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Lumbar Paraspinal Compartment Syndrome in an Active-Duty Army Special Operations Aviation Soldier

Wagner C, Davis G, Donato M, Bedard P, Bridwell R 24(2). 73-77 (Case Reports)

Lumbar paraspinal muscle compartment syndrome is an uncommon, rapidly progressive, and potentially devastating injury with fewer than 40 cases reported in the literature. It initially mimics nonemergent causes of low back pain, disproportionately affects young men, and is most often secondary to acute physical exertion. The disease process is commonly associated with rhabdomyolysis. Diagnostic tools include physical examination, measurement of lactate and creatine kinase levels, MRI, and direct compartment pressure measurement. While medical and nonoperative management strategies have been explored, the gold standard for treatment is emergent lumbar fasciotomy. Opioid and non-steroidal pain management, as well as physical therapy, are the mainstays of post-treatment recovery, with many surgical patients reporting complete symptom resolution at long-term follow-up. This article discusses the case of a 27-year-old, male, active-duty, Special Operations Aviation Soldier who presented to the emergency department and was found to have lumbar paraspinal muscle compartment syndrome.

Social Determinant of Unconventional Resilience: Tactical Engagement with Impression Management

Jeschke EA, Wyma-Bradley J, Baker JB, Dorsch J, Huffman SL 24(2). 103-108 (Journal Article)

Building upon our operational model, we will discuss findings from our ethnographic study titled "The Impact of Catastrophic Injury Exposure on Resilience in Special Operations Surgical Teams" to establish that impression management allows Special Operation Forces (SOF) medics to navigate implicit social status symbols to either degrade or optimize performance. We will use qualitative quotes to explore how Special Operations Surgical Team (SOST) medics engage in impression management to establish individual, team, and/or organizational competency to deal with ambiguity. To achieve our goals, we will: 1) provide a background on impression management and perception of competency; 2) define the social determinant of impression management extrapolated from qualitative data as well as use qualitative data to thematize various types of impression management; and 3) relate tactical engagement with impression to our metaphor of bag sets. We conclude by gesturing to the importance of impression management in orienting SOF medics' proprioception and kinesthesia in the SOF performance space.

Audit and Inventory of Federal Law Enforcement Agency Tactical Medic Bags

Knapp JG, Tang N 24(2). 91-93 (Journal Article)

Separate evidence-based, best practice guidelines and recommendations exist for the prehospital management of traumatic injuries sustained in combat settings and those encountered during high-threat civilian operational incidents. The Bureau of Alcohol, Tobacco, Firearms and Explosives (ATF) Tactical Medic Program is a mature operational medicine asset supporting high-threat federal law enforcement operations. The ATF conducted an audit of its agency-issued tactical medic bags with regards to completeness, as defined by authorized medical protocols, which are aligned with current Tactical Combat Casualty Care and Tactical Emergency Casualty Care guidelines.

Adoption of the CH-47 to MEDEVAC Special Operations Forces in USAFRICOM

Leone R, Remondelli MH, Smith SS, Moore BJ, Wuss SL, D'Angelo M 24(2). 86-90 (Editorial)

Arrhythmogenic Right Ventricular Cardiomyopathy (ARVC) in a Special Operations Soldier: A Case Report

Osborne K, Wenthe A, Mahowald M, Bridwell R 24(2). 82-84 (Case Reports)

Special Operations Servicemembers presenting with palpitations, pre-syncope, or exertional syncope during rigorous physical training are often experiencing a benign condition; however, life-threatening etiologies should be considered. We describe a 43-year-old Special Operator who presented to his medics during selection physical assessment testing with palpitations and lightheadedness, with a subsequent workup revealing arrhythmogenic right ventricular cardiomyopathy (ARVC). His initial electrocardiogram was unremarkable without characteristic ARVC changes. Outpatient evaluation with ambulatory cardiac monitoring recorded numerous episodes of non-sustained ventricular tachycardia. Transthoracic echocardiography demonstrated findings concerning for ARVC, with subsequent cardiac MRI confirming the diagnosis via the 2020 Padua criteria. Management includes activity modification, class III anti-arrhythmic medications, and possible placement of an implantable cardioverter defibrillator to prevent sudden cardiac death. This case demonstrates the importance of maintaining high clinical suspicion for rare diagnoses that present with exertional palpitations, such as arrhythmogenic right ventricular cardiomyopathy, in even our fittest Special Operators.

