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- [00:11]
A
Welcome to the Journal of Special Operations Medicine. I'm your co host, Jessica Rodriguez.
- [00:16]
B
I'm Sydney Duke.
- [00:18]
C
And I'm Matthew Farinella.
- [00:20]
A
And this is where evidence based medicine meets unconventional warfare. 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@sononline.org and don't forget to subscribe, review and rate this podcast on Spotify.
- [00:49]
D
Hello again as usual, this is Dan Godby, Medical Editor of the Journal of Special Operations Medicine. Thank you for joining us for the spring edition of the JSOM Podcast. For this introduction I will highlight another article in addition to the three articles covered in the podcast. The article Relationship between Age and Performance of Police Tactical Group Candidates and Officers Completing an Occupationally Relevant Specialist Police Physical Assessment is a well written article and is well considered in my role as a Public safety official and an EMS Medical Director. I think this article is well worth bringing to your attention. The topic is distinctly relevant for civilian special operations organizations. Fitness exams are a staple of high threat unit selection and there is increasing interest in identifying the most appropriate method for performing this evaluation. An evaluation standard that is at some level demonstrably age neutral is of significant value to law enforcement agencies. There is one more article I'd like to briefly mention because it's relevant to dive medical personnel of all types and in all environments. The article Testing the Emergency Evacuation Hyperbaric Stretcher for FIT in Small Military and Civilian Helicopters provides good information for medical planning of dive operations, particularly as to what airframes the EEHS may not fit in. As always, we at the JSOM really do want to hear from our readership, particularly those of you in the front level positions. I will always take this opportunity to reiterate 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 help them in getting them published. Now here's our team with the podcast.
- [02:52]
A
Hello everyone. Welcome back. We are so happy to be joining you once again for the spring edition for the JSON podcast. We are back again, me, Sydney and Matthew, and we want to give you a little bit of life updates on what's been going on. I actually will be graduating medical school next week, next Friday, and so this will unfortunately be my last podcast with you all. I have so, so so enjoyed my time here on the podcast and all the work that we put into it and all the work that all the editors and all the writers put into the journal. And it has been such a pleasure to be here. I really wanted to be a part of this for the long haul, but I think that just entering my intern year as a surgical resident will be pretty difficult. And I think that this is my time to really focus in on honing my skills as a physician for the future. So I'm sad to go, but I'm really excited for my next chapter of life. And Sydney and Matthew will give you a little bit of updates on what they're doing soon, too.
- [03:51]
B
Yeah, we're so sad to see Jessica go, but so happy for her to start this next phase of training. It's exciting, but unfortunately I'm not graduating just yet because I'm still a third year. So right now I'm just kind of Preparing for Level 2, preparing for audition rotations and obstetrics and gynecology this summer for my navel rotations. So kind of just preparing and studying and all that fun stuff.
- [04:23]
C
Yeah. And you know, like Sydney said, Jessica, we're excited to see, you know, you continue your journey in medicine and moving on. I am also just preparing for next round of board examinations right now and preparing for auditions in orthopedic surgery this summer.
- [04:45]
A
I'm so excited for you both to start your fourth year of medical school after you both take your board exams. It is such a fun year. You're doing exactly what you want to do and all the electives that you're choosing. And I think it's such a fun year of medical school. So I'm really excited for you both with that. If, Sydney, you want to go ahead and start us off with your article.
