BACKGROUND:Increasing global conflicts continue to heighten the need for increased focus on preparedness for military physicians and surgeons. Simulation has recently been adopted by civilian surgical trainees to offset the problem of increased work hour restrictions and shift the current focus toward minimally invasive techniques. We hypothesized that just-in-time trauma training, incorporating both focused clinical and simulated experience at our civilian Level I Trauma Center, would increase the competence and confidence of international military physicians in trauma care. METHODS:We performed a feasibility study of five Ukrainian physicians (four surgeons and one anesthesiologist) undergoing an intensive 2-week trauma course taught by 25 American clinicians. The training consisted of several previously validated courses including Advanced Trauma Life Support (ATLS®), Advanced Surgical Skills for Exposure in Trauma (ASSE'J®), Advanced Trauma Operative Management (ATO ), and Basic Endovascular Skills for Trauma (BES'J®), among several additional simulated and clinical experiences. Pre- and post-course surveys were analyzed using paired t-tests to assess improvement in trauma care. RESULTS:All five physicians had significant improvement in confidence following the completion of the course, including the management of injuries to the neck, chest, abdomen, and extremities. Additionally, each clinician significantly improved in their confidence to perform common ATLS procedures and resuscitative endovascular balloon occlusion of the aorta skills. Overall, the mean confidence over all survey responses improved significantly following the completion of the course, 2.28 (precourse confid ence range 1.25-3.35) to 3.66 (post-course confidence range 2.95-4.22), p-value = 0.002. All five Ukrainian physicians successfully passed the corresponding post-tests and were certified as having completed ATLS, ATOM, ASSET, and BEST Conclusions: A military and civilian partnership in trauma preparedness is feasible to improve surgeon confidence in trauma care.

Prioritizing circulation in trauma care and delaying intubation in noncompressible cases improve outcomes. By prioritizing circulation, patient survival significantly improves, advocating evidence-based shifts in trauma care.

Objective: We hypothesized that medical students would be empowered by hemorrhage-control training and would support efforts to include Stop the Bleed® (STB) in medical education. Design: This is a multi-institution survey study. Surveys were administered immediately following and 6 months after the course. Setting: This study took place at the Association of American Medical Colleges-accredited medical schools in the United States. Participants: Participants were first-year medical students at participating institutions. A total of 442 students completed post-course surveys, and 213 students (48.2 percent) also completed 6-month follow-up surveys. Intervention: An 1-hour, in-person STB course. Main outcomes measures: Student empowerment was measured by Likert-scale scoring, 1 (Strongly Disagree) to 5 (Strongly Agree). The usage of hemorrhage- control skills was also measured. Results: A total of 419 students (95.9 percent) affirmed that the course taught the basics of bleeding control, and 169 (79.3 percent) responded positively at follow-up, with a significant decrease in Likert response (4.65, 3.87, p < 0.001). Four hundred and twenty-three students (97.0 percent) affirmed that they would apply bleeding control skills to a patient, and 192 (90.1 percent) responded positively at follow-up (4.61, 4.19, p < 0.001). Three hundred and sixty-one students (82.8 percent) believed that they were able to save a life, and 109 (51.2 percent) responded positively at follow-up (4.14, 3.56, p < 0.001). Four hundred and twenty-five students (97.0 percent) would recommend the course to another medical student, and 196 (92.0 percent) responded positively at follow-up (4.68, 4.31, p < 0.001). Six students (2.8 percent) used skills on live patients, with success in five of the six instances. Conclusions: Medical students were empowered by STB and have used hemorrhage-control skills on live victims. Medical students support efforts to include STB in medical education.

CO2 capture technologies are key to the ongoing energy transition towards a low-carbon future. Solid adsorption is a promising technology for carbon capture with potential energy savings for regeneration of the material compared to liquid absorption. An interesting route for regeneration is electrical swing adsorption (ESA). An electrically conductive sorbent for direct air capture (DAC) was developed by 3D printing. As sorbent material an amine based ion-exchange resin was selected based on its high CO2 capacity for DAC with silver coated glass flakes as electrically conductive additive. Different amount of flakes were added to study the percolation threshold of the sorbent. The heating of the sorbents was done by Joule heating and monitored by an infrared camera. Furthermore, the influence of humidity and temperature on the electrical resistivity and volume of the sorbent structures were evaluated. Solid amine based sorbents with 15 to 35 vol% of silver coated glass flakes were successfully printed. At 20 vol % of flakes, a higher electrical conductivity could be obtained at room temperature and lower humidity. If the humidity increases up to 75 %, the volume of the structures expands with 7 % which causes an increase in electrical resistivity and loss of percolation. At 25 vol% of flakes, percolation is obtained and the resistivity is low enough (<10 Ohm.m) for Joule heating. This resistivity resulted in a heating time of 60 s for heating up to 70 C, the regeneration temperature of the sorbent. These experiments demonstrate that printed solid amine based sorbent were successfully developed for CO2 capture and regeneration by ESA.