Needle Decompression Complicated by Cardiac Injury in a Prehospital Environment

Davis K, Oury JJ, Reed BL, Grabo DJ, Wilson A, Coleman C 24(2). 78-80 (Journal Article)

Needle decompression is a mainstay intervention for tension pneumothorax in trauma medicine. It is used in combat and prehospital medicine when definitive measures are often not available or ideal. It can temporarily relieve increased intrathoracic pressure and treat a collapsed lung or great vessel obstruction. However, when done incorrectly, it can result in underlying visceral organ and vessel trauma. This is a case of an adult male who presented to the emergency department after sustaining multiple stab wounds during an altercation. On arrival, the patient had a 14-gauge angiocatheter inserted at the 4th intercostal space (ICS), left of the parasternal line traversing the right ventricle and interventricular septum and terminating in the left ventricle. The case emphasizes the importance of understanding the landmarks of performing needle decompression in increasing the procedure's efficacy and reducing iatrogenic complications.

The Effect of Critical Task Auto-failure Criteria on Medical Evaluation Methods in the Pararescue Schoolhouse

Richardson I, Lauria MJ, Gravano B, Swenson JF, Rush S 24(2). 67-71 (Journal Article)

Background: Medical training and evaluation are important for mission readiness in the pararescue career field. Because evaluation methods are not standardized, evaluation methods must align with training objectives. We propose an alternative evaluation method and discuss relevant factors when designing military medical evaluation metrics. Methods: We compared two evaluation methods, the traditional checklist (TC) method used in the pararescue apprentice course and an alternative weighted checklist (AWC) method like that used at the U.S. Army static line jumpmaster course. The AWC allows up to two minor errors, while critical task errors result in autofailure. We recorded 168 medical scenarios during two Apprentice course classes and retroactively compared the two evaluation methods. Results: Despite the possibility of auto-failure with the AWC, there was no significant difference between the two evaluation methods, and both showed similar overall pass rates (TC=50% pass, AWC=48.8% pass, p=.41). The two evaluation methods yielded the same result for 147 out of 168 scenarios (87.5%). Conclusions: The AWC method strongly emphasizes critical tasks without significantly increasing failures. It may provide additional benefits by being more closely aligned with our training objectives while providing quantifiable data for a longitudinal review of student performance.

Incidence of Coagulopathy After Resuscitation at a Role 1 Facility: The Prehospital Trauma Registry Experience

Inman BL, Long B, April MD, Fisher AD, Rizzo J, Schauer S 24(2). 61-66 (Journal Article)

Background: The development of acute traumatic coagulopathy is associated with increased mortality and morbidity in patients with battlefield traumatic injuries. Currently, the incidence of acute traumatic coagulopathy in the Role 1 setting is unclear. Methods: We queried the Prehospital Trauma Registry (PHTR) module of the Department of Defense Trauma Registry (DoDTR) for all encounters from inception through May 2019. The PHTR captures data on Role 1 prehospital care. Data from the PHTR was linked to the DoDTR to analyze laboratory data and patient outcomes using descriptive statistics. We defined coagulopathy as an international normalized ratio (INR) of ≥1.5 or platelet count ≤150×109/L. Results: A total of 595 patients met the inclusion criteria; 36% (212) met our definition for coagulopathy, with 31% (185) carrying low platelet numbers, 11% (68) showing an elevated INR, and 7% (41) with both. The baseline (no coagulopathy) cohort had a mean INR of 1.10 (95% CI 1.09-1.12) versus 1.38 (95% CI 1.33-1.43) in the coagulopathic cohort. The mean platelet count was 218 (95% CI 213-223) ×109/L in the baseline cohort versus 117 (95% CI 110-125) ×109/L in the coagulopathic cohort. Conclusions: Our findings indicate a high incidence of coagulopathy in trauma patients. Approximately one-third of wounded patients had laboratory evidence of coagulopathy upon presentation to a forward medical care facility. Advanced diagnostic facilities are therefore needed to facilitate early diagnosis of acute traumatic coagulopathy. Blood products with a long shelf life can aid in early correction.

