was lower (74.6% vs. 97.5%, p < 0.001). Major complications were similar between groups, but minor complications occurred more frequently in the REBOA cohort (34.7% vs. 6.3%, p < 0.001). Adjusted analyses revealed no differences in mortality (odds ratio [OR], 1.14; 95% confidence interval [CI], 0.34-1.79; p = 0.702) or major complications (OR, 0.87; 95% CI, 0.62-1.87; p = 0.596), while REBOA was associated with higher odds of minor complications (OR, 1.25; 95% CI, 1.01-2.29; p = 0.007). CONCLUSION:Resuscitative endovascular balloon occlusion of the aorta provides comparable survival and major complication outcomes to RT in elderly trauma patients, with an increased risk of minor complications. These results suggest that REBOA is a viable alternative to RT, although further studies are needed to optimize patient selection and procedural techniques. LEVEL OF EVIDENCE:Therapeutic/Care Management; Level III.

Introduction Previous studies suggested that type O blood may be associated with increased mortality and/or thrombotic complications among trauma patients. The purpose of this analysis was to evaluate the relationship between endogenous blood type, mortality, and complications among patients receiving massive transfusions, using data from the Pragmatic Randomized Optimal Platelet and Plasma Ratios trial. Materials and Methods This was a secondary analysis of the Pragmatic Randomized Optimal Platelet and Plasma Ratios trial that included patients with the reported blood type (A, AB, B, or O) data. Outcomes were early and late mortality and clinical complications. Endogenous von Willebrand Factor (vWF) antigen levels, vWF activity, and factor VIII levels were measured with admission labs and compared. Logistical regression was used to assess associations between mortality and blood type. Results Among 680 patients, 655 who had admission blood type data were included. 322 (49.2%) were type O, 186 (28.4%) were type A, 27 (4.1%) were type AB, and 120 (18.3%) were type B. The mean age, gender distribution, mechanism of injury, injury severity, and injury patterns were similar between blood types. There were significant racial and ethnic differences (P < 0.001 and P < 0.0018, respectively), and patients with endogenous type O blood had decreased levels of vWF activity and vWF antigen (P = 0.022 and P = 0.016, respectively). Logistical analyses showed no significant associations between blood type and complications, and type O blood was not associated with increased mortality. Conclusions We found that endogenous blood type was not associated with increased mortality or clinical complications in severely injured patients requiring massive transfusion based on the data from a large multicenter trial.

Introduction: Veno-venous extracorporeal membrane oxygenation (VV ECMO) improves hypoxemia and carbon dioxide clearance in patients with severe respiratory derangements. A greater understanding of the potential benefits of VV ECMO in trauma patients could lead to broader adoption. We hypothesize that trauma patients who receive VV ECMO have improved mortality outcomes when compared to those receiving conventional ventilator management given the rapid stabilization VV ECMO promotes. Methods: We performed a single-center, propensity score-matched cohort study. All trauma patients from January 1, 2014, to October 30, 2023, who were placed on VV ECMO or who would have met institutional guidelines for VV ECMO but were managed with conventional ventilator strategies were matched 1:1. The primary outcome analysis was survival at hospital discharge. Significance was defined as P < 0.05. Results: Eighty-one trauma VV ECMO patients and 128 patients who received conventional management met criteria for inclusion. After matching, VV ECMO and conventional treatment cohort characteristics were similar in age and mechanism of injury. Matched ISS, SI, lactate levels, and frequency of traumatically brain injured were also similar. Finally, respiratory parameters including preintervention, pH, partial pressure of carbon dioxide, lactate levels, and oxygen saturation were similar between matched groups. VV ECMO patients had higher survival rates at discharge when compared to the matched conventional treatment group (70% vs. 41%, P < 0.001). Corresponding hazard ratio for VV ECMO use was 0.31 (95% CI 0.18-0.52; P < 0.001). The odds ratio of mortality in matched trauma patients who receive VV ECMO versus conventional treatment was 0.29 (95% CI 0.14-0.58; P < 0.001). Conclusion: VV ECMO may represent a safe, alternative treatment approach for appropriately screened trauma patients with acute respiratory failure; however, further studies are warranted.

