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Avilla J, Rerucha C, Hu C 23(2). 99 (Journal Article)

The presentation of Type 3c diabetes is atypical, accounting for 0.5-1% of all types of diabetes. Combining this with the healthy Special Operations community is even more profound. A 38-year-old active-duty male in Special Operations developed acute abdominal pain and vomiting while deployed. He was diagnosed with severe acute necrotizing pancreatitis secondary to Type 3c diabetes, and the management of his condition became increasingly difficult. This case highlights Type 3c diabetes and the complexity of formulating a comprehensive treatment plan for a tactical athlete.

Biggs A, Jewell J, Littlejohn LF 23(2). 94 (Journal Article)

Special Operations medicine must provide highly reliable healthcare under intense and sometimes dangerous circumstances. In turn, it is important to understand the principles inherent to building a High Reliability Organization (HRO). These principles include (1) sensitivity to operations; (2) preoccupation with failure; (3) reluctance to simplify; (4) resilience; and (5) deference to expertise. Understanding them is crucial to turning good ideas into sound practical benefit in operational medicine. A prime teaching opportunity involves an interesting coincidence that occurred during the emergence of HROs. Specifically, United States Special Operations Command (USSOCOM) adopted five Special Operations Forces (SOF) Truths that contribute to success in Special Operations, including (1) humans are more important than hardware; (2) quality is better than quantity; (3) SOF cannot be mass produced; (4) competent SOF cannot be created after emergencies occur; and (5) most Special Operations require non-SOF support. These five Truths have more in common with the five HRO principles than merely quantity. They describe the same underlying ideas with a key focus on human performance in high-risk activities. As such, when presented alongside the five HRO principles, there is an opportunity to improve the overall health and performance of SOF personnel by integrating these principles across the range of Special Operations medicine from point of injury care to garrison human performance initiatives. The following discussion describes in greater detail the five HRO principles, the five SOF Truths, and how these similar ideas emerged as more than just a useful coincidence in illustrating the key concepts to produce high performance.

de Lesquen H, Paris R, Fournier M, Cotte J, Vacher A, Schlienger D, Avaro JP, de La Villeon B 23(2). 88 (Journal Article)

Introduction: To prepare military doctors to face mass casualty incidents (MCIs), the French Army Health Service contributed to the development of TRAUMASIMS, a serious game (SG) for training medical responders to MCIs. Methods: French military doctors participated in a three-phase training study. The initial war trauma training was a combination of didactic lectures (Phase 1), laboratory exercises (Phase 2), and situational training exercises (STX) (Phase 3). Phase 1 lectures reviewed French Forward Combat Casualty Care (FFCCC) practices based on the acronym MARCHE (Massive bleeding, Airway, Respiration, Circulation, Head, hypothermia, Evacuation) for the detection of care priorities and implementation of life-saving interventions, triage, and medical evacuation (MEDEVAC) requests. Phase 2 was a case-control study that consisted of a traditional text-based simulation of MCIs (control group) or SG training (study group). Phase 3 was clinical: military students had to simultaneously manage five combat casualties in a prehospital setting. MCI management was evaluated using a standard 20-item scale of FFCCC benchmarks, 9-line MEDEVAC request, and time to evacuate the casualty collection point (CCP). Emotional responses of study participants were secondarily analyzed. Results: Among the 81 postgraduate military students included, 38 took SG training, and 35 trained with a text-based simulation in Phase 2. Regarding the error rates made during STX (Phase 3), SG improved FFCCC compliance (11.9% vs. 23.4%; p < .001). Additionally, triage was more accurate in the SG group (93.4% vs. 88.0%; p = .09). SG training mainly benefited priority and routine casualties, allowing faster clearance of the CCP (p = .001). Stress evaluations did not demonstrate any effect of immersive simulation. Conclusion: A brief SG-based curriculum (2 hours) improved FFCCC performance and categorization of casualties in MCI STX.

