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Concepts of Prehospital Advanced Airway Management in the Operational K9: A Focus on Cricothyrotomy

Palmer LE 19(1). 99 - 106 (Journal Article)

Similar to people, airway obstruction is a potentially preventable cause of combat and line of duty death for civilian law enforcement Operational K9s (OpK9) and military working dogs (MWD). Basic (i.e., body positioning, manual maneuvers, bag-valve-mask ventilation) and advanced (i.e., endotracheal intubation, surgical airways) airway techniques are designed to establish a patent airway, oxygenate and ventilate, and protect from aspiration. A surgical airway (cricothyrotomy [CTT] or tracheostomy [TT]) is warranted for difficult airway scenarios in which less invasive means fail to open an airway (aka "Cannot intubate, cannot oxygenate"). In people, the surgical CTT is the preferred surgical airway procedure; most human prehospital providers are not even trained on the TT. Currently, only the TT is described in the veterinary literature as an emergent surgical airway for MWDs. This article describes the novel approach of instituting the surgical CTT for managing the canine difficult airway. The information provided is applicable to personnel operating within the US Special Operations Command as well as civilian tactical emergency medical services that may have the responsibility of providing medical care to an OpK9 or MWD.

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Ranger Athlete Warrior Assessment Performance in a Reserve Officer Training Corps Training Environment

Meckley DP, Hulbert K, Stewart D, O'Brien N, Barringer N, Hornsby JH 19(1). 96 - 98 (Journal Article)

Muscular strength, power, and aerobic capacity are vital to Army Reserve Officer Training Corps (AROTC) Cadets as well as active-duty Soldiers, especially when lifting heavy objects, traveling long distances, or moving with maximum speed and agility. The purpose of this study was to examine the change (after a pre/post intervention) of 5 weeks of resistance strength training and aerobic capacity training on a Ranger Athlete Warrior (RAW) assessment. Twelve (males, n = 10; females, n = 2) college-aged AROTC Cadets volunteered for this study during their train-up for the annual Ranger Challenge Competition. Each training week consisted of two resistance, two aerobic, and one tactical training session lasting about 90 minutes. The RAW assessment consisted of the following: 5-10-5 shuttle, standing broad jump, 3-repetition maximum (RM) trap bar deadlift, pull-ups, metronome pushups, heel claps, and two 300-yard shuttles. Paired samples t tests produced statistically significant differences (pre vs post): 5-10-5 (p = .04), 3-RM trap bar deadlift (p = .01), and metronome push-ups (p = .01). The results suggest that combining resistance strength and endurance and aerobic capacity training at a set volume with a self-selected intensity improved the Cadets' agility, lower-body strength, and upper-body muscular endurance. Implementing a program similar to this in other AROTC programs could also improve Cadet performance in the field. This study also showed the benefit of an AROTC program collaborating with human performance professionals to optimize Cadets' human performance capabilities.

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Impact of Marine Exposure on Hemostatic Gauzes Using Thromboelastography

George T, Jordan M, Bianchi W, Boboc M, Zarow GJ, Natarajan R, Walchak AC, Roszko PJ 19(1). 89 - 94 (Journal Article)

Background: Military forces render emergency care in marine environments, where care for exsanguination is challenging. However, the effect of saltwater on the functionality of hemostatic agents is unknown. In this study, we used thromboelastography (TEG) to quantify the effect of saltwater on the efficacy of five gauze products. Methods: Blood from 24 healthy adult men was diluted by 30% with hetastarch to mimic hemodilution. Dry and saltwater-soaked Kerlix™, ChitoGauze®, Combat Gauze®, NuStat™, and WoundClot™ were contrasted in terms of the TEG parameters of speed of clot initiation (R), clot amplification (K), α angle (i.e., clot formation rate), and maximum amplitude of clot (MA), using repeated-measures analysis of variance at the p < .05 statistical significance threshold. Results: Compared with untreated dilute blood, R was significantly faster when any dry or wet gauze was added, with the fastest R values recorded for Combat Gauze. K and α angle findings were mixed. MA was greater than diluted blood for dry hemostatic gauze, but in the wet condition, only the MA for Combat Gauze was significantly greater than that of diluted blood. Conclusion: Gauze products, wet or dry, improved clotting compared to diluted blood without gauze. Saltwater exposure did not significantly detract from this benefit. Our findings suggest that Combat Gauze may be the choice hemostatic gauze for maritime environments.

