Page 118 - JSOM Winter 2025

allies based on lessons from the Ukraine War—cultural context operations demand a distinct medical approach, grounded in
and the human factor. Mil Med. Published online June 3, 2025. prevention, performance optimization, and scenario-driven
doi:10.1093/MILMED/USAF217 training.
2. Onderková A, Quinn J, Meoli M, et al. Enhancing prehospital
care during the conflict in Ukraine: NATO’s role in global health Discussion: Hypothermia remains a critical threat, not only in
engagement. Mil Med. Published online February 27, 2024. frigid waters but also through cumulative exposure to wind,
doi:10.1093/milmed/usae380 metal surfaces, and moisture. Comprehensive thermal strate-
gies, emphasizing prevention, active rewarming, and dexterity
Wargaming: Implementations for Mastering Junctional preservation, are vital.
Hemorrhage Control in LSCO Environments
MAJ. Eric Akrish RN BSN TCRN CEN C-TMP MAJ, CA Maritime trauma care poses unique operational challenges.
Vertical movement across decks, narrow corridors, and dy-
In large-scale combat operations (LSCOs), where high casu- namic platforms complicate triage, evacuation, and resuscita-
alty rates and severe injuries prevail, junctional hemorrhage— tion. These constraints require integrated training in rope-based
bleeding from critical transitional areas, like the groin, axilla, extrication, confined-space navigation, and effective use of illu-
or neck—poses a significant challenge and remains a substan- mination tools under tactical conditions.
tial cause of preventable battlefield mortality. This presentation
assesses the proactive advancement of wargaming method- Additional risks, including drowning, toxic inhalation (nota-
ologies as an essential training mechanism explicitly aimed bly hydrogen cyanide from vessel fires), motion sickness, and
at heightening the efficacy of interventions under the unique slamming-induced impact, further compromise both short-
pressures of LSCOs. Integrating both tabletop and high-fidelity term capability and long-term health. Each element must be
simulations, the training modules designed cover a spectrum addressed with tailored prevention, appropriate pharmaco-
of realistic LSCO scenarios, which include high- velocity gun- logical support, and protective equipment, such as suspension
shot wounds, massive blast injuries, and shrapnel penetrations, seats to mitigate repetitive impact. Hybrid threats, combining
prevalent in such settings. terrorism, criminal activity, cyberattacks, disinformation, and
disruptive technology, add complexity to maritime missions,
These scenarios incorporate the application and challenges of requiring SOF/SWAT teams to incorporate digital resilience
using advanced hemorrhage control technologies, such as he- and cross-agency coordination into planning and response.
mostatic dressings, junctional tourniquets; immediate use of
blood products; and resuscitative endovascular balloon occlu- Prolonged Field Care (PFC) is a defining feature of maritime
sion of the aorta (REBOA) strategies. Wargames enhance re- operations. Medical personnel must be equipped not only with
al-world applicability by simulating the resource-constrained clinical skills but also the adaptive thinking necessary for pro-
and logistically complex environments typical of LSCOs, fo- longed, resource-limited care in austere maritime environments.
cusing on swift hemorrhage control, precise application of Conclusion: Medical readiness in maritime SOF and SWAT
life-saving devices, and optimal decision-making under duress operations hinges on mastery of the fundamentals, environ-
and preparation for casualty movement. mental adaptation, and relentless, scenario-based training. The
Furthermore, this enriched training protocol delves into inte- ability to prevent hypothermia, preserve performance, and
grating biodynamic monitoring systems that assist in real-time, operate effectively in multi-level, unpredictable settings define
data-driven decision-making and implementing enhanced sta- operational medical excellence in the maritime domain.
bilization techniques crucial for managing prolonged field
care (PFC) situations, thereby potentially extending the golden References
hour in remote battlefield conditions. These wargaming exer- 1. Singh M V, Ray, S, Goyal S, Singh RJ, Sharma R. Tactical combat
casualty care in the navy–challenges and way ahead. Journal of
cises aim to substantially bolster technical skills and cognitive Marine Medical Society. 2019;21(2):105–107. doi:10.4103/jmms.
preparedness through detailed after-action reviews and iter- jmms_67_19
ative learning cycles, ultimately enhancing survivability and 2. Melau J, Hisdal J, Solberg PA. Impact of a 10,000-m cold-water
operational lethality in LSCO environments. swim on Norwegian naval special forces recruits. J Spec Oper Med.
2021;21(3):55–59. doi:10.55460/qe23-511p
The findings advocate for the strategic deployment of advanced 3. Glassberg E, Lipsky AM, Abramovich A, Sergeev I, Hochman O,
wargaming as a pivotal educational and preparation tool that Ash N. A dynamic mass casualty incident at sea: lessons learned
not only refines individual competencies but also ensures co- from the Mavi Marmara. J Trauma Acute Care Surg. 2013;75(2):
hesive team performance in managing complex battlefield in- 292–297. doi:10.1097/TA.0b013e318294662d
juries effectively within the LSCO framework. This accords 4. Myers SD, Dobbins TD, King S, et al. Physiological consequences of
with the current strategic shift towards preparing military military high-speed boat transits. Eur Jour Appl Physiol. 2011;111:
2041-2049. doi:10.1007/s00421-010-1765-3
medical personnel and tactical first responders for high-inten- 5. Granholm F, Tin D, Ciottone GR. The complexities of hybrid war-
sity conflicts where traditional medical response tactics must fare and the Impact on tactical emergency medical support. Health
be adapted to meet the escalated demands of modern warfare. Secur. 2023;21(3):242–245. doi:10.1089/hs.2022.0161

Performance and Medicine in The October 7, 2023, Attack on Israel Indicates a
Maritime High-Risk Environments Change in Trauma: Patterns of Terror Victims, due to
Dr. Fredrik Granholm, Department of Anesthesiology and the Use of Thermobaric Weapons
Intensive Care. Sundsvall County Hospital, Sundsvall, Sweden Ishay Ostfeld, MD; Erez Kachel, MD; Oleg Shafir, MD;
Itay Gal, MD; Yehonatan Cohen, MD; Chen Kugel, MD;
Background: Special Operations Forces (SOF) and Special Jay R. Hoffman, PhD
Weapons and Tactics (SWAT) teams are increasingly tasked
with high-risk maritime missions, operating in environ- Introduction: The terror attack on October 7, 2023, in south-
ments that are cold, confined, and dynamically hostile. These ern Israel resulted in approximately 1,200 civilians and security

116 | JSOM Volume 25, Edition 4 / Winter 2025