Qureshi I, Simecek J, Mitchener TA 23(2). 82 (Journal Article)

A literature review was performed to determine the frequency of medical evacuations (MEDEVAC) that are required for dental emergencies (DE) and oral-maxillofacial (OMF) injuries. Fourteen studies were reviewed altogether - eight which quantified evacuation of DEs or OMF injuries in military personnel (from 1982-2013) and six studies that discussed medical evacuation of DEs occurring in civilians working in offshore oil and gas rigs and wilderness expeditions (from 1976-2015). Among military personnel, DE/OMF issues were frequently among one of the top categories of medical evacuations, ranging from 2-16% of all evacuations. Among oil and gas industry workers, 5.3-14.6% of evacuations were dental-related, while one study of wilderness expeditions found that DEs ranked as the third most frequent type of injury that required evacuation. Previous studies have shown that dental and OMF problems often account for one of most frequently cited reasons for evacuation. However, due to the limited study base of DE/OMF medical evacuations, further research is needed to determine their impact on the cost of health care delivery

Wagner R, Cole R, Thompson J, Egan SJ, VanShufflin MW, Tilley L 23(2). 78 (Journal Article)

Operation Gunpowder is a high-fidelity military medical field practicum conducted by the Uniformed Services University of Health Sciences, Bethesda, MD. During this multi-day combat simulation, Special Operations Medics and Corpsmen teach military medical students how to treat patients in an austere, resource-limited environment. To investigate the effectiveness of this teaching model, our research team used a qualitative phenomenological design to explore medical students' experiences being taught by Special Operations Medics and Corpsmen during Operation Gunpowder. We found two themes regarding the medical students' personal and professional development: an increased understanding of medics' skills and capabilities and the realization of their future roles as educators and leaders. Our study suggests that the use of Special Operations Corpsmen and Medics in medical student training is a valuable model for both military and civilian medical education and training

Lopachin T, Treager CD, Sulava EF, Stuart SM, Bohan ML, Boboc M, Fernandez P, Bianchi WD, McGowan AJ, Friedrich EE 23(2). 73 (Journal Article)

Objective: Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a method of gaining proximal control of noncompressible torso hemorrhage (NCTH). Catheter placement is traditionally confirmed with fluoroscopy, but few studies have evaluated whether ultrasound (US) can be used. Methods: Using a pressurized human cadaver model, a certified REBOA placer was shown one of four randomized cards that instructed them to place the REBOA either correctly or incorrectly in Zone 1 (the distal thoracic aorta extending from the celiac artery to the left subclavian artery) or Zone 3 (in the distal abdominal aorta, from the aortic bifurcation to the lowest renal artery). Once the REBOA was placed, 10 US-trained locators were asked to confirm balloon placement via US. The participants were given 3 minutes to determine whether the catheter had been correctly placed, repeating this 20 times on two cadavers. Results: Overall, US exhibited an average sensitivity of 83%, specificity of 76%, and accuracy of 80%. For Zone 1, US showed a sensitivity of 78% and specificity of 83%, and for Zone 3, a sensitivity of 88% and specificity of 76%. In addition, US exhibited a likelihood positive ratio (LR+) of 3.73 and a likelihood negative ratio (LR-) of 0.22 for either position, with similar numbers for Zone 1 (+4.57, -0.26) and Zone 3 (+3.16, -0.16). Conclusion: Ultrasound could prove to be a useful tool for confirming placement of a REBOA catheter, especially in austere environments.

Ibarra C, Bass L, Saler E, Daniels R, Davis N, Washington M 23(2). 70 (Journal Article)

SARS-CoV-2 is the virus responsible for the disease that is known as COVID-19. While there have been numerous studies detailing the survival rates of SARS-CoV-2 on various materials, there are currently no published data regarding whether this virus is stable on standard military uniforms. Consequently, there are no standard operating procedures for washing uniforms once exposed to the virus. This study aimed to determine whether SARS-CoV-2 could be removed from Army combat uniform material by washing with a commercially available detergent and tap water. Washing the fabric with detergent followed by a rinse step with tap water effectively removes detectable viral particles. Importantly, it was found that washing with hot water alone was not effective. Therefore, it is recommended that military personnel wash their uniforms with detergent and water as soon as possible after exposure to SARS-CoV-2; hot water should not be used as a substitute for detergent.

