Page 120 - JSOM Winter 2025

Summary Table of Take-Home Points
Capability Area Key requirements/practices Implementation notes
Point-of-injury care • Universal TCCC certification for all service members • Build into basic training and annual
• Rapid tourniquet and junctional hemorrhage control recertification; establish small blood hubs
(REBOA where available) with portable cold-chain kits
• Airway adjuncts and hypothermia prevention
• Forward whole-blood transfusion at platoon/company
level
Forward resuscitation • Damage-Control Resuscitation (DCR) and PFC/PCC to • Open ASSET+, HEST, and DCR courses to
and surgery bridge evacuation delays junior surgeons, PAs, senior medics; strict
• Modular 4-6-person damage-control surgical teams near NATO CPG adherence
FLOT
Medical logistics • Armored ground evacuation platforms with en-route care • Design ground evac fleet for contested
and evacuation packages airspace; stock vehicle-mounted
• Cold-chain extension for blood and critical drugs down to refrigerators and power backups
platoon level
Interoperability and • Coalition-wide framework for credentialing, scope of • Led by NATO MilMed COE; integrate
clinical governance practice, audit lessons-learned loops after each deployment/
• Standardized digital documentation and data dictionaries exercise
Data, surveillance and • Near-real-time sharing of battlefield biogram • Secure, interoperable platforms; automate
CBRNe readiness (microbiology) data alerts for resistance patterns and CBRNe
• Integrated CBRNe biosurveillance linked to medical data early warning indicators (i.e., acetylcholine
streams esterase, etc).
• Encrypted, coalition-wide casualty-tracking system

2. Onderková A, Quinn J, Meoli M, et al. Enhancing prehospi- prognostic value of the lethal triad versus the lethal diamond
tal care during the conflict in Ukraine: NATO‘s role in global for predicting 24-hour mortality in severely injured trauma
health engagement. Mil Med. 2025;190(3-4):86–94. doi:10.1093/ patients requiring early transfusion.
milmed/usae380
3. Benhassine M, Quinn J, Stewart D, et al. Advancing military We conducted a multicenter retrospective cohort analysis from
medical planning in large scale combat operations: insights from TraumaBase , covering 26 French trauma centers (January
®
computer simulation and experimentation in NATO‘s Vigorous 2011 to September 2023). Inclusion criteria involved adult
Warrior Exercise 2024. Mil Med. 2024;189(Suppl 3):456–464. doi: trauma patients (age >15 years) receiving ≥1 unit of red blood
10.1093/milmed/usae152
4. Quinn JM. Lessons for NATO to be learned from Putin’s war in cells within 6 hours of hospital admission. Hypocalcemia was
Ukraine: global health engagement, interoperability, and lethality. defined as ionized calcium <1.10mmol/L. Primary endpoint
Connections. 2022;21(1):103–118. was 24-hour mortality. Statistical analysis included receiver
5. Quinn V JM, Dhabalia TJ, Roslycky LL, et al. COVID-19 at War: operating characteristic (ROC) curves and logistic regression
The Joint Forces Operation in Ukraine. Disaster Med Public to assess associations.
Health Prep. 2022;16(5):1753–1760. doi:10.1017/dmp.2021.88
6. Quinn JM, Bencko V, Bongartz AV, et al. NATO and evidence-based From an initial cohort of 44,234 patients, 2,141 patients met
military and disaster medicine: case for Vigorous Warrior Live inclusion criteria (median age 39 years, 72% male, median ISS
Exercise Series. Cent Eur J Public Health. 2020;28(4):325–330. 27). The 24-hour mortality rate was 16.1%. Hypocalcemia oc-
doi:10.21101/cejph.a6045
7. Benhassine M, Van Utterbeeck F, De Rouck R, et al. Open-air curred in 64% of patients. ROC analysis revealed similar pre-
artillery strike in a rural area: a hypothetical scenario. In: Pro- dictive capacities for the lethal diamond (AUC 0.71[95% CI
ceedings of the 2023 Winter Simulation Conference (WSC). IEEE; 0.68–0.74]) and lethal triad (AUC 0.72 [95% CI 0.69–0.74],
2023:2391–2402. doi:10.1109/WSC56905.2023.10123799 P=.26). Effect size analysis using Cramer’s V also showed no
8. Committee on Tactical Combat Casualty Care. Tactical Combat significant difference (triad: 0.29; diamond: 0.28). Multivar-
Casualty Care (TCCC) Guidelines—2024 Update. Joint Trauma iate logistic regression demonstrated significant independent
System; 2024. associations of coagulopathy (OR 3.33 [95% CI 1.70–7.54],
9. Spinella PC, Holcomb JB. Whole blood in combat casualty care:
lessons from history and ongoing experience. Curr Opin Hematol. P=.001), acidosis (OR 4.43 [95% CI 3.24–6.14], P<.001), and
2022;29(6):450–456. doi:10.1097/MOH.0000000000000750 hypothermia (OR 1.67 [95% CI 1.28–2.19], P<.001) with 24-
10. Holcomb JB, Shackelford SA, del Junco DJ, et al. The impact of hour mortality. Hypocalcemia, however, did not retain signifi-
prolonged field care on combat mortality in modern warfare. cance (OR 1.11 [95% CI 0.84–1.48], P=.5).
J Trauma Acute Care Surg. 2022;93(2 Suppl 1):S160-S168. doi:10.
1097/TA.0000000000003524 Our study identified no superiority of the lethal diamond over
the lethal triad for predicting early mortality, raising questions
Comparison of the Lethal Triad and the Lethal Diamond regarding the independent prognostic role of hypocalcemia. Al-
in Severe Trauma: Implications for Early Mortality though strongly associated with coagulopathy and transfusion
Dr. Olivier Duranteau, MD, PhD (FRA), Intensive Care Unit, requirements, hypocalcemia alone might not independently
HNIA Percy Military Training Hospital, Clamart, France predict early death. These findings support continued emphasis
on managing the lethal triad while advocating cautious, indi-
The lethal triad, defined by coagulopathy, hypothermia, and vidualized management of calcium levels during resuscitation.
acidosis, is well established as a critical predictor of early mor-
tality in severe trauma. Recent studies propose the inclusion of This study demonstrates no significant prognostic difference
hypocalcemia, creating a “lethal diamond,” due to calcium’s between the lethal triad and the lethal diamond regarding
pivotal role in coagulation, myocardial function, nerve con- 24-hour mortality in severely traumatized patients. Future
duction, and vascular tone. This study aimed to compare the prospective studies are necessary to determine the clinical

118 | JSOM Volume 25, Edition 4 / Winter 2025