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- [00:00]
A
Foreign. This is Sophia Leishman, Director of Marketing and Social Media Communications for the Journal of Special Operations Medicine. You can find us on Instagram, Facebook, X LinkedIn and threads asommonline. Subscribe to our bi weekly newsletter@jsomonline.org and and don't forget to subscribe review and rate this podcast on Spotify.
- [00:37]
B
Hello again as usual, this is Dan Godby, Medical Editor of the Journal of Special Operations Medicine. Thank you for joining us with the summer edition of the JSOM podcast. For this introduction I will highlight two additional articles to the three articles covered in this podcast. The article Expeditionary Point of Care Ultrasound for Combat and Austere Environments addresses a critical skill and presents a timely and important discussion on the use of point of care ultrasound in austere environments. The authors clearly identify the challenges of forward deployed ultrasound, including environmental extremes, limited power and skill sustainment. They also propose a structured framework to address these gaps. The manuscript is well organized and also provides a thorough review of the literature. The article the Use of Trauma Gel for Hemorrhage Control and Tourniquet Removal, which is a case series of traumatic extremity injuries, is an overall interesting topic and TraumaGel seems to have some promise for a difficult issue that is of particular importance to special operations and special operations medicine in particular. As always, we at the JSOM sincerely do want to hear from our readership, particularly those of you in the front level positions. I will always take this opportunity to keep mentioning our mentoring program specifically created to help medics get through the publishing process. A select group of editors are dedicated to concentrate on articles submitted by medics and aid in getting their articles into publishable form. Now here's our team with the podcast.
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A
Welcome to the Summer 2026 Journal of Special Operations Medicine Podcast. I'm your co host Matthew Farinella with Sydney Duke and Paul Rajan. And this is where evidence based medicine meets unconventional warfare. So just getting started, you heard me say Paul Rajan, new member, fill in the void where Jessica previously had been. I'm just going to give Paul a couple of minutes here to kind of introduce himself, say where he's from, where he's been and what he's looking forward to doing in medicine here.
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C
Awesome guys. Thank you so much for bringing me onto the team. Hi guys, my name's Paul. I'm from originally from Clark Summit, Pennsylvania. Prior to being in the Army I finished a four year degree in Biology and then enlisted in the army in 2013 because I had a passion for operational medicine and wanted to do something in that Realm. I served as a soccer medic. I served for about 10 years enlisted before finally being selected for the enlisted Medical Degree Preparatory Program. I'm currently a third year medical school student at the Uniformed Services University doing my clinical rotations. And while I'm still trying to figure out what I want to do when I grow up, I'm really thinking physical medicine, rehabilitation.
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A
That's awesome, man. Thanks for introducing yourself. And, you know, Paul and I got connected. We actually ran into each other on a, on a rotation. And I think it's funny, I don't know if it was him that said it to me or someone else recently that said, you know, within your prospective branch, your. Your one relationship away from knowing someone. And Paul and I actually had a mutual friend. My first senior medic, Ben Wickerham, and him had spent some time together overseas. And, you know, Ben was talking to me about him and really seemed like he would be a good fit for the podcast. So we wanted to bring him on and get his operational experience and get his experience in his life and just add it to the team and thought it would be a real good addition here. So we're really happy to have Paul with us starting off first. We're gonna have Sydney kind of tell us what's going on in her life and what she's got planned coming up for the summer.
- [04:44]
D
Awesome. And yeah, we're really excited to have Paul and kind of give us, you know, more perspective on all this is going. I know that I'm a very traditional medical student and don't necessarily have a background on the operational side of things, so I always love hearing from both Matt and now Paul. Right now I'm heading into my fourth year of medical school. Kind of just studying for boards right now. I take those soon and then preparing for my audition rotations in obstetrics and gynecology. So, you know, working hard and hoping for the best at this point and city.
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A
Where are you doing your auditions at?
- [05:23]
D
Yeah, so I'm gonna start off Naval Medical Center San Diego, and then I'll do another four weeks at Naval Medical Center Portsmouth in Norfolk, Virginia.
- [05:34]
A
That's awesome. Gonna be very exciting. And just real quick, I'm kind of in the same boat as Sydney. I'm going into my fourth year. I've fortunately taken the board examinations and done. And I head out for auditions starting next week. Actually headed up to Womack first and then up to Walter Reed and out to San Antonio. All those in orthopedic surgery. So praying for the best in all this. For you know, myself and for Sydney and then Paul as he goes forward. And Sydney is going to go ahead and lead us off.