Continuous Assessment of Active-Duty Army Special Operations and Reconnaissance Marines Using Digital Devices and Custom Software: The Digital Comprehensive Operator Readiness Assessment (DcORA) Study

Saxon L, Faulk RT, Boberg J, Barrett T, McLelland S 24(2). 52-60 (Journal Article)

Background: Continuous exposure to extreme and chronic stress from uncontrollable events has been linked to increased psychological and physiological reactivity. Prolonged, frequent deployments may test coping skills over time, ultimately rendering Servicemembers vulnerable to mental health problems and suicide. This study develops a methodology for accurately collecting holistic health measures from Servicemembers using digital tools, including custom-built phone software and body-worn sensors. Methods: The secure research platform and mobile app continuously collect multiple health measures and, after data analysis, deliver continuously updated summary data back to the Servicemember. This system provides novel insights into the relationships between the measures while helping individuals track their progress toward self-established goals. Participants were given an iPhone (including the study app) and an Apple Watch. Participants tracked their data for more than 6 months and responded to baseline, daily, and weekly questions and assessments. Physiologic, psychologic, and cognitive assessment data across the Preservation of the Force and Family program (POTFF) domains were collected, displayed to the individual, and analyzed in aggregate. Results: When coupled with custom-built software, this hardware can be elevated from a fitness tracker to a user-facing health monitoring, educational, and delivery system. Conclusion: This wearable system measured vital factors associated with the health and human performance of Servicemembers. In real-time, it engaged Servicemembers in health and human performance optimization practices to achieve a goal of prevention of physical or mental injury.

Factors Influencing Omega-3 Index Status in Active-Duty Military Personnel

Brown J, Soto MA, Lindsay KG, Harris M, Karagosian SA, Bailey K, Hutchins A 24(2). 44-50. (Journal Article)

Background: This study assessed omega-3 fatty acid (O3FA) status, previous brain injury risk exposures, and associations between O3FA status and risk exposures among active-duty military personnel. Methods: O3FA status was measured by a Holman omega-3 blood test. A survey was conducted to assess brain injury risk history and dietary O3FA factors. Results: More than 50% of the participants had high-risk status, based on an omega-3 index (O3I) <4%, while less than 2% of the participants recorded low-risk O3I (>8%). O3FA supplementation (p<.001, Cramer's V=0.342) and fish consumption (p<.001, Cramer's V=0.210) were positively correlated with O3FA status. Only 5 O3FA supplement users (n=97 [5.2%]) had a low-risk O3I status, while all nonusers (n=223) had moderateto high-risk O3I status. Conclusions: Supplementing with O3FA was associated with better O3I status in this population. However, only a few participants achieved optimal O3I status even when taking an O3FA supplement. Participants who ate fish and did not supplement were in the moderateor high-risk O3I groups.

Conducted Electrical Weapon Fire Risk in the Presence of Supplemental Oxygen

Ho J, Dawes DM, Driver B 24(2). 39-43 (Journal Article)

Background: Conducted electrical weapons (CEWs) are nonlethal weapons used in tactical environments. Tactical EMS (TEMS) operators provide patient care in environments where CEWs are present. CEWs may produce a spark that can be a source of ignition. When supplemental oxygen is in use by a TEMS operator, the flammability risk from the CEW is unknown. Methods: We measured oxygen levels over 20 minutes in an enclosed space with a supplemental oxygen source maximally flowing. Measurements were taken at various distances from the oxygen source to establish baseline concentrations. These concentrations were replicated within a plexiglass box where a CEW was activated to create a sparking arc between probes embedded in a fresh swine shoulder (with skin intact). Various flammable materials, typically found in a patient care setting were used as potential fuel sources. Results: The highest oxygen levels were achieved directly at the source. At 15cm from the source, the maximum oxygen concentration was 31.5%. Within the box, ignition was only achieved at oxygen concentrations greater than 45% and only when human hair was present as fuel. No ignition was achieved at oxygen levels below this regardless of the tested fuel present. Conclusion: Ignition from a CEW is possible at supplemental oxygen levels greater than 45% when human hair is present. In an enclosed space, oxygen concentration levels of 45% are only present within 15cm of a flush rate oxygen source. The likelihood of CEW-caused ignition in such settings with supplemental oxygen in use is extremely low.