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Low-Resource Tactical Combat Casualty Care Training for Peshmerga Units in Remote Areas of Kurdistan

Taylor D, Murphy J, Stolley Z 19(1). 81 - 87 (Journal Article)

The Peshmerga are the official military of the autonomous region of Kurdistan, Iraq. There remains a high level of variability across Peshmerga units in medical equipment and training. Presumably, Peshmerga soldiers are dying from preventable causes of death due to combat-related injuries, just as US troops did before the introduction of Tactical Combat Casualty Care (TCCC) training and supplies. This report outlines the efforts of a small US-based collective to provide TCCC training at the TCCC for all combatants skill level to Peshmerga forces and develop members of the Peshmerga as trainers.

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EpiNATO-2: Enhancing Situational Awareness and Overall Force Health Protection While Deployed in the Combined Joint NATO Environment: Describing the Identified 2016 Q Fever Outbreak in Kosovo Force (KFOR)

Hoysal N, McCown ME, Fazekas L, Krabbe C 19(1). 76 - 80 (Journal Article)

EpiNATO-2 is the only interoperable health surveillance system that is defined in North Atlantic Treaty Organization (NATO) doctrine. It was first implemented in the Kosovo Force and European Union Training Mission Mali in 2013. EpiNATO-2 is mandated for use during all NATO operations. Its coverage has steadily increased and now includes all NATO Joint and Component Command Operations and several non-NATO operations. The system monitors morbidity predominately for Role 1 sites by using weekly reports from the medics and other medical providers. The reports for all sites in theater are sent to the Combined Joint Medical (CJMED), which consolidates and submits them to NATO Deployment Health Surveillance Capability (DHSC), the satellite branch of NATO Centre of Excellence for Military Medicine (MILMED COE), for analysis and feedback. Although EpiNATO-2 will likely have a number of overlaps with most nations' disease and nonbattle injury trackers, a distinguishing characteristic is that it has specific categories for classifying more clinical activity. Sustaining the quality of data collection is paramount and achieved through contemporaneous analysis and feedback that are disseminated via CJMED to all providers. This enhances situational awareness about evolving trends in health issues across the deployed force and is intended to provide information for action and medical decision-making and force health protection assurance at the local and theater levels. The awareness imparted by this article can add to the Special Operations Forces (SOF) medics' tool kit to ensure success for the SOF medic and SOF community while deployed or collaborating with NATO and NATO partner nation militaries at any level in theater.

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Battlefield Analgesia: Adherence to Tactical Combat Casualty Care Guidelines

Schauer SG, Fisher AD, April MD, Carter R, Cunningham CW, Aden JK, Fernandez JD, DeLorenzo RA 19(1). 70 - 74 (Journal Article)

Background: Low rates of prehospital analgesia, as recommended by Tactical Combat Casualty Care (TCCC) guidelines, have been demonstrated in the Joint Theaters combat setting. The reasons for this remain unclear. This study expands on previous reports by evaluating a larger prehospital dataset for determinants of analgesia administration. Methods: This was part of an approved quality assurance project evaluating adherence to TCCC guidelines across multiple modalities. Data were from the Prehospital Trauma Registry, which existed from January 2013 through September 2014, and comprises data from TCCC cards, Department of Defense 1380 forms, and after-action reports to provide real-time feedback to units on prehospital medical care. Results: Of 705 total patient encounters, there were 501 documented administrations of analgesic medications given to 397 patients. Of these events, 242 (34.3%) were within TCCC guidelines. Special Operations Command had the highest rate of overall adherence, but rates were still low (68.5%). Medical officers had the highest rates of overall administration. The low rates of administration and adherence persisted across all subgroups. Conclusion: Rates of analgesia administration remained low overall and in subgroup analyses. Medical officers appeared to have higher rates of compliance with TCCC guidelines for analgesia administration, but overall adherence to TCCC guidelines was low. Future research will be aimed at finding methods to improve administration and adherence rates.