Objective: This project aimed to successfully implement the Stop the Bleed® (STB) program in Guatemala by targeting key providers in various communities across the country. Setting: The course was conducted in rural community centers, fire stations, tertiary care centers, and medical school facilities. Participants: We included agricultural occupational health workers, firefighters, medical providers, and medical students throughout the course. Results: We successfully trained 247 people in Guatemala in STB and certified 13 instructors and four associate instructors. Through pre- and post-course surveying, we determined that the course improved the participants’ comfort level in managing bleeding emergencies. Conclusions: Creating partnerships with key providers at different community levels leads to the successful implementation of public health initiatives. Further research should be geared at determining the course’s dissemination by new instructors.

BACKGROUND:Extremity tourniquets have proven to be lifesaving in both civilian and military settings and should continue to be used by first responders for trauma patients with life-threatening extremity bleeding. This is especially true in combat scenarios in which both the casualty and the first responder may be confronted by the imminent threat of death from hostile fire as the extremity hemorrhage is being treated. Not every extremity wound, however, needs a tourniquet. One of the most important aspects of controlling life-threatening extremity bleeding with tourniquets is to recognize what magnitude of bleeding requires this intervention and what magnitude of bleeding does not. Multiple studies, both military and civilian, have shown that tourniquets are often applied when they are not medically indicated. Overuse of extremity tourniquets has not caused excess morbidity in either the recent conflicts in Iraq and Afghanistan or in the US urban civilian setting. In the presence of prolonged evacuation, however, applying a tourniquet when it is not medically indicated changes tourniquet application from being a lifesaving intervention to one that may cause an avoidable amputation and the development of an array of metabolic derangements and acute kidney injury collectively called prolonged tourniquet application syndrome. METHODS:The recent literature was reviewed for papers that documented the complications of tourniquet use resulting from the prolonged casualty evacuation times being seen in the current Russo-Ukrainian war. The literature was also reviewed for the incidence of tourniquet application that was found to not be medically indicated, in both the US civilian setting and from Ukraine. Finally, an in-person meeting of the US/Ukraine Tourniquet Working Group was held in Warsaw, Poland, in December of 2023. RESULTS:Unnecessary loss of extremities and life-threatening episodes of prolonged tourniquet application syndrome are currently occurring in Ukrainian combat forces because of nonindicated tourniquet use combined with the prolonged evacuation time seen in the Russo-Ukrainian war. Specific numbers of the complications experienced as a result of tourniquet use by Ukrainian forces in the current conflict are treated as classified information and are not available, but multiple sources from the Ukrainian military medical personnel and from the US advisors providing medical assistance to Ukraine have all agreed that the problem is substantial. CONCLUSION:Unnecessary tourniquet morbidity might also occur in US forces in a variety of potential future combat scenarios in which evacuation to surgical care is delayed. Prehospital trauma training programs, including but not limited to tactical combat casualty care, place insufficient emphasis on the need to avoid leaving tourniquets in place when they are not medically indicated. This aspect of training should receive emphasis in future Tactical Combat Casualty Care (TCCC) and civilian first responder curriculum development. An interim ad hoc training solution on this topic is available at the websites noted in this articles. Additional training modalities may follow in the near future. LEVEL OF EVIDENCE:Therapeutic/Care Management; Level V.

The sequence of trauma care has traditionally prioritized the airway, then ensure appropriate breathing, and lastly, focusing on circulation, to stop the bleeding and improve perfusion. However, this sequence might not be the best practice when managing patients that are exsanguinating. Physiologically, patients that have injuries that are bleeding profusely have minutes to live. Using the time wisely can result in improved outcomes.1,2 When patients are exsanguinating there is a pronounced vasoconstriction.