Renkiewicz G, Hubble MW, Hunter SL, Kearns RD 23(2). 60 (Journal Article)

Introduction: The coronavirus disease pandemic has pro-foundly affected emergency medical services (EMS) profes-sionals, but the emotional impact is unknown. Methods: This was a cross-sectional survey of North Carolina EMS profes-sionals from April to May 2021. EMS professionals on an ac-tive roster were included. With pandemic-related perceptions, the 15-item Posttraumatic Maladaptive Beliefs Scale (PMBS) was used to quantify the severity of maladaptive cognition. Significant univariate variables were used to create a hier-archical linear regression to assess the potential impact of pandemic-related factors on maladaptive cognition scores. Results: Overall, 811 respondents were included; of those, 33.3% were female, 6.7% were minorities, and 3.2% were Latinx; the mean age was 41.11 ± 12.42 years. Mean scores on the PMBS were 37.12 ± 13.06 and ranged from 15 to 93. PMBS scores were 4.62, 3.57, and 3.99 points higher, respec-tively, in those with increased anxiety, those who trusted their sources of information, and those who reported to work de-spite being symptomatic. Pandemic-specific factors accounted for 10.6% of the variance in PMBS total scores (ΔR2 = 0.106, ΔF[9, 792]; p < .001). Psychopathological factors accounted for an additional 4.7% of the variance in PMBS total scores (ΔR2 = 0.047, ΔF[3, 789]; p < .001). Conclusion: Given that 10.6% of the difference in PMBS scores can be explained by pandemic- related factors, maladaptive cognitions in EMS are a considerable concern and could lead to the development of significant psychopathology post-trauma.

Caldwell RM, Dickey W, Sawyer A, Mann-Salinas EA, Crozier L, Montgomery HR, Moody G 23(2). 55 (Journal Article)

The Joint Trauma System (JTS) publishes Clinical Practice Guidelines (CPGs) used by military and civilian healthcare providers worldwide. With the expansion of CPG development in recent years, there was a need to collate, sort, and deconflict existing and new guidance using systematic methodology both within and across CPGs. This need became readily apparent at the start of the COVID-19 pandemic when guidelines were rapidly developed and fielded in deployed environments. To meet the needs of deploying units requesting immediate and concise guidance for managing COVID-19, JTS developed the CPG entitled Management of Covid-19 in Austere Operational Environments. By applying a deconstruction process to organize clinical recommendations across multiple categories, JTS was able to present clear clinical recommendations across "role of care" and "scope of practice." The use of a deconstruction process supported the rapid socialization of the CPG and may have improved clinical understanding among deployed medical teams.

Walker S, Agree O, Harris R, DesRosiers TT 23(2). 49 (Journal Article)

Introduction: Timely vascular access is critical, as hemorrhage is the number one cause of death on the battlefield. Anecdotal evidence in the Military Health System identified an operationally relevant procedural skills gap in vascular access, and data exist in civilian literature showing high rates of iatrogenic injuries when lack of robust procedural opportunity exists. Multiple pre-deployment training courses are available for surgical providers, but no comprehensive pre-deployment vascular access training exists for non-surgical providers. Methods: This mixed-method review aimed to find relevant, operationally focused, vascular access training publications. A literature review was done to identify both relevant military clinical practice guidelines (CPGs) and full text articles. Reviewers also investigated available pre-deployment trainings for both surgeons and non-surgeons in which course administrators were contacted and details regarding the courses were described. Results: We identified seven full-text articles and four CPGs. Two existing surgical training programs and Army, Navy, and Air Force pre-deployment training standards for non-surgeons were evaluated. Conclusion: A cost-effective and accessible pre-deployment curriculum utilizing reviewed literature in a "learn, do, perfect" structure is suggested, building on pre-existing structures while incorporating remotely accessible didactics, hands-on practice with portable simulation models, and live-feedback training.

Brandt M, Liccardi C, Heidle J, Woods TD, White C, Mullins JR, Blackwell J, Le L, Brantley K 23(2). 44 (Journal Article)

Background: Recent data published by the Special Operations community suggest the Lethal Triad of Trauma should be changed to the Lethal Diamond, to include coagulopathy, acidosis, hypothermia, and hypocalcemia. The purpose of this study is to determine the prevalence of trauma-induced hypocalcemia in level I and II trauma patients. Methods: This is a retrospective cohort study conducted at a level I trauma center and Special Operations Combat Medic (SOCM) training site. Adult patients were identified via trauma services registry from September 2021 to April 2022. Patients who received blood products prior to emergency department (ED) arrival were excluded from the study. Ionized calcium levels were utilized in this study. Results: Of the 408 patients screened, 370 were included in the final analysis of this cohort. Hypocalcemia was noted in 189 (51%) patients, with severe hypocalcemia identified in two (<1%) patients. Thirty-two (11.2%) patients had elevated international normalized ratio (INR), 34 (23%) patients had pH <7.36, 21 (8%) patients had elevated lactic acid, and 9 (2.5%) patients had a temperature of <35°C. Conclusion: Hypocalcemia was prevalent in half of the trauma patients in this cohort. The administration of a calcium supplement empirically in trauma patients from the prehospital environment and prior to blood transfusion is not recommended until further data prove it beneficial.