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Integrating Prolonged Field Care Into Rough Terrain and Mountain Warfare Training: The Mountain Critical Care Course

Nicholson B, Neskey J, Stanfield R, Fetterolf B, Ersando J, Cohen J, Kue R 19(1). 66 - 69 (Journal Article)

Current prolonged field care (PFC) training routinely occurs in simulated physical locations that force providers to continue care until evacuation to definitive care, as based on the staged Ruck-Truck-House-Plane model. As PFC-capable teams move further forward into austere environments in support of the fight, they are in physical locations that do not fit this staged model and may require teams to execute their own casualty evacuation through rough terrain. The physical constraints that come specifically with austere, mountainous terrain can challenge PFC providers to initiate resuscitative interventions and challenge their ability to sustain these interventions during lengthy, dismounted movement over unimproved terrain. In this brief report, we describe our experience with a novel training course designed for PFC-capable medical teams to integrate their level of advanced resuscitative care within a mountainous, rough terrain evacuation-training program. Our goals were to identify training gaps for Special Operations Forces medical units tasked to operate in a cold-weather, mountain environment with limited evacuation resources and the challenges related to maintaining PFC interventions during dismounted casualty movement.

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Psychological Strategies During Military Training Are Linked to Resilience in US Navy Explosive Ordnance Disposal Operators

Taylor MK, Rolo C, Stump J, Mayo J, Hernandez LM, Gould DR 19(1). 61 - 65 (Journal Article)

Purpose: We describe the psychological strategies (PS) used by a specialized military population, US Navy explosive ordnance disposal (EOD), during training and military operations. We also aim to establish the relationship between PS and resilience. Methods: The Test of Performance Strategies was adapted to the military environment and subsequently was administered to 58 EOD Operators in conjunction with the 10-item Connor- Davidson Resilience Scale. Differences between high- and low-resilience Operators for PS were evaluated with discriminant models. Results: The PS of EOD Operators were comparable to those of Olympic athletes described in our prior study. The most frequently used strategies during training and military operations were goal setting and emotional control. Discriminant analysis indicated an overall difference between high- and low-resilience Operators with respect to the six training subscales (ρ < .05), with goal setting, emotional control, and attentional control contributing most to the discriminant function. Conclusion: EOD Operators' use of PS was comparable to that of elite athletes. We provide evidence that more-resilient EOD Operators differ from their less resilient counterparts in the strategies they use. These findings have implications for mental preparation strategies used during military training and operations.

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Comparison of Postexercise Cooling Methods in Working Dogs

Davis MS, Marcellin-Little DJ, O'Connor E 19(1). 56 - 60 (Journal Article)

Background: Overheating is a common form of injury in working dogs. The purpose of this study was to evaluate the relative efficacy of three postexercise cooling methods in dogs with exercise-induced heat stress. Methods: Nine athletically conditioned dogs were exercised at 10kph for 15 minutes on a treadmill in a hot environmental chamber (30°C) three times on separate days. After exercise, the dogs were cooled using one of three methods: natural cooling, cooling on a 4°C cooling mat, and partial immersion in a 30°C water bath for 5 minutes. Results: Time-weighted heat stress was lower for immersion cooling compared with the cooling mat and the control. The mean time required to lower gastrointestinal temperature to 39°C was 16 minutes for immersion cooling, 36 minutes for the cooling mat, and 48 minutes for control cooling. Conclusion: Water immersion decreased postexercise, time-weighted heat stress in dogs and provided the most rapid cooling of the three methods evaluated, even with the water being as warm as the ambient conditions. The cooling mat was superior to cooling using only fans, but not as effective as immersion. The placement of simple water troughs in working- dog training areas, along with specific protocols for their use, is recommended to reduce the occurrence of heat injury in dogs and improve the treatment of overheated dogs.

