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September 2022
Avi Benov MD MHA, Shaul Gelikas MD MBA, Noam Fink MD, and Elon Glassberg MD MHA MBA

War is as old as history. Some may say it is older. The first Biblical war, dated 1880–1875 BCE, is depicted in the book of Genesis between nine kings in the vicinity of the Jordan river near Jericho. By the end of the war, Abraham (Abram) gets involved in saving his nephew Lot.

In addition to war, military medicine also has its roots in historical times. Hippocrates (460–377 BCE), the father of medicine, derived his medical knowledge from the battlefield, and Sushruta [1], the father of plastic surgery, mentioned the physician's preventive role in noting environmental hazards: "A common practice of the enemy is to poison the wells on the roadside, the articles of food, the shades of trees, and the fuel and forage for cattle; hence, it is incumbent on a physician marching with the troops to inspect, examine, and purify these before using any of them, in case they are poisoned."

The Greeks stated new ideas of military health, pointing to fitness promotion, gymnastics, and healthy diets to prevent illness. Over the centuries, from Alexander the Great to Napoleon’s army and wars in the 20th century, military conflicts have led to the death of hundreds of millions of people from trauma and war-related disease. Amazingly analyses of the 18th and 19th centuries have shown that 80% of the soldiers died from disease, and historians and military personnel agree that during armed conflicts in known history, only a minority of soldiers perished by the sword.

In Israel, the Israel Defense Forces-Medical Corps (IDF-MC) holds a unique position embedded in military and civilian national medicine. All medical personnel (e.g., physicians, nurses, technicians, veterinarians) who work in the IDF-MC receive their diplomas from civilian universities, train in civilian hospitals, and continue to practice in the national health system. The majority of these professionals continue to work in different civilian medical platforms in Israel after finishing their mandatory service. The IDF-MC's primary mission is to provide optimal medical care to IDF soldiers at all times (including wartime), to prevent disease and promote health, advance military medicine, and aid the civilian sector as ordered by the Government of Israel.

In this special issue of Israel Medical Association Journal (IMAJ) is to expose readers to the continuous efforts of the IDF-MC to fulfill its mission by promoting research in multiple medical fields, including trauma, ambulatory care, health administration. In addition, in this issue of IMAJ, authors discuss the unique collaboration with the civilian system during the coronavirus disease 2019 (COVID-19) pandemic.

Trauma and trauma-related injuries are the main focus of military medical research. Ben-Avi and colleagues [2] described outcomes of emergent exploratory thoracotomies on military casualties and addresses parameters that may impact the survival of these casualties. Minervini [3] further discussed the issue. Bez et al. [4] researched the impact of isolated versus non-isolated traumatic brain injuries on injury identification and decision-making by care providers in austere scenarios. Tsur and co-authors [5] described the characteristics of a unique type of terror attack: vehicle ramming.

Additional examples of treatments provided in the military prehospital arena were analyzed by Nakar and colleagues [6] who discussed how to assess pain medications administered to trauma casualties in the past two decades by IDF-MC care providers. Rittblat et al. [7] further described the use of freeze-dried plasma, a blood component used in the prehospital arena and administered via intraosseous vascular access.

The IDF-MC is a continuously changing organization emphasizing the adoption of advanced technologies and devices. Chen et al. [8] presented a blinded study on the use of point-of-care ultrasound and remote telementored ultrasound by inexperienced operators, and Sorkin et al. [9] described the BladeShield 101: a novel device for the battlefield designed to continuously measure vital signs and medical treatment provided and to transfer data through roles of care.

In this special issue of IMAJ, authors also discusse gender-related aspects at the core of medical treatment. Segal et al. [10] examined whether missed injuries were related to the medical provider's gender, while Gelikas et al. [11] assessed whether treatment with analgesia was associated with casualty gender in the military prehospital trauma setting

Over the past two and a half years, the COVID-19 pandemic has been a significant part of our lives. During these years, medical systems and teams throughout Israel and around the world struggled to adapt to this new disease and save lives fighting the pandemic. Geva et al. [12] and Shental et al. [13] discussed the impact of COVID-19 on the IDF medical system, lessons learned during the outbreak, and effects of different diseases during these times on medical treatment provided by the IDF to soldiers.