Military-civilian partnerships have emerged as essential platforms for preparing military trauma surgeons and health care teams for deployment. These programs, many of which were developed following congressional initiatives to enhance military trauma readiness, address the critical issue of sustaining trauma skills during peacetime avoiding a phenomenon known as the "Walker Dip," when skills and proficiency in treating battlefield injuries decline during peacetime after periods of intense conflict. They also provide military surgeons and other providers with training in research methodology and trauma systems management, skills that are difficult to obtain solely within the military structure. This article examines three distinct military-civilian partnership models based on West Coast trauma centers: Oregon Health & Science University (affiliated with the US Army), Los Angeles General Medical Center (affiliated with the US Navy), and UC Davis Medical Center (affiliated with the US Air Force). These programs provide critical trauma exposure while fostering advanced academic and leadership skills. The Joint Trauma System, with its focus on data-driven improvements in trauma care, has further shaped these programs. By comparing these models, we identify their strengths, deficits, and strategies for enhancing training effectiveness. The conclusion highlights the uniqueness of each site and affirms that there are multiple successful approaches to fostering military readiness.

The Joint Trauma System (JTS) has become a cornerstone of modern trauma care, revolutionizing battlefield treatment and saving countless lives through standardized, evidence-based protocols. Its development and success are rooted in lessons learned from the wars in Iraq and Afghanistan, where fragmented systems were transformed into cohesive, high-performing networks. The JTS has influenced not only military but also civilian trauma care, fostering a symbiotic relationship that advances innovation across both sectors. Despite its proven effectiveness, a growing movement within the US military questions its relevance during peacetime, threatening its existence. This article examines the history, impact, and future of the JTS while emphasizing the critical need for civilian advocacy to preserve its role as a key enabler of military readiness and trauma care innovation.

Although the overall incidence is low, penetrating neck trauma can result in devastating injuries. The traditional zonal approach is being increasingly abandoned in favor of selective approaches, especially as mandatory exploration can result in non-therapeutic interventions and associated complications. Additionally, the trajectory of the missile cannot be accurately assessed based on external wounds. Decision-making using the hard and soft signs of trauma and increased resolution of imaging modalities are progressively supplanting the older zonal approaches. Here we discuss the modern diagnostic approach, operative interventions, and the appropriateness of observation.

Advancements in military medicine have had profound impacts on civilian trauma care. The current practices in civilian prehospital care focus on providing limited interventions in the field and rapid transport to higher levels of care. Very few prehospital emergency medical services in the United States have the capability to provide prehospital blood transfusions or advanced hemorrhage control procedures for trauma patients in hemorrhagic shock. As such, prehospital mortality from hemorrhage remains high. The United States military has adopted the use of prehospital blood transfusions during recent combat operations in the Middle East to mitigate prehospital mortality. Additionally, select military surgical teams capable of providing damage-control surgery as close to the point of injury as possible have been used to decrease the time to lifesaving interventions. This review seeks to assess current practices in civilian prehospital care within the United States while evaluating recent military medical lessons learned on prehospital blood products and minimizing time to lifesaving interventions, to identify potential opportunities to reduce mortality in civilian prehospital trauma care.

Prehospital blood transfusion improves survival after injury. Understanding potential demand for and usage of prehospital blood transfusion is important to help improve supply and utilization of this prehospital intervention. The primary objective of this study is to describe potential current demand for prehospital blood product in adults after blunt and penetrating injury from 2020 to 2023. We also estimate the extent to which this potential demand is being met. Patients ≥16 years with blunt/penetrating injuries included in the National Emergency Medical Services Information System (NEMSIS) from 2020 to 2023 were identified. Patients were classified into Cohort 1 (systolic blood pressure (SBP) <90 and heart rate (HR) >108 or SBP <70) and Cohort 2 (shock index ≥1), and total numbers in each cohort were reported. Additionally, the number and percentage of patients who were potentially eligible for and who received prehospital blood transfusion were calculated and trended over time. After exclusions, 20.4 million trauma patients were included. A total of 262,761 Cohort 1 patients and 1,227,556 Cohort 2 patients were potentially eligible for transfusion. Estimated demand for blood transfusion increased from 2020 to 2023 ( p < 0.001) in both cohorts. Cohort 1 had the highest estimated proportion of patients (0.9%, n = 2,289) who received transfusion, demonstrating that few potentially eligible adult trauma patients received blood product. Altogether, 1.2 million hemodynamically unstable trauma patients were potentially eligible for prehospital blood transfusion after injury during 2020–2023, yet less than 1% received this intervention. These data underscore the need to evaluate and resolve barriers to wider use of prehospital blood transfusions.