Reyes J, Kelly J, Badaki-Makun O, Anders J 23(2). 40 (Journal Article)

Introduction: Although the instances of Special Operations Forces (SOF) medical providers treating pediatric pelvic fractures are rare, such fractures are notable injuries in terror attacks and are at high risk for morbidity and mortality for the patient as well as stress for the provider. Presently, guidelines for pediatric-sized pelvic stabilization device application are limited to measured pelvic circumference. This study aims to inform more practical sizing guidelines. Methods: Subjects aged 1 year to 14 years were enrolled. Subject height, weight, pelvic circumference, and fit on the Broselow Pediatric Emergency Tape® (Armstrong Medical Industries), fit with the Pediatric PelvicBinder® (PelvicBinder), and fit with the small SAM Pelvic Sling® (SAM® Medical) were collected. The primary outcome was the proportion of subjects fitting each device. Results: Sixty-five subjects were recruited; median age was 5 years (interquartile range, 1-8 years); 40 (62%) subjects were male. Ninety-one percent of subjects fit within the scale of the Broselow Tape (height <143-cm). One hundred percent of subjects with a height <143-cm had an appropriate fit with the Pediatric PelvicBinder (95% confidence level [CI], 91.8-100%), while 91.7% of subjects with a height >143-cm fit the SAM Pelvic Sling (95%CI, 61.5-99.8%). Conclusions: Providers should attempt to fit the Pediatric PelvicBinder for children >1 year old with suspected unstable pelvic fracture who fall on the Broselow Tape (<143-cm). The small SAM Pelvic Sling should be used for those taller than 143-cm.

Samutsakorn DK, Carius BM 23(3). 36 (Journal Article)

Introduction: Extremity bleeding and subsequent hemorrhagic shock is one of the main causes of preventable battlefield death, leading to mass-fielding of modern tourniquets, such as the Combat Application Tourniquet (CAT; Composite Resources). Numerous look-alike tourniquets, such as the Military Tactical Emergency Tourniquet (MTET; SZCTKlink), flood commercial markets, offering visually near-identical tourniquets for drastically reduced prices. We examined the performance of the MTET compared with that of the CAT. Methods: We undertook a randomized crossover trial to observe self-applied tourniquets to the lower extremity by combat medics, comparing the CAT to the MTET in application time and success rates, proven by loss of distal pulse assessed by Doppler ultrasound in <1 minute. Results: All 50 participants (100%) successfully applied the CAT versus 40 participants (80%) using the MTET (p = .0001). Median application time for the CAT (29.03 seconds; range, 18.63 to 59.50 seconds) was significantly less than those of successful MTET applications (35.27 seconds; range, 17.00 to 58.90 seconds) or failed MTET applications (72.26 seconds; range, 62.84 to 83.96 seconds) (p = .0012). Of 10 MTET failures, three (30%) were from application time >1 minute and seven (70%) from tourniquet mechanical failure. Conclusion: The MTET performed worse than the CAT did in all observed areas. Despite identical appearance, look-alike tourniquets should not be assumed to be equivalent in quality or functionality to robustly tested tourniquets.

Bedolla C, Zilevicius D, Copeland G, Guerra M, Salazar S, April MD, Long B, Naylor JF, De Lorenzo RA, Schauer SG, Hood RL 23(2). 19 (Journal Article)