Omri Shental MD MHA, Ilan Y. Mitchnik MD, Edward Barayev MD MHA, Lior Solomon MD, Liron Gershovitz MD, Shaul Gelikas MD MBA, Avi Benov MD MHA, and Yuval Ran MD MHA MPA

Background: Coronavirus disease 2019 (COVID-19) led to two nationwide lockdowns in Israel, reducing both supply and demand for medical services in the Israel Defense Force (IDF). IDF soldiers serve on bases within Israel, and most of them return home at the end of the day, similar to other armies in the world.

Objectives: To analyze the health services provided by the IDF with regard to policy changes during lockdowns.

Methods: We compared medical encounters between different services provided by the IDF Medical Corps. We related them to specific time periods: pre-first lockdown, first lockdown (and corresponding timeframes of the previous 3 years), between lockdowns, second lockdown, and post-second lockdown.

Results: Compared to past periods, we found a similar reduction of 27–30% in primary care medical encounter rates during the two lockdowns: 42–43% in sick days and 50–54% in referrals to the emergency department. Referral rates to all specialist medical encounters and elective surgeries decreased significantly during the first lockdown period and increased 1.2–3.5 times during the second lockdown.

Conclusions: A continuance of the shift to telehealth is required to withstand a future lockdown, with a full supply of secondary medical services attuned to core medical issues relevant for combat personnel. A liberal sick leave policy is required to eliminate unnecessary in-person visits, thus reducing the risk of infection.

Ronny Ben-Avi MD, Alex Sorkin MD, Roy Nadler MD, Avishai M. Tsur MD, Shaul Gelikas MD MBA, Jacob Chen MD MHA, and Avi Benov MD MHA; and Israel Trauma Group

Background: Chest trauma is among the most common types of trauma, corresponding to 10% of trauma patients admitted to hospitals. In the military setting, thoracic trauma was reported as a significant cause of death. With well-timed treatment, chest trauma is regarded as survivable. Emergency thoracotomy (ET) is considered when the patient with trauma to the chest needs immediate resuscitation. Survival rate is reported as low as 1% in some reports and 20% in others. The survival rate depends on injury mechanism, protocols for intervention, and other decompressive procedures.

Objectives: To determine parameters that may impact survival of ET.

Methods: We conducted a retrospective cohort study to compare prehospital and in-hospital data regarding ET in the emergency department (ED) versus the operating room (OR).

Results: Between 2009 and 2017, 6532 casualties presented to the ED; 1125 with trauma to the chest. Fifty-four of those with chest trauma underwent ET in the hospital (4.8%), 22 (41%) in the ED, and 32 (59%) in the OR. The overall mortality of the ET subgroup was 48%. With regard to thoracotomies, 19/22 of patients (86%) who underwent ET in the ED died compared to 2/28 in the OR (13%).

Conclusions: Utilizing ET after chest trauma with appropriate clinical indications, well-trained personnel, and prompt transportation poses a significant challenge, but may be associated with better survival than that reported previously with military casualties. Adoption of indications and timed allocation to the OR may improve outcomes with chest trauma casualties.

Avishai M. Tsur MD MHA, Roy Nadler MD, Alex Sorkin MD, Ilona Lipkin BEMS, Shaul Gelikas MD MBA, Jacob Chen MD MHA, and Avi Benov MD MHA

Background: Vehicle-ramming attacks have become a common tactic for terror organizations worldwide. However, the medical implications of vehicle-ramming attacks remain unknown.

Objectives: To investigate the characteristics of vehicle-ramming attack incidents and casualties in order to assist in guiding the policy of medical organizations. 

Methods: In this study we included all vehicle-ramming attacks recorded in the Israel Defense Forces-Trauma Registry between 2015 and 2019. Records were screened using text mining of incident, casualty, and injury descriptions. The selected records were examined manually to ensure that they were vehicle-ramming attacks. Incident and casualty data were retrieved from the trauma registry.

Results: During the years 2015–2019, a total of 36 vehicle-ramming attacks with 113 casualties were documented in the trauma registry. The median number of casualties, urgent casualties, and fatalities per incident was 3 (interquartile range [IQR] 2–5), 1 (IQR 1–2), and 1 (IQR 1–1), respectively. Of the incidents, 15 (42%) had three or more casualties. The most prevelant day of the week was Friday with 9 incidents (25%). Within the day, 21 incidents (58%) occurred between the hours of 12:00 and 18:00. Commonly injured body regions were lower extremities (55%), head (28%), and upper extremities. Ten victims (9%) died before arriving at a hospital.