Evaluation of a Rebreathing System for Use with Portable Mechanical Ventilators

Blakeman T, Smith M, Branson R 24(2). 34-38. (Journal Article)

Introduction: Maximizing the capabilities of available lowflow oxygen is key to providing adequate oxygen to prevent/treat hypoxemia and conserve oxygen. We designed a closed-circuit system that allows rebreathing of gases while scrubbing carbon dioxide (CO2) in conjunction with portable mechanical ventilators in a bench model. Methods: We evaluated the system using two portable mechanical ventilators currently deployed by the Department of Defense-Zoll 731 and AutoMedx SAVe II-over a range of ventilator settings and lung models, using 1 and 3L/min low-flow oxygen into a reservoir bag. We measured peak inspired oxygen concentration (FiO2), CO2-absorbent life, gas temperature and humidity, and the effect of airway suctioning and ventilator disconnection on FiO2 on ground and at altitude. Results: FiO2 was ≥0.9 across all ventilator settings and altitudes using both oxygen flows. CO2-absorbent life was >7 hours. Airway humidity range was 87%-97%. Mean airway temperature was 25.4°C (SD 0.5°C). Ten-second suctioning reduced FiO2 22%-48%. Thirtysecond ventilator disconnect reduced FiO2 29%-63% depending on oxygen flow used. Conclusion: Use of a rebreathing system with mechanical ventilation has the potential for oxygen conservation but requires diligent monitoring of inspired FiO2 and CO2 to avoid negative consequences.

The Role of Motivation to Excel in the Etiology of Exertional Heat Stroke

Lalli K, Charkoudian N, Moreh Y, Degroot D 24(2). 28-33. (Journal Article)

Exertional heat stroke (EHS) is a medical emergency characterized by elevated body temperature and central nervous system dysfunction, and it can include dizziness, confusion and loss of consciousness, as well as long-term organ and tissue damage. EHS is distinct from classic, or passive, heat stroke and is most commonly observed during intense physical activity in warfighters, athletes, and laborers. EHS is an ongoing non-combat threat that represents a risk to both the health and readiness of military personnel. Potential risk factors and their mitigation have been the subject of investigation for decades. One risk factor that is often mentioned in the literature, but not well quantified, is that of individual motivation to excel, wherein highly trained military personnel and athletes exert themselves beyond their physiological limits because of a desire to complete tasks and goals. The motivation to excel in tasks with high standards of achievement, such as those within elite military schools, appears to create an environment in which a disproportionately high number of exertional heat illness casualties occur. Here, we review existing biomedical literature to provide information about EHS in the context of motivation as a risk factor and then discuss five cases of EHS treated at Martin Army Community Hospital at Fort Moore, GA, from 2020 to 2022. In our discussion of the cases, we explore the influence of motivation on each occurrence. The findings from this case series provide further evidence of motivation to excel as a risk factor for EHS and highlight the need for creative strategies to mitigate this risk.