Background Early detection of abdominal hemorrhage via ultrasound has life-saving implications for military and civilian trauma. However, strict adherence to light discipline may prohibit the use of ultrasound devices in the deployed setting. Additionally, current night vision devices remain noncompatible with ultrasound technology. This study sought to assess an innovative night vision device with ultrasound capable picture-in-picture display via a intraabdominal hemorrhage model to identify noncompressible truncal hemorrhage in blackout conditions. Methods 8 post mortem fetal porcine specimens were used and divided into 2 groups: intrabdominal hemorrhage (n = 4) vs no hemorrhage (n = 4). Intrabdominal hemorrhage was modeled via direct injection of 200 mL of normal saline into the peritoneal cavity. Under blackout conditions, 5 participants performed a focused assessment with sonography for trauma (FAST) exam on each model using the prototype ultrasound-capable night vision device. Results Of the 40 FAST exams performed, 95% (N = 38) resulted in the correct identification of intraabdominal hemorrhage. Of the incorrectly identified exams, both were false positives resulting in a 100% sensitivity, 90% specificity, 91% positive predictive value, and a 100% negative predictive value. All participants noted the novel device was easy to use and provided superior visualization for performing FAST exams under blackout conditions. Conclusion The ultrasound-enabled night vision prototype demonstrated promising results in identifying noncompressible truncal hemorrhage while maintaining strict light discipline in blackout conditions. Further research efforts should be directed at assessing the ability of providers to perform procedures in blackout conditions using the ultrasound-enabled prototype night vision device.

Introduction Whole blood (WB) transfusion represents a promising resuscitation strategy for trauma patients. However, a paucity of data surrounding the optimal incorporation of WB into resuscitation strategies persists. We hypothesized that traumatically injured patients who received a greater proportion of WB compared with blood product components during their resuscitative efforts would have improved early mortality outcomes and decreased transfusion requirements compared with those who received a greater proportion of blood product components.Methods Retrospective review from our Level 1 trauma center of trauma patients during their initial resuscitation (2019–2022) was performed. WB to packed red blood cell ratios (WB:RBC) were assigned to patients based on their respective blood product resuscitation at 1, 2, 3, and 24 hours from presentation. Multivariable regression models were constructed to assess the relationship of WB:RBC to 4 and 24-hour mortality, and 24-hour transfusion requirements.Results 390 patients were evaluated (79% male, median age of 33 years old, 48% penetrating injury rate, and a median Injury Severity Score of 27). Overall mortality at 4 hours was 9%, while 24-hour mortality was 12%. A significantly decreased 4-hour mortality was demonstrated in patients who displayed a WB:RBC≥1 at 1 hour (5.9% vs. 12.3%; OR 0.17, p=0.015), 2 hours (5.5% vs. 13%; OR 0.16, p=0.019), and 3 hours (5.5% vs. 13%, OR 0.18, p<0.01), while a decreased 24-hour mortality was displayed in those with a WB:RBC≥1 at 24 hours (7.9% vs. 14.6%, OR 0.21, p=0.01). Overall 24-hour transfusion requirements were significantly decreased within the WB:RBC≥1 cohort (12.1 units vs. 24.4 units, p<0.01).Conclusion Preferential WB transfusion compared with a balanced transfusion strategy during the early resuscitative period was associated with a lower 4 and 24-hour mortality, as well as decreased 24-hour transfusion requirements, in trauma patients. Future prospective studies are warranted to determine the optimal use of WB in trauma.Level of evidence Level III/therapeutic