- [05:07]
B
Perfect. All right, so my article, this edition is a case report on the augmentation of cognitive processing therapy with spiritual counseling to address faith based concerns for an operator with high religiosity. The authors of this case report are Blake Schroeder, Mark Schmidt, Shimmel Fenig and Jonathan Murphy. So essentially this article focuses on treating PTSD and moral injury in a Special Operations Forces service member using a combination of psychotherapy and spiritual counseling. And kind of a little bit on the background of this is with kind of the advances in military technology, especially with, like real time drone feeds, Service members are now able to experience trauma indirectly. Kind of different from what we've seen in, you know, combat and wars previously. So even though they're not physically present, watching traumatic events unfold can still lead to PTSD and depression and something called Moral injury. This is also especially relevant in special operations forces who already have a high exposure to trauma. So just kind of like a few key concepts to understand before we kind of dive in is that PTSD results from exposure to certain traumatic events. And then moral injury refers to psychological distress that occurs when somebody feels that they violated or failed to uphold their moral or ethical beliefs. And then cognitive processing therapy or CPT is structured therapy that helps patients challenge negative thoughts related to trauma. Then the spiritual counseling in this case study was added to address the religious concerns. So again, the purpose of this case report was to explore whether combining CPT with spiritual counseling could improve outcomes in a patient with PTSD and moral injury, specifically when those injuries are tied to religious beliefs. And this was really important because this combination really hasn't been studied in special operations populations before. Before. So getting into the patient case, our patient was a 40 year old special operations officer with very strong religious beliefs. He developed PTSD after watching via drone footage and ambush involving a unit that he had previously trained. So he experienced significant guilt and self blame along with religious conflicts like questioning why God would allow the event to happen. He, he was later then diagnosed with PTSD and major depressive disorder. And some of the symptoms that he had were intrusive thoughts, guilt, shame, and difficulty reconciling with the trauma with his faith. Important they noted that he also had not previously completed a trauma focused therapy. Before this, the treatment kind of consisted of two main components. He completed cognitive processing therapy, Cognitive processing therapy. He did about 16 sessions in two weeks done virtually. And then he also had one session of spiritual counseling with a chaplain to specifically address his faith related concerns. And during the first week his symptoms actually worsened, which is actually very common in trauma therapy as patients begin to confront these difficult memories. However, after the spiritual counseling session, he became more engaged in therapy and was better able to process his beliefs. So in the second week his symptoms actually improved significantly and he was really able to challenge his negative thoughts, especially around like the self blame and the responsibility. And this kind of led to a rapid decrease in both his PTSD and depressive symptoms. So overall his PTSD symptoms decreased significantly with a clinical meaningful drop in his PCL 5 score. His depression also improved with a notable decrease in his PHQ9 score. And so interestingly, his symptoms pattern kind of followed like this curve where they worsened initially and then like sharply improved after the intervention. So this case report really does highlight the importance of addressing moral injury, especially when it's tied to religious beliefs. And according to this case report, the spiritual counseling did help resolve barriers that were preventing him from fully engaging in that cognitive processing therapy. One of those, once those barriers were addressed, the standard PTSD treatment became much more effective and kind of, you know, there are some limitations with this case study. It was only one case, and there's also no standardized way to measure moral injury. And they only did do one session of spiritual counseling. So it's hard to determine exactly how much it contributed. However, the case really suggests that computer combining cognitive processing processing therapy with spiritual counseling may improve outcomes in patient with PTSD and moral injury, especially those with strong religious beliefs. And it does highlight, like, the importance of addressing indirect trauma exposure in the modern military setting. So kind of I thought this article was really fascinating for several reasons is back when I was actually in college, I wrote a paper on PTSD and police officers because we usually think of that PTSD as like that boots on the ground, combat, warfare related kind of illness. And we. I did a paper on how, like, police officers get PTSD because their trauma they see is in the neighborhoods that they live in. So they're constantly being reminded of their traumas. So then when I was reading this article and coming from a religious background myself, I really, to me, it kind of made sense. Like, well, dude, don't we all think that addressing our religious concerns can help augment the therapy? But also, it had me thinking about, you know, this is the Journal of Special Operations Medicine. Is that, you know, what about PTSD in our healthcare workers as well? Right. Like, it's also different. I feel like a lot of things that healthcare workers see are some pretty traumatic things in certain acute hospital settings. And so that just kind of had me thinking on, like, kind of what we know about PTSD and, you know, how that all these things can occur. And also, especially, like, the use and utility of the military chaplains. I really liked how that article highlighted this as well. So I thought this was a super interesting article and I really enjoyed reading it.
- [11:43]
C
Yeah. And, you know, the other side of it too, that, you know, know it's different now. You know, you may not necessarily have the boots on the ground aspect of it now, but with the way we use technology. And in that specific case, you were talking about the drone footage. I mean, I think there's so much access to information, Sydney, that, you know, PTSD can come in many different shapes and forms now. And having just so much access to technology and to be able to view what's going on in current conflicts around the world, it kind of creates a sense of Unlimited access to that morally scarring or emotionally scarring footage that can further drive or precipitate that ptsd.