Incidence of Traumatic Brain Injuries within the Prehospital Trauma Registry System

Braden SF, Long B, Rizzo J, April MD, Dengler BA, Schauer S 24(2). 24-33. (Journal Article)

Background: Traumatic brain injury (TBI) is often underreported or undetected in prehospital civilian and military settings. This study evaluated the incidence of TBI within the Prehospital Trauma Registry (PHTR) system. Methods: We reviewed PHTR and the linked Department of Defense Trauma Registry (DoDTR) records of casualties from January 2003 through May 2019 for diagnostic data and surgical reports. Results: A total of 709 casualties met inclusion criteria. The most common mechanism was blast, including 328 (51%) in the non-TBI and 45 (63%) in the TBI cohorts. The median injury severity scores in the non-TBI and TBI cohorts were 5 and 14, respectively. The survival scores in the non-TBI and TBI cohorts were 98% and 92%, respectively. Subdural hematomas, followed by subarachnoid hemorrhages were the most common classifiable brain injuries. Other nonspecific TBIs occurred in 85% of the TBI cohort casualties. Seventy-two cases (10%) were documented by the Role 1 clinician. Based on coding or operative data, 15 of the 72 (21%) were identified as TBIs. Of the 637 cases, which could not be decided based on coding or operative data, TBI was suspected in 42 (7%) cases based on Role 1 records. Conclusions: Over 1 in 10 casualties presenting to a Role 1 facility had a TBI requiring transfer to a higher level of care. Our findings suggest the need for improved diagnostic technologies and documentation systems at Role 1 facilities for accurate TBI diagnosis and reporting.

An Analysis of Tube Thoracostomy in Combat Implications for Improved Prehospital Recognition and Treatment

Fisher AD, Jude JW, April MD, Lavender S, Augustson XS, Maitha J, Schauer S 24(2). 17-21 (Journal Article)

Background: Thoracic trauma occurs frequently in combat and is associated with high mortality. Tube thoracostomy (chest tube) is the treatment for pneumothorax resulting from thoracic trauma, but little data exist to characterize combat casualties undergoing this intervention. We sought to describe the incidence of these injuries and procedures to inform training and materiel development priorities. Methods: This is a secondary analysis of a Department of Defense Trauma Registry (DoDTR) data set from 2007 to 2020 describing prehospital care within all theaters in the registry. We described all casualties who received a tube thoracostomy within 24 hours of admission to a military treatment facility. Variables described included casualty demographics; abbreviated injury scale (AIS) score by body region, presented as binary serious (≥3) or not serious (<3); and prehospital interventions. Results: The database identified 25,897 casualties, 2,178 (8.4%) of whom received a tube thoracostomy within 24 hours of admission. Of those casualties, the body regions with the highest proportions of common serious injury (AIS >3) were thorax 62% (1,351), extremities 29% (629), abdomen 22% (473), and head/neck 22% (473). Of those casualties, 13% (276) had prehospital needle thoracostomies performed, and 19% (416) had limb tourniquets placed. Most of the patients were male (97%), partner forces members or humanitarian casualties (70%), and survived to discharge (87%). Conclusions: Combat casualties with chest trauma often have multiple injuries complicating prehospital and hospital care. Explosions and gunshot wounds are common mechanisms of injury associated with the need for tube thoracostomy, and these interventions are often performed by enlisted medical personnel. Future efforts should be made to provide a correlation between chest interventions and pneumothorax management in prehospital thoracic trauma.

Advancing Combat Casualty Care Statistics and Other Battlefield Care Metrics

Janak J, Kotwal RS, Howard JT, Gurney J, Eastridge BJ, Holcomb JB, Shackelford SA, De Lorenzo RA, Stewart IJ, Mazuchowski EL 24(2). 11-16. (Journal Article)

Aggregate statistics can provide intra-conflict and inter-conflict mortality comparisons and trends within and between U.S. combat operations. However, capturing individual-level data to evaluate medical and non-medical factors that influence combat casualty mortality has historically proven difficult. The Department of Defense (DoD) Trauma Registry, developed as an integral component of the Joint Trauma System during recent conflicts in Afghanistan and Iraq, has amassed individual-level data that have afforded greater opportunity for a variety of analyses and comparisons. Although aggregate statistics are easily calculated and commonly used across the DoD, other issues that require consideration include the impact of individual medical interventions, non-medical factors, non-battle-injured casualties, and incomplete or missing medical data, especially for prehospital care and forward surgical team care. Needed are novel methods to address these issues in order to provide a clearer interpretation of aggregate statistics and to highlight solutions that will ultimately increase survival and eliminate preventable death on the battlefield. Although many U.S. military combat fatalities sustain injuries deemed non-survivable, survival among these casualties might be improved using primary and secondary prevention strategies that prevent injury or reduce injury severity. The current commentary proposes adjustments to traditional aggregate combat casualty care statistics by integrating statistics from the DoD Military Trauma Mortality Review process as conducted by the Joint Trauma System and Armed Forces Medical Examiner System.