- [06:09]
D
Yeah. Awesome. So today I will be presenting telemedicine consultation lessons learned from the pararescue experience. This article is by Austin Gotchick, Jacob Oding, Mason Blacker, Eric Dasauce and Steven Rush. So this article is a study where they reviewed 13 telemedicine consultations involving 28 patients over a 10 year period in an attempt to evaluate really how telemedicine supports military and medical operations in austere environments. So a little bit of background on this is that obviously, as we all know that based off different articles we've talked about and kind of just the trajectory that things are going, that modern military operations are increasingly incurring in remote locations where evacuations could take hours or even days. This is creating a real need for prolonged casualty care where medics kind of have to manage critically ill or injured patients without immediate access to physicians or surgeons. And so telemedicine has evolved into a tool that's kind of helping bridging that gap. So as far as methods, the authors reviewed all pararescue telemedicine consultations from 2010 to 2020, and they analyzed mission reports, after action reviews and interviews with flight surgeons and pararescue men to identify how telemedicine was used and then the challenges that they encountered. So the results were there were 13 consultations involving 28 patients in cases like this included cave entrapment, trauma, burns, and medical illnesses. Most consultations occurred between pararescue men's and flight surgeons, although specialists such as orthopedic surgeons, dermatologists and burn physicians were also involved when needed. What they found was that telemedicine was mostly used for medication recommendations, burn management, surgical decision making, and determining whether rescue missions should even be launched. One notable example was the Thai cave rescue. And I remember when this happened in 2018, I believe, where telemedicine was used to help guide pediatric sedation decisions during the extraction of 13 trapped individuals. I actually remember watching a movie about this where they were discussing how they had to divers went in to help rescue. I think it was a soccer team. And they had to sedate the patients in order to get them out safely. So they mentioned that in this article as well, which I thought was interesting. Some of the biggest challenges that were faced within telemedicine weren't technological. They were communication related. One case, a provider reported that a patient was urinating okay, which led to confusion because urine output was not actually being measured. Other issues included unfamiliarity between providers and occasional communication failures. And the authors really identified three major lessons from this. First was that teams need a shared communication framework. The second was that simple communication such as voice calls often work best. And then third was that telemedicine should be rehearsed before deployment so providers know each other and communicate effectively. So a lot of like themes around, like effective communication. So in conclusion, the authors concluded that telemedicine is a valuable force multiplier that provides remote access to expert medical guidance during complex cases. However, it can't really replace strong clinical training and experience. And success really does depend on effective communication, standardization and then just regular rehearsal. So I think the take home message from this is that telemedicine can help improve decision making and confidence, but does work best when paired with strong training in standard communication. And then the limitations with this study was it was a small sample size, it was a retrospective review and it was also limited to the Air Force, but it had some strengths of real world operational experience and then practical lessons for military medicine.
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A
Yes, Sidney, that's super interesting. And you know, I think it's telemedicine, it's super beneficial when you have providers that can fill knowledge gaps and drive treatments and help better, you know, assist casualty care. Where I think it gets difficult is the disconnect between what medics on the ground are carrying and what a physician has at hand in a hospital and understanding that there are differences and limitations in that. And I've seen that in my past experiences. I'd be curious if Paul's also experienced similar things of physicians not understanding necessarily why medics aren't doing something, but it may be because we don't have the means to carry that tool that the physician has access to in a clinic or in a hospital. And so really just goes into teamwork and communication prior to mission sets and going out the door to ensure that everyone's on the same page. So when that physician is communicating with that medic on the ground that they have an understanding of what, what is there, what equipment they have access to and can be used.
- [11:32]
C
Yeah, Matt, I think you really hit the nail on the head with that as far as, you know, the, the first time you do telemedicine should not be the first time you're doing it operationally. I think like rehearsing and knowing at least having an idea of who you're going to be speaking to and both knowing how both parties, thought processes works and just having an understanding of SOPs and also equipment that they're carrying and everything. I think that all kind of plays into having a smooth actual usage of teleconsult when the time comes for sure.
- [12:08]
A
Sydney, did it talk about any like failed telemedicine or instances where it provide like hindered casualty care or anything like that?