- [12:38]
A
I agree. I'm glad we talked about the indirect exposures that could be occurring in these places. I think that, like Matt, we have a lot of access to information nowadays, and the more that technology advances, I can see the more indirect and just different ways of exposure happening for ptsd. And so it's interesting to think about taking the next step forward and talking about treatments and how treatment will look in our combat men and women indirectly and directly. But I also like how, Sydney, you mentioned utilizing the military chaplains and how the article spoke about that, because I actually, I was at a military facility on one of my rotations, and I had never really seen the role of a military chaplain in a hospital. But every trauma that came in, the military chaplain had a pager. And they would get called in, too, and they would show up to the traumas, and they would show up to. I would run into the military chaplain my whole shift. Like, we would run into them in the trauma. We would run into them on the floors when an emergency happened. And I think that their role has a really great purpose in helping the families and other people around who are experiencing these events have a better explanation, someone to lean on. Whether you find religious belief, whether you, I guess, identify with religious beliefs or not, I think that they could be really helpful. And I know, I remember the one specific moment the military chaplain actually was, like, sitting down with the family while we were running a code and. And explaining kind of what was happening and what was going on with their family and let the healthcare workers take care of the patient while the family was not neglected. And so I thought that was really interesting and that the role of a chaplain could have many different roles in the military, especially in healthcare and especially in these different circumstances as well, with PTSD and different types of exposures.
- [14:32]
B
Those are both really, really incredible points. And, Jessica, I really liked, kind of like, your experiences with the military chaplains. My experience has only been when I went through officer development school, we had a military chaplain there. And he kind of. He gave various lectures at our time there, but he was. He was awesome. He was just amazing. And I also. I think I recently saw somewhere that military chaplains are no longer displaying their rank on their uniform, that they're displaying their religion, the symbol for their religious affiliate affiliation, which I think was done with the purpose of making sure that, you know, everybody could, when speaking to a military chaplain, can speak freely and. And kind of have that, you know, that rapport and trust. So I thought that was interesting too. But yeah, and Matt, I do totally agree what you say. The access to information, it's like even, you know, we're allowed, we can see exactly what's going on anywhere in the world just from our phones, you know, immediately after they've happened or just not at the same time. So those are both really, really great points.
- [15:37]
A
Thank you so much for sharing all of that Cindy and for doing a great analysis and debrief for us. Matt, if you want to go ahead and debrief on your article next.
- [15:46]
C
Yep, sounds good. So the title of my article today is Combat Related Orthopedic Trauma in the Russia Ukrainian War A System systematic review by Drs. Garcia Canyes and Dr. Navarro Suay. So this article really just does a really good analysis of kind of the injury types and trauma patterns that that they're seeing in the Russia Ukraine conflict. Really looking at it in a long term span. So not just the 2010, 2022 on, but looking from 2014 on. So they did an analysis of some 2000 plus articles and ended up dwindling viable studies down to around 31 into their that were able to be reviewed. So based off of what they found in their studies, it's not groundbreaking. It's just refreshing to re see it and understand the implications that we see from these trauma casualties that are not just, you know, that of a trauma surgeon, but also the orthopedic implications and long term psychological and physical toll that it takes on the casualties. So they went through and they looked at some of the injury characteristics and what the injury patterns were, mechanisms, mechanisms of injury and really found obviously a majority of what we're seeing right now and have seen long standing in the Russia Ukraine has been from mines and from now these drones and things like that that are causing more explosive type injuries with a lot of high velocity trauma happening, shearing energies and then also the, you know, the shrapnel being produced, throwing shrapnel into you know, cavities and body parts that aren't necessarily the, the focal point of what's being injured but just byproduct of the sheer force of what is happening. And then they go into kind of, you know, the management of it and talking about how you know, the initial is going to be your stabilization through whatever means necessary. They talk about the Ilazarov method of external fixation with internal fixation bone grafting procedures to restore structural integrity. But you know, I think it's been a Conversation that we've had in the past on previous podcasts and other writers have touched on it. It's, it's viability in that time and how, how much can you do on the ground? And as you continue to move, you know, through higher levels of care, as you move further and further away from the battlefield, one of the other, you know, types of repairs they talk about is obviously going to be soft tissue repairs. Talking about flaps, they talk about a vacuum assisted closure being widely introduced in the theater to try to mitigate wound infection. But overall that, you know, early surgical intervention needs to be had to try to mitigate, you know, furthering of injuries, wound infections, and then just try to stabilize till we can get to the next level of care. You know, their discussion goes into the need for then multidisciplinary rehab programs. Looking at, you know, kind of touching on what Sydney just talked about, the psychological component of what the service members are going through or casualties are going through, and then, you know, using telemedicine as a potential option for treating to try to improve outcomes. So they go into, you know, a good bit of discussion on each of those and how it can further, you know, drive that, you know, point of providing the highest level of care as quick as possible and as close to the front lines as possible while still doing it to keep as many people safe.