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The Prehospital Trauma Registry Experience With Intraosseous Access

Schauer SG, Naylor JF, April MD, Fisher AD, Cunningham CW, Fernandez JD, Shreve BP, Bebarta VS 19(1). 52 - 55 (Journal Article)

Background: Peripheral intravenous (IV) cannulation is often difficult to obtain in a patient with hemorrhagic shock, delaying the appropriate resuscitation of critically ill patients. Intraosseous (IO) access is an alternative method. To date, few data exist on use of this procedure by ground forces in Afghanistan. Here, we compare patient characteristics and concomitant interventions among patients undergoing IO access versus those undergoing IV access only. Methods: We obtained data from the Prehospital Trauma Registry (PHTR). When possible, patients were linked to the Department of Defense Trauma Registry for outcome data. To develop the cohorts, we searched for all patients with documented IO or IV access placement. Those with both IO and IV access documented were placed in the IO group. Results: Of the 705 available patients in the PHTR, we identified 55 patients (7.8% of the population) in the IO group and 432 (61.3%) in the IV group. Among patients with documentation of access location, the most common location was the tibia (64.3%; n = 18). Compared with patients with IV access, those who underwent IO access had higher urgent evacuation rates (90.9% versus 72.4%; p = .01) and air evacuation rates (58.2% versus 14.8%; p < .01). The IO cohort had significantly higher rates of interventions for hypothermia, chest seals, chest tubes, needle decompressions, and tourniquets, but a significantly lower rate of analgesic administration (ρ ≤ .05). Conclusion: Within the registry, IO placement was relatively low (<10%) and used in casualties who received several other life-saving interventions at a higher rate than casualties who had IV access. Incidentally, lower proportions of analgesia administration were detected in the IO group compared with the IV group, despite higher intervention rates.

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Improvised Ground Evacuation Platforms for Austere Special Operations Casualty Transport

Antosh IJ, McGrane OL, Capan EJ, Dominguez JD, Hofmann LJ 19(1). 48 - 51 (Journal Article)

There are no established ground medical-evacuation systems within Special Operations Command Africa (SOCAFRICA), given the austere and varied environments. Transporting the injured casualty requires ingenuity and modification of existing vehicles. The Expeditionary Resuscitative Surgical Team (ERST) assigned to SOCAFRICA used four unconventional means for ground evacuation. This is a retrospective review of the various modes of ground transportation used by the ERST-3 during deployment with SOCAFRICA. All handcarried litter and air evacuation platforms were excluded. Over 9 months, four different ground casualty platforms were used after they were modified: (1) Mine-Resistant Ambush-Protected All-Terrain Vehicle (MAT-V; Oshkosh Defense); (2) MRZR-4 ("Razor"; Polaris Industries); (3) nonstandard tactical vehicles, (NSTVs; Toyota HiLux); and (4) John Deere TH 6x4 ("Gator"). Use of all vehicle platforms was initially rehearsed and then they were used on missions for transport of casualties. Each of the four methods of ground evacuation includes a description of the talon litter setup, the necessary modifications, the litter capacity, the strengths and weaknesses, and any summary recommendations for that platform. Understanding and planning for ground casualty evacuation is necessary in the austere environment. Although each modified vehicle was used successfully to transfer the combat casualty with an ERST team member, consideration should be given to acquisition of the MAT-V medical-specific vehicle. Understanding the currently available modes of ground casualty evacuation transport promotes successful transfer of the battlefield casualty to the next echelon of care.

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Masimo Perfusion Index Versus Doppler for Tourniquet Effectiveness Monitoring

Wall PL, Buising CM, Nelms D, Grulke L, Renner CH 19(1). 44 - 46 (Journal Article)

