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basic airway maneuvers, such as BVM and nasopharyngeal 2. Unit commanders should report on a quarterly basis med-
airway (NPA) placement, could have been performed in lieu ical for assigned medical personnel in accordance with
of cricothyrotomy. TCCC guidelines and recommendations.T his is consis-
tent with individual and collective task training reports
Expert evaluation of AARs on prehospital airway interven- compiled by units for nonmedical personnel. To this end,
tions, especially cricothyrotomy, led to several of the same re- unit commanders should be held accountable to meeting
marks. The panel reached a clear consensus for training and these required metrics.
emphasizing basic airway maneuvers over advanced airway 3. Medical sustainment training for airway management
procedures. The experts also agreed that feedback from the should emphasize basic airway maneuvers, such as po-
field suggests that the emphasis placed on cricothyrotomy sitioning, BVM, and NPA. However, these findings likely
during medic training and in prehospital management guide- extend beyond airway management and other training
lines may have misled some, if not most, medics into think- should be commensurate.
ing cricothyrotomy is the preferred airway intervention, as 4. Advanced airway skills training should include LMA,
opposed to an alternative in the management of the difficult endotracheal intubation, RSI, video laryngoscopy, and
airway. 4,5 cricothyrotomy.
5. The US Army Medical Research and Material Command
Medical providers across the entire spectrum of the deployed (USAMRMC) should form a working group to identify
military medical system frequently cited insufficient stocks of optimal training methodologies for airway skills, as cur-
medical airway supplies and equipment. Specific items repeat- rent mannequin and simulation training is not sufficient.
edly noted include endotracheal tubes, suction apparatuses, There needs to be uniform, evidence-based platform for
rapid sequence intubation (RSI) medications, and all things training if live tissue is going to continue to be phased out.
pediatric. During the conflicts, endotracheal intubation was 6. Medical sustainment training should include supervised
typically performed by advanced medical providers in medical clinical engagements, ideally within military treatment fa-
facilities (e.g. battalion aid stations, combat support hospitals, cilities, civilian hospitals, or prehospital emergency medi-
etc.). Consequently, these deficiencies for the life-saving in- cal services systems.
3,5
tervention of endotracheal intubation indicate critical short- 7. The USAMRMC should form a working group to review
ages within medical facilities designed to deploy with a full and update the contents of medical sets, kits, and outfits,
complement of medical supplies and supported by dedicated with particular attention to advanced airway devices and
medical logistics personnel for resupply. Our findings sug- pediatric-specific supplies.
15
gest the military medical logistics system, even in the devel- 8. The USAMRMC should form a working group to de-
oped combat theater, is challenged to fully support combat velop future solutions for intratheater medical logistical
casualty care and deploying medical providers should expect support and sustainment, including consideration for
equipment and supply shortages. 16 prepositioned caches, unmanned aerial vehicle delivery,
and oxygen-producing devices.
Expert review of all equipment and supply related lessons 9. Theater-level surgeons or deployed Joint Trauma System
learned prompted several comments. The group clearly agrees (JTS) assets should develop more robust, mechanisms by
that pediatric-specific equipment and supplies are commonly which to capture mortality and morbidity data for patient
insufficient and undoubtedly needed. Additionally, members care delivered in the deployed setting at or near the point-of-
of the group believe that the current equipment and supply injury for performance improvement purposes in real-time.
listings in the medical sets should be reviewed by an expert 10. The operational force should enforce the use of lessons
panel and updated. learned feedback mechanisms for ongoing performance
improvement.
Expert evaluation of AARs was not strictly related to training
shortfalls and equipment deficiencies. Other reports using our Limitations
keywords search prompted expert panel recommendations for
enhanced capabilities and performance improvement enabled Limitations of our findings focus on the selection bias inherent
by improved data collection. in lessons learned systems that collect information on a volun-
tary basis in largely free-text form without robust systematic
Of note the Defense Health Agency (DHA) is assuming the data validation. Comments focusing on the need for improve-
leadership of Military Treatment Facilities (MTFs) soon. The ment far outnumber positive comments, skewing the analysis
DHA partnership with the Joint Trauma System (JTS) is in- towards perceived gaps. This is likely the effect of a voluntary
tended to optimize TCCC training throughout the MTFs.It is reporting system in which uniform submission is not required.
unclear what effect this will have on these challenges. How- This may have effects on the type of feedback received thus
ever, if the right training techniques are developed, the new limiting the generalizability. Feedback from other branches
command restructuring placing the AMEDD/HCRoE under of the US military may not have been available for review. A
TRADOC may be able to address some of these short comings more systematic sampling of end-user opinions might reveal
across the operational components as well. a more balanced set of perceptions. However, more rigorous
data collection often lags and lessons learned information can
direct organizations towards problem areas. 12
Expert Panel Recommendations
1. The US Army Medical Department/Health Readiness Cen- Conclusion
ter of Excellence (AMEDD/HCRoE) should form a work-
ing group with the aim to establish a standardized medical In this review of military lessons learned systems, most of
sustainment training program for combat and flight medics. the feedback referenced equipment malfunctions and gaps in

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