- [12:17]
D
Not really. They really just, I think focused on. It wasn't necessarily failed care. It was really more about miscommunication. It was never specific to actual medicine. But really again, like how both you guys were saying with those commute, those differences in communication and when you guys were talking, it kind of had me thinking like I wonder if, because you know how we have like flight surgeons and you know, dive docs and all those things, if maybe this is a role that can open up within the military, maybe it already does exist of where, you know, doctors or physicians where their sole, their sole role is to be able to be available to these operational settings. I thought maybe that was something that has the potential to move forward. But I really love hearing your guys's experience in all this.
- [13:12]
A
Yeah, definitely, you know, something to consider like dedicated providers for those positions, you know, typically the, the, you know, battalion or unit, you know, provider surgeon or whatever kind of physician they end up being fill that role. But having someone who's dedicated for telemedicine would be extremely nice and be able to go around and provide like an SOP for what is expected as far as telemedicine in an operational environment would be awesome. But yeah, Paul, also, you know, yeah, your first rep can't be the first, first time you're making that call with a casualty overseas and, and expect that to go well because there's going to be problems, I'm sure with the communication back to wherever that physicians located as well as, you know, gaps in knowledge and gaps in equipment of what's on the ground at that time. So good points and, and Sydney, I really appreciate you presenting the article. Next up we have Paul presenting his article.
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C
All right, so for this article I chose one IFAC isn't Enough Rethinking the Individual Medical Loadouts for Modern War. This authored by max Beerbohm and Dr. John Henderson and this article uses a first hand account from trench fight in the Ukraine to argue that the current individual medical loadouts or IFACs in use may not match the realities of modern large scale combat operations. So in this article a soldier is forced to transition from his original role as a designated marksman to a ad hoc medicine after multiple casualties were occurred and had to execute skills outside of his normal role and resulting in him exhausting both his medical resources and the medical resources around him. This article really demonstrates that the old model of the IFAC which was based on one casualty, one major injury stabilization and then rapid evacuation, it doesn't always apply in modern battlefields.
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A
Matt, for those listeners that don't know the IFAC is the individual first aid kit, usually everyone on the battlefield has one and that supplies is used to treat their injuries so that a medic doesn't have to go to his aid bag. But really it's just a very limited supply of Class 8. And in the new landscape of warfare I think we'll run into a problem of how much medical equipment we'll have access to on the battlefield.
- [15:58]
C
Oh yeah, no, I, I, I agree. And you know, I think some of the, the big key points are like actionable pearls. You know, I took from this, you know, I think, you know, I would hope people listening would be able to take kind of aligns with what you were saying. But you know, like the modern battlefield, the easy injury pattern that they're sustaining, they're just more than what a IFAC can, can treat. And you also have instead of these isolated injuries that kind of like what you or I were seeing Matt, they're now these, you know, multi system trauma wound patterns with just multiple away arrays of different ways in which the body's getting injured and that as a result of these, this drone warfare and really how, you know, just a few casualties can really deplete these IFAC supplies requiring like rapid reconsolidation and, and also just due to the nature of these drones and these blasts, you know, the supplies in these kits are not immune to damage. You know the same weapons that are injuring the troops are also damaging these ifacs with shrapnetal. And it's just showing that these supplies can be both rapidly consumed and physically destroyed, making it kind of just like a really challenging way which we handle like this logistically. And also rapid evacuation may not be realistic in this modern combat. And so consequently these soldiers may need to be providing care for longer periods of time at a casualty collection point or even closer to the point of injury than like traditionally preferred.
- [17:32]
A
Did they discuss instances of ifax being destroyed or percentages that did or didn't have ifax?
- [17:41]
C
Not so much the did or didn't but they like direct first hand account of this actual medic that they were interviewing when reaching in to actually provide care in. You know fortunately he had multiple different bags for his ifac. But at Least some of them were damaged. Rendering the. When he reached in to render care, actually had the supplies damaged beyond their ability to treat. So I thought that was definitely something worth note.
- [18:07]
A
Yeah, interesting. Not not being able to, you know, carrying it all around, having the. The right stuff, but losing it to, to, you know, the damage or whatever the mechanism of injury is, you know, don't really think about that all the time. You know, especially in training. I feel like when we're running casualty lanes or, you know, doing FMPs and stuff like that, you know, everyone's got their full kit and it's outfitted appropriately. So, you know, how do we look forward into the next conflict and train for that and train for the fact that we may be severely equipment depleted with these casualties?