Chemical Looping with Oxygen Uncoupling (CLOU) is a technological adaptation of CLC, most applicable for the combustion of solid fuels. In the CLOU process, an oxygen carrier in the fuel reactor, avoiding the direct contact of the fuel with the air, releases the oxygen needed for the fuel combustion. The oxygen carrier is regenerated with air in the interconnected air reactor. The present work explores the behavior of the system Mn/Mg/Si as oxygen carriers for chemical-looping with oxygen uncoupling (CLOU). Six different mixed oxides of the system Mn/Mg/Si were investigated for the CLC/CLOU process. Materials were prepared by spray drying with different metal ratios used in the investigation. The properties of interest for the viability of these materials are the lattice oxygen supply for CLC and the gaseous oxygen release for CLOU, properties that were explored in a TGA. Further, the fluidization behavior and the mechanical resistance were investigated in a batch fluidized bed reactor. In the TGA it was observed that the most reactive oxygen carriers for the CLOU process were materials without Si in the structure, more specifically M24Mg76 and M48Mg51 which had a molar ratio of Mn/Mg of 0.17 and 0.51 respectively. It was also observed that for the oxygen carriers with Si in the composition, the regeneration was very poor. Oxygen carriers M24Mg76 and M48Mg51 were selected for batch fluidized bed reactor testing showing good behavior with respect to the CLOU reactivity, and mechanical stability. One of the materials, the M24Mg76 showed activation during the experiments in the batch fluidized bed reactor experiments, increasing the oxygen transport capacity by 20 % during the experiment. However, 10 vol% of O2 was needed to regenerate both oxygen carriers at 850 degrees C. No agglomeration tendencies were seen, and the attrition rate was low, obtaining high-extrapolated lifetime values. The fact that highly reactive oxygen carriers can be made with cheap and highly available metals oxides, i.e. Mn and Mg, makes this system very promising and a possible alternative to benchmark Cu-based CLOU materials.

This study investigates the innovative use of a deposition technique, spray coating, for the fabrication of optimal thicknesses of solid oxide cell (SOC) layers on a range of SOC-compatible materials. The work has been carried out as part of the European KEROGREEN project that aims to utilize CO2 into sustainable aircraft kerosene. To separate the oxygen at higher operating temperatures after CO2 dissociation (plasmolysis) for creating a CO stream for Fischer–Tropsch downstream synthesis, a solid oxide electrolyzer cell is used. For the electrodes, the most promising LaSr-based perovskite materials were selected based on their electrical conductivity and ability to suppress the CO to CO2 back reaction at the CO2 (plasma) splitting side. The spray-coating suspension was adjusted to improve the adhesion and quality of the adjacent SOC layers. The electrode coatings showed good adhesion to the yttria-stabilized zirconia electrolyte, with a thickness of 10–15 µm and porosity of circa 45

This commentary discusses a randomized clinical trial published in JAMA Surgery comparing the effects of point-of-care vs video instructions vs in-person training about tourniquet use on correct tourniquet application and skill retention 3 to 9 months after hemorrhage control training.

Traumatic injuries remain the leading cause of death for those under the age of 44 years old. Nearly a third of those who die from trauma do so from bleeding. Reducing death from severe bleeding requires training in the recognition and treatment of life-threatening bleeding, as well as programs to ensure immediate access to bleeding control resources. The Stop the Bleed (STB) initiative seeks to educate and empower people to be immediate responders and provide control of life-threatening bleeding until emergency medical services arrive. Well-planned and implemented STB programs will help ensure program effectiveness, minimize variability, and provide long-term sustainment. Comprehensive STB programs foster consistency, promote access to bleeding control education, contain a framework to guide the acquisition and placement of equipment, and promote the use of these resources at the time of a bleeding emergency. We leveraged the expertise and experience of the Stop the Bleed Education Consortium to create a resource document to help inform and guide STB program developers and implementers on the key areas for consideration when crafting strategy. These areas include (1) equipment selection, (2) logistics and kit placement, (3) educational program accessibility and implementation, and (4) program oversight, facilitation, and administration.

Background: Antibiotic prophylaxis is a common, established practice at trauma centers worldwide for patients presenting with various forms of serious injury. Many patients simultaneously present with hemorrhage. The current guidelines by the Eastern Association for the Surgery of Trauma recommend re-dosing prophylactic antibiotic agents for every 10 units of blood products administered. However, these guidelines are only mildly supported by dated research.Methods: A literature search was completed through Medline EBSCO Host using antibiotic prophylaxis and transfusion as keywords. Articles judged to be relevant to the study question were selected for full-text review. Case studies were not included. Altogether, 18 articles were cited in our results through this process.Results: Risk of infection increases in patients resuscitated with large volume of blood products. Animal models of trauma offered conflicting findings on whether blood loss and blood resuscitation altered tissue antibiotic concentrations compared with controls. Studies focused on antibiotic pharmacokinetics in non-trauma human patients revealed agreement surrounding reported decreases in serum and tissue concentrations, although there was discrepancy surrounding the clinical relevancy of the reported decreases.Conclusions: Trauma, hemorrhage, and transfusion impair the immune response resulting in increased incidence of infection. Both animal and human models of antibiotic pharmacokinetics show decreased serum and tissue concentrations during hemorrhage. However, available data are insufficient to conclude that trauma patients experiencing hemorrhage are at elevated risk of infection and thus require more frequent redosing of antibiotic agents than the current guidelines suggest. An upcoming, prospective study by our institution seeks to evaluate this question.