- [20:21]
B
One thing I was kind of thinking about, Matt, when you were discussing was last year when I went to the association of Military Osteopathic Physicians and Service Surgeons conference, the Surgeon General of the army, she was there and was discussing on how, like, their main goal for military medicine is to get our service members, like our warriors back in the fight. And so when you were kind of saying, like, how can we give the highest level of care and the, you know, in the front lines as quickly as we can, I think that all kind of goes around that central idea of, like, how can we get back in the fight quickly? So I did think that was interesting because I've heard topics like this come up, you know, before and I thought that was a great article you reviewed, Matt.
- [21:14]
C
Yeah. And, you know, ultimately, you know, they talk about it too in the article is we're trying to mitigate complications, long term, chronic pain and, you know, just that, psychological relief as physicians for our patients. So I think this article does a really good point. I think, I think like you said, the surgeon General of the army hit it on the head with when she was speaking to you guys. And, you know, obviously she's seeing it at the highest level and seeing all the different aspects of it.
- [21:49]
A
Thank you for your debrief, Matt. I think this article has great relevance right now and I'm glad we were able to speak on it on the podcast. We will now be moving on to the next article which is titled AI Assisted Lung Sliding Detection in Point of Care Ultrasound by Marine Corps Corpsman By Melissa Co Ross Prager CO Tran, Nicholas Orozco Delaney Smith, Zoe Holiday and Robert Arndfeld I'm really excited to talk about this article. With the advancing evolution of AI, it's interesting to see how it's being applied to the healthcare field. So this study specifically is a pilot study on AI pocus in military medics and how AI can improve diagnostic accuracy and confidence in resource limited environments. A little background about it A lung ultrasound is used in the field in multiple well, point of care ultrasound is used in multiple different ways in the battlefield, but specifically in the EFAST exam. We have trauma protocols that have EFAST exam. The lung ultrasound is a part of it. And the lung ultrasound can be used to detect urgent problems like a pneumothorax, which is life threatening, and it's a collapsed lung that needs to be fixed immediately. And so there are some challenges that go with that. That is a skill that requires experience, and it requires experience to interpret it correctly as well. Many frontline providers like military medics, have very limited training in these skills and these skills can degrade over time, especially in high stress or austere environments. And so because of these, the lung ultrasound is underutilized even though it's highly effective. So the study explores whether artificial intelligence can help bridge that skills gap by assisting with interpretation in real time. The goal was to introduce this point of care ultrasound, specifically a lung ultrasound, to novice military medics and to try to detect absent lung sliding, which is the key sign of a pneumothorax, and also to compare it to an AI's decision of that same ultrasound. How it was done is they had a they had five military Marine Corps medics who had no prior ultrasound training and they showed them each five lung ultrasound video clips and they interpreted each clip twice, once without AI and then once with AI. Then the AI system would give a binary prediction stating whether it sees lung sliding present or lung sliding absence. Importantly, the sessions were randomized and they were separated to reduce bias. The study took place in realistic field environments with noise, distractions, time pressure, and then things that were measured were accuracy, sensitivity, specificity, overall diagnostic performance, and then confidence rating from the participants with the usage Of AI assistance, there were clear and significant improvements. The accuracy increased from 67% to 88%, sensitivity rose from 63% to 90%, specificity improved from 70% to 86%, and their overall diagnostic performance increased from 0.72 to 0.93. So all of these were statistically significant. And not only that, but the confidence also improved. So it didn't just make AI, didn't just make the participants more accurate, it made them more confident. Their confidence nearly doubled and the low confidence responses decreased. The not confident at all responses were cut in half. So it's important because in emergency care, competence affects decision making, speed and action. So the quicker that we can get to these decisions, the quicker that we can, we can lead to treatment like needle decompressions in the field, which, I mean, seconds can have life determining effects on these patients. So it's important to make these decisions fast, especially if you have limited experience to pocus as a whole. So some limitations with the study is that it was a small sample size, like there were only five medics that were involved in this study. Another limitation is that it only focused on one ultrasound finding which was lung sliding. And the other limitation was that it used pre recorded clips and it was not using real time scanning. And it also mentions in the article that there was possible learning effects between sessions because the participants would see the 50 randomized 50 different lung sighting. So they would see the ultrasound findings and then they would take a break and then they'd go see another 50. So they're saying in between there they could have had a learning bias that could have potentially happened. But the one, the limitation that I'm a little bit more concerned about is that they were using pre recorded clips. And while prerecorded clips are important and useful in learning how to detect absent lung sliding, I do think that there is some technical aspect to performing a point of care ultrasound that is also important when you're out in the field and learning how to actually perform the technique. To even get the view is important as well and should be really considered. While it was really helpful, I think that also maybe it would have been a little bit more helpful had we taught the medics how to do the pocus and then recorded the results based on that. Because your results are only as good as your technicality and actually finding the lung sliding.