- [18:51]
C
No, I agree. I kind of thought about this, you know, and some, some kind of takeaways from this article is. And like you said, like, our training needs to reflect, you know, kind of what we're seeing now in this modern battlefield with both, like some nasty wound patterns that kind of really force us to rethink how we pack our aid bags. I know, Matt, kind of speaking from probably both of our experience, you know, a lot of the wound patterns that we train with are pretty, pretty consistent, have been the same for, for, you know, quite some time. And I think, you know, what we're seeing now with Ukraine, with what these drones can do, I think probably pulling some of that data and some of those room patterns and actually using those as our training models as opposed to kind of what we've been doing in the past, I think is probably a good way forward, especially then giving these scenarios so that soldiers can have a better understanding of, you know, what supplies they actually need, what get used to, and just how they're going to be able to adapt those individual loadouts to kind of meet, you know, what we've been. What they've been seeing, you know, in the Ukraine and just any modern battlefield.
- [19:59]
A
Yeah, for sure. I mean, definitely gonna, you know, drive the way that we're gonna have to train in the future and kind of alter our next scope into our next fight and what we're gonna be doing in medicine, both as providers and as medics, moving forward. All right, so we'll go into the last article, which is going to be my article. So my article is Prediction Factors Associated with Success in Military Special Operations Courses. It's a systematic review. It's by Torino et al. And basically what they did was they screened through a whole bunch of studies initially and dwindled it down to approximately 23 studies from 1990 to 2022 involving special operations candidates from roughly 10 different countries. And you know, it looked at selections from, from SFAs, from Buds, Air Force Special Tactics Officer Training, it looked at Italian Rangers and then other international special operations selection courses to try to find, you know, what, what ultimately makes the highest level of success in an operator in that setting. And what they found was initially aerobic fitness matters more than almost anything else. I think that that is to no one's surprise. So VO2 max values in those who were successful was higher in those that failed. So, you know, looking at your run times, your ruck times, overall endurance times showed higher success rates. And then as far as like the muscular endurance and strength factors that played a role in it, the ones that they really saw the highest increase in success rates comparatively were in pull ups and push ups as well as the loaded marches and rucking. And I can definitely tell you from, you know, my experience that the guys who could crank out a bunch of pull ups and push ups and were really good at rucking seemed, definitely seemed to have an easier time than the guys that were struggling to pass PT tests for push ups or barely making time on rucks. I think that most of those people ended up dwindling out and fading out of the courses pretty quickly. And then I thought this was interesting that they reported that body composition was less important than expected. So it really didn't, you know, guarantee success. So, you know, your traditional image of what you think an operator looks like of, you know, 6 foot 3 and, and, you know, 6% body fat is not necessarily going to be what your, your actual operator looks like on the ground. Unsurprising findings were psychological factors being that, you know, increased resilience prior to coming into selection showed a greater instance of, of success, strong character traits, ability to handle stress, and then lower levels of dissociative symptoms under stress. So being able to stay present and mindful in the moment and understand what's expected of you, you know, going forward. And then one of the last ones that they talked about was that prior experience matters. They said that candidates who had been recycled or previously been to selection programs had higher success rates in their selection programs, the current ones, due to the fact that they either had some knowledge of what was coming next or they understood the demands of that course. Overall, you know, obviously it's going to be aerobic fitness. Muscle endurance and psychological resilience were the big factors that they used as predictors to success and decreased attrition. They Said that their limitations were significant variation existed between the courses and countries and that many outcomes were only supported by a small number of studies. And the grading criteria was kind of gray in some of the studies. So definitely some studies. But overall I think that this is not surprising.