Introduction Medical readiness is of paramount concern for active-duty military providers. Low volumes of complex trauma in military treatment facilities has driven the armed forces to embed surgeons in high-volume civilian centers to maintain clinical readiness. It is unclear what impact this strategy may have on patient outcomes in these centers. We sought to compare emergent trauma laparotomy (ETL) outcomes between active-duty Air Force Special Operations Surgical Team (SOST) general surgeons and civilian faculty at an American College of Surgeons verified level 1 trauma center with a well-established military-civilian partnership.Methods Retrospective review of a prospectively maintained, single-center database of ETL from 2019 to 2022 was performed. ETL was defined as laparotomy from trauma bay within 90 min of patient arrival. The primary outcome was to assess for all-cause mortality differences at multiple time points.Results 514 ETL were performed during the study period. 22% (113 of 514) of patients were hypotensive (systolic blood pressure ≤90 mm Hg) on arrival. Six SOST surgeons performed 43 ETL compared with 471 ETL by civilian faculty. There were no differences in median ED length of stay (27 min vs 22 min; p=0.21), but operative duration was significantly longer for SOST surgeons (129 min vs 110 min; p=0.01). There were no differences in intraoperative (5% vs 2%; p=0.30), 6-hour (3% vs 5%; p=0.64), 24-hour (5% vs 5%; p=1.0), or in-hospital mortality rates (5% vs 8%; p=0.56) between SOST and civilian surgeons. SOST surgeons did not significantly impact the odds of 24-hour mortality on multivariable analysis (OR 0.78; 95% CI 0.10, 6.09).Conclusion Trauma-related mortality for patients undergoing ETL was not impacted by SOST surgeons when compared with their civilian counterparts. Military surgeons may benefit from the valuable clinical experience and mentorship of experienced civilian trauma surgeons at high volume trauma centers without creating a deficit in the quality of care provided.Level of evidence Level IV, therapeutic/care management.

Introduction: The Assessment of Blood Consumption (ABC) score is used to predict massive transfusions (MT). However, its diagnostic performance has not been widely examined, especially when used as an objective tool to enroll patients in multi-center clinical trials. The purpose of this study was to evaluate the performance of the ABC score in enrolling patients in the Pragmatic Randomized Optimal Platelet and Plasma Ratios (PROPPR) trial. We hypothesized the ABC score would have a similar diagnostic performance to predict the need for massive transfusion as previous studies. Methods: This is a retrospective analysis of the PROPPR trial. Patients were enrolled either on the basis of an ABC score >= 2, or by Physician Gestalt, when the ABC score was <2. We calculated the sensitivity, specificity, positive (PPV) and negative (NPV) predictive values and likelihood ratios of the ABC score (>= 2) for predicting MT (>10 units of red blood cells/24 h or transfusion of >3 units of red blood cells within the first hour). Results: Of the 680 patients, 438 patients (64 %) had an ABC score of >= 2 and 242 (36 %) had an ABC score of <2. An ABC score of >= 2 had 66.8 % sensitivity and 37.0 % specificity for predicting the need for MT, with a PPV of 88.2 % and NPV of 13.1 %. Similarly, an ABC >= 2 had 65.6 % sensitivity and 44.6 % specificity for predicting the need for >3 units RBCs in 1 hour, with a PPV of 89.5 % and NPV of 15.3 %. Conclusion: The ABC score had lower performance than previously reported for predicting MT, when applied to PROPPR trial patients. The performance for predicting the need for a 3-unit red blood cell transfusion (or more) in the first hour was slightly higher.

IntroductionGraduate medical education (GME) lacks a standardized military training program for general surgery residents, and concern exists that they may not be prepared to serve as combat surgeons on training completion. The purpose of this study was to assess military surgery trainee satisfaction with their programs. Our hypothesis was that military residents were not completely confident to care for combat casualties on completion of current GME training.MethodsWe surveyed US Army, Navy, and Air Force general surgery residents and fellows between November 2023 and March 2024 to assess their confidence in managing combat injuries. Queried residents further rate their overall satisfaction with surgical training, perceived level of deployment preparedness and curriculum elements which they thought would be most beneficial to their training.ResultsThe survey yielded an overall 43% response rate (132/305) with a response rate of 42% (61/147) from the Army, 56% (44/79) from the Navy, and 34% (27/79) from the Air Force. Most trainees were trained in military medical treatment facility residency programs (n=91, 68.9%) and nearly half of respondents (n=64, 49%) were senior trainees (postgraduate year (PGY)4, PGY5, and fellows). Among all trainees, only two-thirds (n=88, 67%,) thought they were adequately prepared to deploy and operate on military combat casualties by the end of residency but 114 (86%) were satisfied with the training they received during general surgery residency in adult trauma, 103 (78%) in critical care, and 112 (85%) in acute care surgery. However, more than half were unsatisfied with the training they received in obstetric/gynecologic and urologic emergencies (n=72, 55%; and n=67, 51%, respectively).ConclusionAlthough the majority of military surgical residents surveyed are satisfied with their training in adult trauma, critical care, and emergency general surgery, a large number of trainees thought they would not be ready to deploy and manage combat casualties.Level of evidencePrognostic and epidemiological, Level IV.