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subjective symptoms increases the risk for long-term injury Medical Capability Development Integration Directorate’s
if re-exposed to a cold environment. This pathway attempts development of an MES-AoECE supplement with a COTS
to safely return these Soldiers to duty to best reconstitute the handheld COHb oximeter (analogous to environment-specific
commander’s combat power within 24 hours. The efficient CBRNE detection equipment) enables a quantifiable prehospi-
and safe disposition of large numbers of Soldiers with possible tal diagnosis; this supports real-time monitoring, appropriate
frostbite is a significant problem for medical units in Arctic disposition for medical evacuation, and the preservation of
conditions and is an active area of study. limited resources (like oxygen) in an environment with con-
tested logistics.
Carbon Monoxide as an Example of
Logistical Constraints in the AoECE Conclusion

Scenario 5 Operations in AoECE demand an environment-specific ap-
During a brigade-level training rotation with ambient proach. The renewed emphasis on the Arctic environment has
temperatures below –37°C (–35°F), a supporting Role 2 is enabled assessments in the prehospital delivery of medical
presented with 10 casualties complaining of headaches, care, helped identify capability gaps, and aided in the devel-
confusion, and muscle weakness. Their accompanying opment of best practices. However, significant capability gaps
platoon medic reports they spent all night in their ahkio impacting casualty survivability and disability still exist with-
tent with the heater on and believes the carbon monox- out clear solutions.
ide detector was not functioning. Role 2 providers clini-
cally diagnose carbon monoxide poisoning and, without Hypothermia remains a persistent threat and an obvious con-
the ability to assess carboxyhemoglobin levels, triage on tributor to mortality. Active rewarming methods capable of
presentation. Because of the significant oxygen require- functioning in subzero temperatures and improved environ-
ment for the treatment of carbon monoxide (CO) poison- mental protection at the point of injury will increase survivabil-
ing, only two casualties are definitively treated at the Role ity by preventing further heat loss and optimizing a casualty’s
2, while eight casualties are evacuated via three ground physiology until more definitive resuscitation can begin at
transports to the nearest hospital. higher echelons of care. Fluid warmers capable of sustaining
temperatures above the hypothermic level are needed. Procur-
Carbon monoxide exposure is a significant threat in AoECE, ing sheltering that provides a bubble of warmth through tacti-
as fuel-based heaters remain a standard method of warmth for cal field care and fielding improved tentage with robust heaters
sleeping quarters. While carbon monoxide detectors are used for military treatment facilities will improve hypothermia pre-
within Akio tents to mitigate exposure, they are susceptible vention and treatment. Further research is needed to identify
to human and equipment failure. Additionally, available CO “warm chain” storage options for temperature-sensitive items
detectors are limited to commercial off-the-shelf (COTS) prod- (e.g., blood, medications) and to enable temperature-controlled
ucts intended for use in fixed facilities and not engineered for transport of medications at individual or collective levels.
the rigors of military use in field operations. As the tempera-
ture drops, Soldiers may use creative methods to stay warm Adjusting the Modified Table of Organization and Equipment
with butane or other fuel-based heaters, causing CO poison- or fielding an MES-AoECE Supplement for units operating in
ing outside of enclosed environments. While most exposures the AoECE to include Bair Huggers, sous vides, and handheld
16
manifest with headaches, nausea, and dizziness, severe expo- carbon monoxide oximeters would fill critical capability gaps.
sures may present with neurological impairment and cardiac Combined, these adjustments improve Army Health System
dysrhythmias. 17,18 capabilities in the AoECE and will reduce the already high
mortality expected in an MDO.
The primary treatment method for a conscious CO poisoning
is 100% O via a nonrebreather mask at 15 liters-per-minute Author Contributions
2
(LPM) until the carboxyhemoglobin (COHb) level is <10% DJR drafted the original manuscript. MTC, SEM, and TJR as-
and for an additional four hours if the casualty is suffering sisted in manuscript editing and drafting.
from additional sequela or high-level exposure. 18,19 Oxygen ca-
pabilities within a BCT are available in D-size O cylinders. A Disclaimer
2
full D-tank will provide 21 minutes of O therapy at 15LPM, The views expressed herein are those of the author(s) and do
2
quickly expending available O supplies. It is possible to ex- not reflect the official policy or position of the Uniformed Ser-
2
tend O supplies and increase the removal of COHb using an vices University, the Department of the Army, the Department
2
emergency evacuation hyperbaric stretcher; however, this tra- of the Navy, the Department of the Air Force, the Department
ditionally requires approval from a hyperbaric medical officer of Defense, or the U.S. Government.
and presents significant logistical considerations.
Institutional clearance approved.
Obtaining a COHb level requires equipment beyond the capa-
bilities of a Role 2 lab section, limiting providers to triage and Funding
direct treatment based on clinical presentation or other co- No funding was received for this work.
morbidities. This becomes problematic in diagnosing if the his-
tory is not suggestive of CO exposure or, in triage, if multiple References
casualties present with CO exposure. Wearable colorimetric 1. United States Army. Regaining Arctic Dominance: The U.S. Army
17
in the Arctic. Department of the Army; 2021.
carbon monoxide badges are a possible early detection tool; 2. Committee on Tactical Combat Casualty Care. Tactical Combat
however, their practicality in a frequently dark field environ- Casualty Care (TCCC) Guidelines: 25 January 2024. Joint Trauma
ment where thermal stress cycling occurs is undetermined. The System; 2024.
Arctic or Extreme Cold Casualty Care Considerations | 41