Conclusions: Vehicle-ramming attacks tend to have multiple casualties, be deadly, occur more often on Fridays and in the afternoon, and result mostly in injuries to the extremities and the head. These findings could guide policymaking to improve medical response to vehicle-ramming attacks.

Helit Nakar MD, Alex Sorkin MD, Roy Nadler MD, Avishai M. Tsur MD, Shaul Gelikas MD MBA, Guy Avital MD, Elon Glassberg MD MHA MBA, Tarif Bader MD MHA MA, Lidar Fridrich MD, Jacob Chen MD MHA MSc, and Avi Benov MD MHA

Background: Pain control in trauma is an integral part of treatment in combat casualty care. More soldiers injured on the battlefield need analgesics for pain than life-saving interventions (LSIs). Early treatment of pain improves outcomes after injury, while inadequate treatment leads to higher rates of post-traumatic stress disorder (PTSD).

Objective: To describe the experience of the Israel Defense Forces (IDF) Medical Corps with prehospital use of analgesia.

Methods: All cases documented in the IDF-Trauma Registry between January 1997 and December 2019 were examined. Data collection included analgesia administered, mechanism of injury, wound distribution, and life-saving interventions performed.

Results: Of 16,117 patients, 1807 (11.2%) had at least one documented analgesia. Demographics included 91.2% male; median age 21 years. Leading mechanism of injury was penetrating (52.9%). Of injured body regions reported, 46.2% were lower extremity wounds. Most common types of analgesics were morphine (57.2%) and fentanyl (27%). Over the two decades of the study period, types of analgesics given by providers at point of injury (POI) had changed. Fentanyl was introduced in 2013, and by 2019 was given to 39% of patients. Another change was an increase of casualties receiving analgesia from 5–10% until 2010 to 34% by 2019. A total of 824 LSIs were performed on 556 patients (30.8%) receiving analgesia and no adverse events were found in any of the casualties.

Conclusions: Most casualties at POI did not receive any analgesics. The most common analgesics administered were opioids. Over time analgesic administration has gained acceptance and become more commonplace on the battlefield.

Mor Rittblat MD, Lilach Gavish PhD, Avishai M. Tsur MD MHA, Shaul Gelikas MD MBA, Avi Benov MD MHA, and Amir Shlaifer MD

Background: Freeze dried plasma (FDP) is a commonly used replacement fluid in the prehospital setting when blood products are unavailable. It is normally administered via a peripheral intravenous (PIV) line. However, in severe casualties, when establishing a PIV is difficult, administration via intraosseous vascular access is a practical alternative, particularly under field conditions.

Objectives: To evaluate the indications and success rate of intraosseous administration of FDP in casualties treated by the Israel Defense Forces (IDF).

Methods: A retrospective analysis of data from the IDF-Trauma Registry was conducted. It included all casualties treated with FDP via intraosseous from 2013 to 2019 with additional data on the technical aspects of deployment collected from the caregivers of each case.

Results: Of 7223 casualties treated during the study period, intravascular access was attempted in 1744; intraosseous in 87 of those. FDP via intraosseous was attempted in 15 (0.86% of all casualties requiring intravascular access). The complication rate was 73% (11/15 of casualties). Complications were more frequent when the event included multiple casualties or when the injury included multiple organs. Of the 11 failed attempts, 5 were reported as due to slow flow of the FDP through the intraosseous apparatus. Complications in the remaining six were associated with deployment of the intraosseous device.

Conclusions: Administration of FDP via intraosseous access in the field requires a high skill level.

Shaul Gelikas MD MBA, Dotan Yaari MD MHA, Guy Avital MD, Or Bainhoren MD, and Avi Benov MD MHA

Background: Pain management is fundamental in the treatment of a trauma casualty. Adequate pain management is associated with decreased long-term morbidity and chronic pain. Nonetheless, pain is frequently not documented nor adequately treated in the prehospital setting, a phenomenon described as oligoanalgesia. Gender bias has been suggested as a risk factor for oligoanalgesia.