From the Department of Surgery, University of Connecticut, Hartford, CT; and the American College of Surgeons Stop the Bleed Program, Chicago, IL. Received November 3, 2021; Accepted November 4, 2021. Disclosure Information: Nothing to disclose. Presented virtually at the American College of Surgeons, 107th Annual Clinical Congress, Scientific Forum, October 2021. Correspondence address: Lenworth Jacobs, MD, MPH, FACS, University of Connecticut, Trauma Program Hartford Hospital, 37 Belknap Rd, West Hartford, CT 06117.

In Brief The strategy of successfully identifying and solving significant problems such as Implementing Advanced Prehospital Care. Increasing competence in trauma surgical operative procedures and training the public to stop severe bleeding is described

BACKGROUND Our trauma performance improvement initiative recognized missed treatment opportunities for patients undergoing massive transfusion. To improve patient care, we developed a novel cognitive aid in the form of a poster entitled "TACTICS for Hemorrhagic Shock." We hypothesized that this reference and corresponding course would improve the performance of trauma leaders caring for simulated patients requiring massive transfusion. METHODS First, residents and physician assistants participated in a one-on-one, socially distanced, screen-based virtual patient simulation. Next, they watched a short presentation introducing the TACTICS visual aid. They then underwent a similar second virtual simulation during which they had access to the reference. In both simulations, the participants were assessed using a scoring system developed to measure their ability to provide appropriate predetermined interventions while leading a trauma resuscitation (score range, 0-100%). Preintervention and postintervention scores were compared using a one-group pre-post within-subject design. Participants' feedback was obtained anonymously. RESULTS Thirty-two participants (21 residents and 11 physician assistants) completed the course. The median score for the first simulation without the use of the visual aid was 43.8% (interquartile range, 33.3.8-61.5%). Commonly missed treatments included giving tranexamic acid (success rate, 37.5%), treating hypothermia (31.3%), and reversing known anticoagulation (28.1%). All participants' performance improved using the visual aid, and the median score of the second simulation was 89.6% (interquartile range, 79.2-94.8%; p < 0.001). Ninety-two percent of survey respondents "strongly agreed" that the TACTICS visual aid would be a helpful reference during real-life trauma resuscitations. CONCLUSION The TACTICS visual aid is a useful tool for improving the performance of the trauma leader and is now displayed in our emergency department resuscitation rooms. This performance improvement course, the associated simulations, and visual aid are easily and virtually accessible to interested trauma programs. LEVEL OF EVIDENCE Therapeutic/Care Management; Level IV.

Racial inequity has influenced both personal and public health in the United States and has impacted enrollment in medical schools and training programs. The effects of racial inequity on training and how it is perceived can differ depending on who is being affected. Recommendations are offered for positive changes through mentoring of individuals, institutional leadership, and structural changes in organizations.

SiO2/TiO2 composite sol-gel coatings can be used in many industrial applications for their self-cleaning and photocatalytic properties. In this study, SiO2/TiO2 composite sol-gel coatings were deposited by spray coating as it allows a better thickness control than dip coating, which is now mostly used. The most critical spray coating parameters were first determined by a fractional factorial experimental design for a TiO2 sol coating. Then, the effect of silica addition in combination with a hydrophobic precursor on the thickness, the water contact angle and the adhesion strength of the coatings was studied.The most critical spray parameters for controlling the thickness of the coating were the reservoir pressure and the height of the spray gun above the substrate, while the atomisation pressure had almost no effect. A thin coating can be obtained by using a great height in combination with a low reservoir pressure.

Connecticut was impacted severely and early on by the COVID-19 pandemic due to the state’s proximity to New York City. Hartford Healthcare (HHC), one of the largest healthcare systems in New England, became integral in the state’s response with a robust emergency management system already in place. In this manuscript, we review HHC’s prepandemic emergency operations as well as the response of the system-wide Office of Emergency Management to the initial news of the virus and throughout the evolving pandemic. Additionally, we discuss the unique acquisition of vital critical care resources and personal protective equipment, as well as the hospital personnel distribution in response to the shifting demands of the virus. The public testing and vaccination efforts, with early consideration for at risk populations, are described as well as ethical considerations of scarce resources. To date, the vaccination effort resulted in over 70 percent of the adult population being vaccinated and with 10 percent of the population having been infected, herd immunity is eminent. Finally, the preparation for reestablishing elective procedures while experiencing a second wave of the pandemic is discussed. These descriptions may be useful for other healthcare systems in both preparation and response for future catastrophic emergencies of all types.