- [27:42]
C
Yes, it. So that's kind of what I was when I was reading through it and looking over it and then listening to you again, it kind of reaffirmed what my thoughts were is like, if you're doing the, you know, pocus out in the field in that context for that and having AI assist, like, in my head, they're probably using pretty good images of, you know, what lung sliding is or isn't at the time to help AI diagnose. But real world on the ground is probably going to be your worst image that you could possibly think of. So, like, you know, I don't want to see how, how much efficacy it had in reading really bad images. And, you know, it goes into kind of the other point of, like, point of care ultrasound is becoming more and more common. But I would argue that some of it is overstepping what the person or the carrier of that point of care ultrasound can do. And what I mean by that is, you know, as a, as a medic, if you're carrying the ultrasound probe and you find, you know, let's just say, and you know, obviously this one's talking about lung sliding. So you can do, you know, the NCDs and you can do maybe finger thoracostomies or chest tube thoracostomies. Like, you can do those things. And that makes sense to with pneumothoraces and hemothoraces and stuff like that. But, you know, you talk about other, you know, efast exam and looking at free fluid in the abdomen and stuff. A lot of your vitals can also, you know, trend that stuff and let, you know based off of your vitals, your mechanism of injury. So, you know, are we adding something that's taking more time to treat casualties, or are we improving casualty outcomes by incorporating it and incorporating AI into that?
- [29:47]
A
Yeah, I agree with you, Matt. I think that when we're considering what we're able to do in austere environments and at what staging are these different techniques expected to be performed at? Like, if we are in a, in a combat zone, like on the ground, like, I don't really see how this is going to be helpful in that way. When you do have your vitals, you do have like, your physical exam findings as well, it's going to take a little bit more time. I think that once we got to, once we get to a higher level of staging, I think that maybe then we could implement this. But I think at that higher level of staging, we would have potentially a provider who could also assist with this as well. And so it's interesting seeing them teaching medics how to do this while it is important and how they could use it and how they could be more accurate. I think that it's, I Guess it depends on the level of staging that we're at when we're expecting these. These different techniques to be performed at. In your experience, is that when, when. When would you usually see, I guess in what level of staging would you see these techniques being performed at?
- [31:01]
C
To be honest with you, you know, they started to. Towards the. The back half of my time, you know, point of care ultrasound kind of started to increase in popularity. And so it was something that we had the ability to carry and they had talked about us carrying on our persons as medics and using it and like I kind of hinted at earlier, using it for EFAS exams. You know, you can do your lung exam as part of that. But there was considerable pushback from the medit medics. And for, you know, exactly that of like at the point of injury, but, you know, for when it would be really applicable would be like in the case of a mass cal and triaging and making determinations from there. I think once the dust settles a little bit and you're out of the immediate combat zone and kind of pulling back off the line a little bit, you know, those mass cow scenarios definitely have a use for. For ultrasound and being able to identify pathology in patients and casualties that is treatable and stuff that is not treatable at that level. Or, you know, how we're gonna. What order we're gonna evacuate casualties. It played a role there more so than anything.
- [32:24]
A
I can see that. I can see triaging. Who needs to go to surgery emergently. Yeah, I could definitely see how it could be useful in helping triage patients and helping you decide who is most critical and what level of care they need to receive. Well, that about wraps up our spring edition to the JSON podcast. We hope you have enjoyed listening as much as we have had hosting. As always, please reach out and give us feedback. We are always eager to find out how we can make a better product to assist your practice out in the operational environment. Thanks and we will see you next time with Matt and Sydney.
- [33:00]
C
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.