Objectives: To examine the association between casualty gender and pain management in the prehospital trauma setting.

Methods: We conducted a retrospective cohort study of the Israel Defense Forces Trauma Registry between 2015 and 2020. Univariable analysis followed by multivariable logistic regression was used to assess the association between casualty gender and pain management. For adult patients for whom gender was known, pain scores were documented.

Results: A total of 1044 casualties were included in the study; 894 (85.6%) were male. Females and males differed in several demographic and injury characteristics, including age in years (mean 36 vs. 27.6, P value < 0.001) and injury mechanism (16%% vs. 34.5% penetrating injury, P value < 0.001). Female casualties were less likely to be treated for pain (odds ratio [OR] 0.708, 95% confidence interval [95%CI] 0.5–1, P = 0.05). However, after adjustment for various factors, including pain severity, this association was insignificant (OR 0.748, 95%CI 0.46–1.23, P = 0.25).

Conclusions: In this prehospital study, gender bias in pain management was not apparent. As women’s role on the battlefield continues to increase, further studies regarding the role of

David Segal MD MPH, Nitzan Shakarchy-Kaminsky MD MSc, Yair Zloof MD, Tomer Talmy MD, Galina Shapiro MD PHD, Irina Radomislensky BSc, Avishai M. Tsur MD MHA, Shaul Gelikas MD MBA, Erez Karp MD MHA, and Avi Benov MD MHA; Israel Trauma Group

Background: Medical organizations worldwide aim for equity and diversity in the medical profession to improve care quality. Data on whether the caregiver gender affects outcomes in the prehospital setting are essential but scarce compared to available in-hospital studies.

Objective: To analyze the rates of missed injuries in the prehospital setting and determine whether these rates were associated with the gender of the on-field physician or paramedic.

Methods: A retrospective record review was conducted, which included trauma records documented in two trauma registries, the prehospital Israel Defense Forces-Trauma Registry (IDF-TR), and the in-hospital Israeli National Trauma Registry (INTR). Missed injuries were defined as injuries documented in the INTR but not in the IDF-TR. A multivariable regression analysis was performed to assess the association between provider’s gender and missed injuries.

Results: Of 490 casualties, 369 (75.3%) were treated by teams that included only male paramedics or physicians. In 386 (78.8%) cases, a physician was a part of the prehospital team. In all, 94 (19.2%) casualties sustained injuries that were missed by the prehospital medical team. Missed injuries were not associated with the gender of the paramedic or physician (odds ratio 1.242, 95% confidence interval 0.69–2.193).

Conclusions: No association was found between the gender of the medical provider in the prehospital setting and the rate of missed injuries. These results should encourage prehospital emergency medical systems to aim for a balanced and diverse caregiver population.

Alex Sorkin MD, Avishai M. Tsur MD MHA, Roy Nadler MD, Ariel Hirschhorn MD, Ezri Tarazi BDes, Jacob Chen MD MHA, Noam Fink MD, Guy Avital MD, Shaul Gelikas MD MBA, and Avi Benov MD MHA

Background: The Israeli Defense Forces-Medical Corps (IDF-MC) focuses on reducing preventable death by improving prehospital trauma care. High quality documentation of care can serve casualty care and to improve future care. Currently, paper casualty cards are used for documentation. Incomplete data acquisition and inadequate data handover are common. To resolve these deficits, the IDF-MC launched the BladeShield 101 project.

Objectives: To assess the quality of casualty care data acquired by comparing standard paper casualty cards with the BladeShield 101.

Methods: The BladeShield 101 system consists of three components: a patient unit that records vital signs and medical care provided, a medical sensor that transmits to the patient unit, and a ruggedized mobile device that allows providers to access and document information. We compared all trauma registries of casualties treated between September 2019 and June 2020.

Results: The system was applied during the study period on 24 patients. All data were transferred to the military trauma registry within one day, compared to 72% (141/194) with a paper casualty card (P < 0.01). Information regarding treatment time was available in 100% vs. 43% (P < 0.01) of cases and 98% vs. 67% (P < 0.01) of treatments provided were documented comparing BladeShield 101 with paper cards, respectively.

Conclusions: Using an autonomous system to record, view, deliver, and store casualty information may resolve most current information flow deficits. This solution will ultimately significantly improve individual patient care and systematic learning and development processes.

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