- [24:30]
D
Yeah, and I really liked this article, Matt. I kind of thought about it from like a lot of different perspectives. You know, I don't have any experience in special operations and the most exposure I have to that is, I mean, watching like the documentaries on the Navy seals and things like that. But I so specifically remember my dad. What is Father's Day? My dad, when I was younger, making me watch that. It was a documentary on going through buds for the Navy SEALs and how they had to like make their own teams to carry the boats into the water and the, you know, horrific, difficult physical aspects. And it was like a bunch of like all the six foot plus guys got together and then there was a bunch of like shorter men. And the shorter men actually ended up being more successful than the biggest guys out there. And I remember my dad showing me that as like a younger child, as like a life lesson to be like, it doesn't matter what, how big you are, it matters, you know, your resilience, your grit, your intensity, your strength, the confidence you have in yourself. And then I was also thinking about it from the perspective of being a medical student. Um, I've been fortunate enough to interview some candidates for my medical school. Um, and then our, our lead, who sits on the top of our medical school admissions. Dr. Kaiser, he is a former retired Navy admiral, always told me that medical schools are looking for two things. They're looking for students who have big hearts and strong backs and, you know, really meaning that resilience is the most important. And even apart from if you just take it all, like the mental things that they looked at like resilience, teamwork, persistence, self confidence, stress tolerance, that can be applied to any line of work in success. So I really did like this article and I think it really can just be applied to things outside of Special Forces, but also gives us a better look into that as well. So I really liked it.
- [26:33]
C
Yes, I also, I really like, you know, and it's, it's one of those, it's kind of like no surprise. It's like whatever, you know, selection process or, you know, it's an interview process that you're doing in the military. It's like you're probably gonna do some hard stuff, you're probably gonna walk a lot with weight on your back. You're probably gonna have to find some sort of point in the middle of the woods. So a lot of that doesn't change. But what I really found kind of significant and it wasn't until they mentioned it that, you know, I really think thought about how profound it was. But when they mentioned mindfulness, just that kind of act of just not really being overwhelmed or underwhelmed, just being kind of focused on that moment and that task that you're doing, that 25 meter target of what am I doing now? What is going to get me, you know, to the next point? And I just thought that was really interesting. You know, it's something that, you know, you don't really think about as much. But I mean, even in medical school now, it's something they really harp on us is how do you know, how do you be mindful and just kind of present in the situation?
- [27:36]
A
Definitely. I feel like it's a shift in medicine and at the academic level they really harp on it, I feel like. And I'm sure Sydney's felt the same thing of this mindfulness and taking the time to set aside, to kind of focus and be present on what you're doing, where you're at, and it helps kind of with your resiliency in the long run. But some other things that I kind of thought were interesting that came to my mind when doing this article were just because these factors lead to the success in a special operations selection course does not mean that it's going to make for a successful operator get through selection because you have all these tangible and intangible things, but it doesn't necessarily going to mean that you're going to have success in the long run in, in your unit and, and be a successful operator. And then the other thing that kind of came to my mind was, you know, thinking back to when I was, you know, going through rasp and things and the guy next to me, you know, it said a lot about his character. In my opinion. He was a late recycle. I think he went to week seven his first time and then went back through the course. And he was just such a resource for everyone around him. And just like his confidence and, you know, just because he knew what was coming next, his confidence going into different gates and events kind of helped those around him, myself included, to feel confident that like, hey, no matter what we're going through, like it's gonna end, we're gonna make it through it.
- [29:10]
D
I had a similar experience to that Matt, when I went through officer development school for The Navy, by no means was that similar to Ranger school, but I really felt like I was incredibly successful because of the prior enlisted officers that were there, the people who had been in the Navy for years and who poured into us and took the time to. Again, you know, luck favors the prepared and kind of allowed us to be like, this is what's coming next, and here's how you prepare for it. And again, and what we did a lot in the Navy was like, warrior toughness was about, like, being mindful and being present in those moments. And it's like the. We hear a lot of medical school is like, well, how do you eat an elephant? Like, one bite at a time. And I just remember going through my officer training and then being like, okay, we just got to make it to breakfast, child. Then you just gotta make it to lunch, Then you just gotta make it to dinner. And doing the little things you can to just stay present and continue to move forward. Then again, rely on those people who have, you know, that experience in order to help propel you forward. So similar, but different experiences in that.
- [30:18]
A
Definitely nice having those. Just that knowledge around, for sure, Sydney. So we appreciate it. All right, well, that wraps up our summer edition to the JSON podcast. As always, if you have any feedback, please let us know how we can better improve your experience and better talk about the operational environment. We'll see you guys next time. As a reminder, the views and opinions are the speaker's own, and nothing contained herein is to be considered the official opinion of the Journal of Special Operations Medicine or the US Government, including the Defense Health Agency, Department of Defense, Department of the Army, Navy, or Air Force.
- [31:35]
D
Sam.