Background: In addition to a plethysmograph, Masimo pulse oximeters display a Perfusion Index (PI) value. This study investigated the possible usefulness of PI for monitoring limb tourniquet arterial occlusion. Methods: Tactical Ratcheting Medical Tourniquets were applied to the thighs of 15 subjects. Tightening ended at one ratchet-tooth advance beyond Doppler- indicated occlusion. The times and pressures of Doppler and PI signal absences and returns were recorded. Results: Intermittent PI signal error occurred in 149 of 450 runs (PI, 33% versus Doppler, 0%; p < .0001). PI signal loss lagged Doppler-indicated occlusion by 19 ± 15 seconds (mean ± standard deviation, p < .0001). PI Signal Return lagged tourniquet release by 13 ± 7 seconds (Doppler Signal Return took 1 ± 1 seconds following tourniquet release; p < .0001). PI failed to detect early Doppler audible pulse return in 30 of 39 occurrences. Conclusion: The PI available on Masimo pulse oximeters is not appropriate for monitoring limb tourniquet effectiveness

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Limb Tourniquet Configuration: Preliminary Investigation of Problems and Principles

Kragh JF, Aden JK, Dubick MA 19(1). 35 - 43 (Journal Article)

Background: A tourniquet's readiness during emergencies depends on how it is configured. We investigated configuration so ways of improving readiness can be developed. Methods: This study was conducted at the Institute of Surgical Research in 2018 as sequential investigations by one user of Combat Application Tourniquets (C-A-Ts) in a band-and-rod design. Results: Each tourniquet comes packaged with paper instructions for use, which include directions on how to configure it in preparation for caregiving. The paper and video instructions for use omit tensioning of the tourniquet in configuration, and the video misconfigured a time strap over the rod. In first-aid classrooms, we saw unwitting learners troubleshoot that misconfiguration. Problems with configuration were also seen in caregiving and with tourniquets stowed in kits. In deliberate practice, we self-applied a tourniquet to a thigh. In configuration after each of 100 uses, tourniquet elongation due to tensioning averaged 2.4 in was important for restoring the tourniquet to its full length. During configuration, if the C-A-T's stabilization plate slid along the band, out of position, the user slid the plate back into position. In various ways of testing other C-A-Ts, elongations averaged from 0.4 in to 0.9 in, depending on whether the tourniquet was self-applied or applied to a firm manikin. Elongation increments accrued as the tourniquet's band flattened. Configuration time averaged 22 seconds, and accrued experience improved the compactness of configuration. Conclusion: People are too often unreliable at putting C-A-Ts into the optimal configuration for use. That ready-to-use configuration includes the tourniquet being at its full length, having the stabilization plate positioned correctly along the band, and having the strap fastened to its clip of origin. When used, tourniquets had normal, small elongations in part due to band flattening. This tourniquet study showed the importance of optimal configuration to first-aid readiness practices.

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NATO Military Medical Exercise Vigorous Warrior 2017

Fazekas L, McCown ME, Taylor JB, Ferland KA 19(1). 27 - 30 (Journal Article)

Our intent in presenting this information is to increase the awareness of the Special Operations Forces (SOF) medical community and the overall international medical/military communities about the North Atlantic Treaty Organization (NATO) military medicine's premiere Vigorous Warrior Exercises organized by NATO Centre of Excellence for Military Medicine (MILMED COE). The Vigorous Warrior medical exercise series is conducted biennially, with four successful iterations since 2011. These international medical exercises engage military medical elements that enhance NATO capabilities and ensure that new NATO medical concepts are being exercised and tested across the full capability-requirement spectrum. The primary aims of these exercises are to provide NATO and partner nations a multipurpose platform to collectively train their medical forces and personnel; test and experiment new concepts and doctrines; medically evaluate national or multinational medical treatment facilities in accordance with NATO doctrine; produce medical lessons identified and lessons learned; and provide the participants with multinational experience to enhance the provision of health care in NATO operations. These exercises directly strengthen partnerships, improve military medical interoperability, and demonstrate the Alliance's commitment to improving international military collaboration. More than 1,000 medical personnel from 26 NATO and partner nations successfully conducted the joint, multilevel, multinational, medical live exercise Vigorous Warrior 2017 (VW17) throughout three locations in Germany during 4-22 September 2017. This article details the highly successful VW17 and paves the way for a very bright future for the Alliance's military medicine as well as a Vigorous Warrior 2019.