Introduction: Airway obstruction is the second leading cause of death on the battlefield. The harsh conditions of the military combat setting require that devices be able to withstand extreme circumstances. Military standards (MIL-STD) testing is necessary before devices are fielded. We sought to determine the ability of supraglottic airway (SGA) devices to withstand MIL-STD testing. Methods: We tested 10 SGA models according to nine MIL-STD-810H test methods. We selected these tests by polling five military and civilian emergency-medicine subject matter experts (SMEs), who weighed the relevance of each test. We performed tests on three devices for each model, with operational and visual examinations, to assign a score (1 to 10) for each device after each test. We calculated the final score of each SGA model by averaging the score of each device and multiplying that by the weight for each test, for a possible final score of 2.6 to 26.3. Results: The scores for the SGA models were LMA Classic Airway, 25.9; AuraGain Disposable Laryngeal Mask, 25.5; i-gel Supraglottic Airway, 25.2; Solus Laryngeal Mask Airway, 24.4; LMA Fastrach Airway, 24.4; AuraStraight Disposable Laryngeal Mask, 24.1; King LTS-D Disposable Laryngeal Tube, 22.1; LMA Supreme Airway, 21.0; air-Q Disposable Intubating Laryngeal Airway, 20.1; and Baska Mask Supraglottic Airway, 18.1. The limited (one to three) samples available for testing provide adequate preliminary information but restrict the range of failures that could be discovered. Conclusions: Lower scoring SGA models may not be optimal for military field use. Models scoring sufficiently close to the top performers (LMA Classic, AuraGain, i-gel, Solus, LMA Fastrach, AuraStraight) may be viable for use in the military setting. The findings of our testing should help guide device procurement appropriate for different battlefield conditions.

Schauer SG, Damrow T, Martin SM, Hudson IL, De Lorenzo RA, Blackburn MB, Hofmann LJ, April MD 23(2). 19 (Journal Article)

Background: Airway obstruction is the second leading cause of potentially preventable death on the battlefield. The treatment for airway obstruction is intubation or advanced airway adjunct, which has a known risk of aspiration. We sought to describe the variables associated with aspiration pneumonia after prehospital airway intervention. Methods: This is a sub-analysis of previously described data from the Department of Defense Trauma Registry (DoDTR) from 2007 to 2020. We included casualties that had at least one prehospital airway intervention with documentation of subsequent aspiration pneumonia or pneumonia within three days of the intervention. We used a generalized linear model with Firth bias estimates to test for associations. Results: There were 1,509 casualties that underwent prehospital airway device placement. Of these, 41 (2.7%) met inclusion criteria into the aspiration pneumonia cohort. The demographics had no statistical difference between the groups. The non-aspiration cohort had fewer median ventilator days (2 versus 6, p < 0.001), intensive care unit days (2 versus 7, p < 0.001, and hospital days [3 versus 8, p < 0.001]). Survival was lower in the non-aspiration cohort (74.2% versus 90.2%, p = 0.017). The administration of succinylcholine was higher in the non-aspiration cohort (28.0% versus 12.2%, p = 0.031). In our multivariable model, only the administration of succinylcholine was significant and was associated with lower probability of aspiration pneumonia (odds ratio 0.56). Conclusion: Overall, the incidence of aspiration pneumonia was low in our cohort. The administration of succinylcholine was associated with a lower odds of developing aspiration pneumonia.

Thompson P, Ciarglia A, Handspiker E, Bjerkvig C, Bynum JA, Glassberg E, Gurney J, Hudson AJ, Jenkins DH, Nicholson S, Strandenes G, Braverman MA 23(2). 9 (Journal Article)

Introduction: Tension pneumothorax (TPX) is the third most common cause of preventable death in trauma. Needle decompression at the fifth intercostal space at anterior axillary line (5th ICS AAL) is recommended by Tactical Combat Casualty Care (TCCC) with an 83-mm needle catheter unit (NCU). We sought to determine the risk of cardiac injury at this site. Methods: Institutional data sets from two trauma centers were queried for 200 patients with CT chest. Inclusion criteria include body mass index of ≤30 and age 18-40 years. Measurements were taken at 2nd ICS mid clavicular line (MCL), 5th ICS AAL and distance from the skin to pericardium at 5th ICS AAL. Groups were compared using Mann-Whitney U and chi-squared tests. Results: The median age was 27 years with median BMI of 23.8 kg/m2. The cohort was 69.5% male. Mean chest wall thickness at 2nd ICS MCL was 38-mm (interquartile range (IQR) 32-45). At 5th ICS AAL, the median chest wall thickness was 30-mm (IQR 21-40) and the distance from skin to pericardium was 66-mm (IQR 54-79). Conclusion: The distance from skin to pericardium for 75% of patients falls within the length of the recommended needle catheter unit (83-mm). The current TCCC recommendation to "hub" the 83mm needle catheter unit has potential risk of cardiac injury.