Maritime Applications of Prolonged Casualty Care Sepsis on a Destroyer During Distributed Maritime Operations

Tadlock M, Maves R, Flieger DM, Baldino TJ, Adams D, Riesberg JC, Kitchen LK, Brower JJ, Tripp MS 24(2). 94-102 (Journal Article)

During distributed maritime operations, individual components of the naval force are more geographically dispersed. As the U.S. Navy further develops this concept, smaller vessels may be operating at a significant time and distance away from more advanced medical capabilities. Therefore, during both current and future contested Distributed Maritime Operations, Role 1 maritime caregivers such as Independent Duty Corpsman will have to manage patients for prolonged periods of time. This manuscript presents an innovative approach to teaching complex operational medicine concepts (including Prolonged Casualty Care [PCC]) to austere Role 1 maritime caregivers using a hypothetical scenario involving a patient with sepsis and septic shock. The scenario incorporates the Joint Trauma System PCC Clinical Practice Guidelines (CPG) and other standard references. The scenario includes a stem clinical vignette, expected clinical changes for the affected patient at specific time points (e.g., time 0, 1, 2, and 48h), and expected interventions based on the PCC CPG and available shipboard equipment. Epidemiology of sepsis in the deployed environment is also reviewed. This process also identifies opportunities to improve training, clinical skills sustainment, and standard shipboard medical supplies.

Prevalence of Trauma-Induced Hypocalcemia in the Prehospital Setting

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.

Derivation of a Procedural Performance Checklist for Bifemoral Veno-Venous Extracorporeal Membrane Oxygenation Cannula Placement in Operational Environments

Powell E, Betzold R, Kundi R, Anderson D, Haase D, Keville M, Galvagno S 24(1). 32 (Journal Article)

Background: Veno-venous extracorporeal membrane oxygenation (VV ECMO) is a low-frequency, high-intensity procedure used for severe lung illness or injury to facilitate rapid correction of hypoxemia and respiratory acidosis. This technology is more portable and extracorporeal support is more frequently performed outside of the hospital. Future conflicts may require prolonged causality care and more specialized critical care capabilities including VV ECMO to improve patient outcomes. We used an expert consensus survey based on a developed bifemoral VV ECMO cannulation checklist with an operational focus to establish a standard for training, validation testing, and sustainment. Methods: A 36-item procedural checklist was provided to 14 experts from multiple specialties. Using the modified Delphi method, the checklist was serially modified based on expert feedback. Results: Three rounds of the study were performed, resulting in a final 32-item checklist. Each item on the checklist received at least 70% expert agreement on its inclusion in the final checklist. Conclusion: A procedural performance checklist was created for bifemoral VV ECMO using the modified Delphi method. This is an objective tool to assist procedural training and validation for medical providers performing VV ECMO in austere environments.

Special Operations and Space Medicine for a Joint Future

Hetzler MR, Fogarty JA, Frament C 24(1). 95 (Journal Article)

This paper is designed to introduce, propose, inform, and advocate enhanced relationships between the medical communities of special operations and space. Although each provides service support in different roles and functions, similarities in both the operational context and in medical care are notable. During a recent interaction, significant relationship potential was discovered by both communities, and recommendations for greater engagement are proposed herein. By identifying and appreciating similarities and understanding history, key actors, and authorities to analyze and realize opportunities will enable us to find synergy for the development of like efforts and goals. Collaboration in research on the limits of human performance and medical support to the most austere and challenging operational environments may benefit both communities in different but productive ways. Establishing and increasing cooperation will also meet command strategic intent, explore and advance a policy concept, initiate a relationship between unique medical communities, and provide a tangible success for the advancement of operational support.

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