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Testicular Cancer in an American Special Forces Soldier: A Case Report

Ho TT, Rocklein Kemplin K, Brandon JW 19(1). 23 - 26 (Case Reports)

Testicular cancer is the most common solid tumor and the most common cause of cancer mortality in men between 25 and 34 years of age. Limited data exist comparing testicular cancer in military Servicemembers and the general population. Research indicates that Navy, Air Force, and Coast Guard Servicemembers have a higher risk of testicular cancer than do members of the Army or Marines. A military lifestyle including operational tempo and long deployments may contribute to delayed diagnosis and subsequent treatment planning, potentially increasing morbidity and mortality. We used the National Institutes of Health case-study format recommendations as a framework for this presentation of the case of a 36-year-old US Special Forces Soldier who noticed new testicular masses while deployed in Iraq but did not seek help until 5 months later, upon redeployment home.

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Versatility With Far Forward Damage Control Surgery: Successful Resuscitative Thoracotomy in an HH-60 Black Hawk

Pieper MA, Vonderharr MJ, Knutson TL, Sullivan JL, Allison CG, Englert Z 19(1). 20 - 22 (Case Reports)

The military conflicts of the past 17 years have taught us many lessons, including the evolution of the tiered trauma system with en route resuscitation. The evolution of the conflict has begun to limit the reach of this standard trauma system. Recent evidence suggests that 95% of early deaths resulting from traumatic injuries may be prevented if the patient can undergo damage control surgery within 23 minutes of injury. US Military Surgical Resuscitation Teams have been developed to shorten this time from injury to surgical care, as illustrated by this case report.

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Unstable Pelvic Fracture Reduction Under Ultrasonographic Control

Goudard Y, Camus D, de Landevoisin ES, Dobost C, Domos P, Balandraud P 19(1). 16 - 18 (Case Reports)

Managing acute trauma cases in military and low-resource environments usually requires adapted medicosurgical protocols to achieve best medical results with limited technical capacity. We report a case of unstable pelvic fracture that needed ultrasonographic assessment for closed reduction before external stabilization. In our opinion, ultrasonographic control should be considered as a useful technique for unstable pelvic fracture reduction and an alternative to radiographic control.

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An Unusual Wound Infection Due to Acinetobacter junii on the Island of Oahu: A Case Report

Griffin J, Barnhill JC, Washington MA 19(1). 14 - 15 (Case Reports)

The genus Acinetobacter has long been associated with war wounds. Indeed, A baumannii was responsible for so many infected wounds during Operation Iraqi Freedom that it was given the nickname "Iraqibacter." Therefore, it is important to monitor the occurrence and spread of Acinetobacter species in military populations and to identify new or unusual sources of infection. A junii is an infrequently reported human pathogen. Here, we report a case of a slow-healing wound infection with A junii in a woman on the island of Oahu. This case highlights the pathogenic potential of this organism and the need for proper wound care when dealing with slow-healing wounds of unknown etiology. It also underscores the need for identifying species of Acinetobacter that are not A baumannii to better understand the epidemiology of slow-healing wound infections.

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Adapting to Death: Clarifying the Roles of Special Operations Combat Medics in Prolonged Field Care

Jeschke EA 18(4). 153 - 156 (Journal Article)

I suggest that Special Operations Forces (SOF) medicine should explicitly acknowledge the Special Operations combat medic's role in attending death. This acknowledgment will allow researchers to evaluate and delimit the medic's needs in relationship to an expanded set of roles that move beyond life-saving care. This article comprises four sections. First, I provide background to my argument by exploring some assumptions of modern medicine and objections to exploring battlefield death care. Second, I describe how I see the medic's role expanding with the introduction of prolonged field care. Third, I address the implications of the medic's expanded role in relationship to role and function stress and strain. Fourth, I address the moral complexity related to withdrawing or withholding care. I conclude by briefly highlighting some of the implications for future research. In explicitly engaging death as a medical reality for which the medic ought to be prepared, SOF medicine could set the foundational development for seeing death as a valuable gift to be explored, not a failure to be avoided or burden to be overcome.

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