Snyder R, Brillhart DB 99(5). 0 (Journal Article)

Rib fractures are common injuries that cause significant discomfort and can lead to severe pulmonary complications. Rib injury most often results from high-velocity traumatic mechanisms, while rarely representing underlying metastatic disease or secondary injury due to pulmonary illness. Because most rib fractures are caused by obvious trauma, algorithms are focused on treatment rather than investigating the exact mechanism of rib fractures. Chest radiographs are often the initial imaging performed but have proven to be unreliable in identification of rib fracture. Computed tomography (CT) is a diagnostic option as it is more sensitive and specific than simple radiographs. However, both modalities are generally unavailable to Special Operations Forces (SOF) medical personnel working in austere locations. These medical providers could potentially diagnose and treat rib fractures in any environment using a standardized approach that includes clarity of mechanism, pain relief, and point-of-care ultrasound (POCUS). This case demonstrates an approach to the diagnosis and treatment of a rib fracture in a 47-year-old male who presented to a military treatment facility with unlocalized flank and back pain, but the methods employed have applicability to the austere provider working far from the resources of a medical center.

Melanson V, Hershfield J, Deegan MK, Cho H, Perinon D, Bateman SL, Barnhill JC 99(5). 0 (Journal Article)

Massive hemorrhaging remains the most common cause of preventable battlefield deaths. Blood used for trauma care requires a robust donation network, capacity for long-term storage, and extensive and accurate testing. Bioengineering technologies could offer a remedy to these constraints in the form of blood substitutes-fluids that could be transfused into patients to provide oxygen, carry away waste, and aid in coagulation-that would be used in prolonged casualty care and in far-forward settings, overcoming the obstacles of distance and time. The different molecular properties of red blood cells (RBCs), blood substitutes, and platelet replacements contribute to their respective utilities, and each type is currently represented in ongoing clinical trials. Hemoglobin oxygen carriers (HBOCs) are the most advanced RBC replacements, many of which are currently being evaluated in clinical trials in the United States and other countries. Despite recent advancements, challenges remaining in the development of blood alternatives include stability, oxygen capacity, and compatibility. The continued research and investment in new technologies has the potential to significantly benefit the treatment of life-threatening emergency injuries, both on the battlefield and in the civilian sector. In this review, we discuss military blood-management practices and military-specific uses of individual blood components, as well as describe and analyze several artificial blood products that could be options for future battlefield use.

Saint-jean L, Corcostegui S, Galant J, Derkenne C 99(5). 0 (Case Reports)

We report the case of a patient suffering from a chemical burn caused by white phosphorus, for whom initial management required decontamination using multimodal analgesia. This case report should be familiar to other military emergency physicians and Tactical Emergency Medical Support for two reasons: 1) A phosphorus burn occurs from a chemical agent rarely encountered, with minimal research available in the medical literature, despite the use of this weapon in the recent Ukrainian conflict, and 2) We discuss the use of multimodal analgesia, combining loco-regional anesthesia (LRA) and an intranasal pathway, which can be used in a remote and austere environment.

Biggs A, Heller T, Colvin K, Wood D, Jewell JA, Littlejohn LF 99(5). 0 (Journal Article)

Special Operations organizations have recently demonstrated their commitment to enhanced cognitive functioning and improving brain health through the development of a Cognitive Domain. However, as this new enterprise becomes supported by more resources and personnel, a critical question involves what cognitive assessments should be conducted to evaluate cognitive functions. The assessment itself forms a crux in the Cognitive Domain that could mislead cognitive practitioners if not properly applied. Here, the discussion addresses the most important criteria to satisfy in the development of a Special Operations cognitive assessment, including operational relevance, optimization, and speed. Cognitive assessments in this domain must incorporate the following: (1) a task with clear operational relevance to ensure meaningful results, (2) no ceiling effects so that performance can support cognitive enhancement initiatives, and (3) the task itself should impose a minimal time requirement to avoid creating a substantial logistical burden. A dynamic threat assessment task supported by drift diffusion modeling can meet all requisite criteria, while also providing more insight into decision parameters of Special Operations personnel than any currently used test. The discussion concludes with a detailed description of this recommended cognitive assessment task, as well as the research and development steps needed to support its application.