Military inclusion with global burn science alignment: a path of least resistance

Military inclusion with global burn science alignment is a path of least resistance along the international deployment health alliance journey.

Burn care is specific, complex and teams driven. There are advantages when choosing burn medicine as specialty for global alignment. The coordinated care is watchful and research metrics are attainable. Care is generally delivered in hospitals and centers are accustomed to other quality requirements, so professional alignment is ripe. Additionally, the patient population is contained, known and small enough for very specific attention.

Military related burn science should be aligned internationally. The following opportunities in military related burn science are succinctly outlined:

* Much of the research around burn injuries and military personnel is not accessible by the public. This should be funded at time of publication as open access.

* All investments in burn care for military units are investments in burn care for the public, including with civilian patients at military hospitals and including academic research translation. The public invests when military veterans are financially assisted in care, as well. It’s beyond time to make this partnership formally integrated in data and research, including in funding research priorities. Greater healthcare platforms could tackle assistance for military burn science with research on prevention of non-combat burns in military personnel (1, 2) , specialized attention to genitalia, perineum and buttocks burns with funding in early intervention (3), guidelines for gastrointestinal care, and prevention of bacteremia for combat-related burns (4). These topics should be of immediate global health alliance.

* Military branches responsible for burn research are funded with annual budgeting and approvals. This system is outdated. Multi-year funding for research, recommended across science, should be mandated (5).

* The United States priorities in military burn research should be in sync with global militaries and other research initiatives. They are not secret, nor are they topics only needed in the US: development of interventions or therapies that can help, accelerate, or optimize wound healing, development or refinement of interventions or technologies that will enable non-burn specialists, such as a field medic/ corpsman/paramedic, to provide good burn care closer to the point of injury, development of therapeutic interventions that can help treat debilitating scars and prevent contractures and advancement of standard of care practices through conduct of high impact clinical trials are all of global military need (5).

* Burn science research ideas, submitted in various ways to various institutions, may go recognized yet unfunded. A global alliance could find better ways to work these ideas through (6)

* Let’s get so serious. There are appears to be significant global investment in paramedic interest. The energy around this interest should be directed to care on the field for burn injuries. International alliance in theatre should include better approaches to minimize lengthy transport, long air times and lack of trust (lack of standardization) in global treatment centers. Recommendations to improve immediate care (7) should include metrics around transit, excision and other measures for international comparison.

* It is estimated that combat operations in Iraq and Afghanistan have resulted in up to 8.8% of combat-related casualties suffering burns. How does that compare to other countries who deploy? How do the outcomes compare by transport metrics (8)?

* Burn outcomes classified by military and non-military persons, military and non-military related burns, combat and non-combat related burns and outcomes including long-term disability should be ongoing in system reviews (9). Establishing better grade systems for some severity and mortality specifics has been recommended (10) , and should be created with objectives that include ability to distinguish military and non-military trajectories from similar burn stages.

* Methodology and epidemiological concepts should be agreed upon internationally for burn care, including consensus on Injury Severity Score and Non-burn Injury Severity Score (11),

* Interoperability between burn registries by country should be a priority. This would also secure resources for burn registries when countries identify gaps, such as in Korea (12) and in UK alignment (13).

* Alliance in credentialing burn centers should be assisted with military liaisons from military burn centers in national borders. Alliance should align globally with national liaisons as well. When countries remodel and redesign new burn centers, such as in Russia (14), certification or credentialing should be inclusive. American and European Burn Associations should align (15,16) and establish methods for military burn research inclusion and diversity. As planning for burn center partnerships in Africa (17,18) expands, criteria would be ready to go. Because burn center mapping and credentialing paints a global picture, areas in Central and South America could also be identified for partnership. it is important to keep military clinicians a part of civilian burn center science, and vice versa.

* Infection preventionist requirements at burn centers should be clear, and infection preventionist expansion into deployment fields should not be considered a funding luxury. This conversation should start now.

* International clinician training benefits from global alliances in military burn science, and clinician staffing should be tracked. It is a specialty that can be accounted for. Consensus to care team requirements should also be clear. It is kind of other countries – especially in the Middle East - to speak to this in English, and we should all be so collegial (19).

* Metrics reports on quality assurance to wound care should be standard. Guidelines that specify anti-fungal use, application and require quality assurance in wound rounding are necessary. Research on anti-fungals is lessened (20) without assurance of quality in care management. Wound management, infection prevention rounding and assurance of properly trained clinicians is an easy metric and should be required of military burn units (and all burn centers).

* Consideration to supply readiness, pharmaceuticals, medication adherence, long-term access, utilization and surveillance software should be compared across military units and countries in burn science.

* Formal international military burn science communication platforms should be established. This not only secures better science, it provides for updated public messaging consistency. When research and clinician colleagues from institutions in Europe communicate military burn science insight online, such as in Germany (21), that outreach should be respected with formality.

* Severity to burns should be assured in training, research, surveillance and publication. Basics in skin and burn stages may be common, severity definitions such as a 7% facial region may not be common (22).

* Radiological burn training for clinician specialty should remain at the academic and military partnership level (23), and public governance should be accountable to this.

* Long term tracking for burns in military personnel should include psychological wellness and screening standards. Standardized surveillance and wellness data could also begin to tackle hurdles in research, such as privacy barriers(25).

* Long term tracking should be accountable to pain management.

* Technology that would assist should be funded. Consideration to improved technology for remote surgeon oversight may help, particularly when wound debridement and care calls for judgement (26).

* Military personnel with burn injuries should have funded patient care equipment updates. This should not require charitable contribution and ask (5), and should be budgeted for based on economic analyses of known personnel with injuries.

* Non-medical governance, as well as global health, can assist with considerations outside of patient care as well. How does global peacekeeping prepare local deployment civilian zones for burn and weapon injury prevention (27)? Would improvements also positively impact deployed military units?

* Pulmonary system burn effects may be classified or even scientifically addressed in grey zones, particularly when there is mild evidence. This area needs cross-specialty attention and specialist insight in research data needs should be identified. If air metrics can assist, technology to measure it while deployed should be secured.

Military personnel require the best burn prevention and care science. The population affected is manageable for successful global alliance, the science is not under national security risk, the healthcare trajectory for burns is most serious, and applications for burn science have global public benefit. National and regional burn associations should partner with registries and militaries without delay. Health service research, insurance and payers should also be at the quality accreditation for burn science and military inclusion. Military inclusion and global burn science alignment is a path of least resistance along the international deployment health alliance journey.

1. https://www.sciencedirect.com/science/article/abs/pii/S0022480406000849

2. https://academic.oup.com/jbcr/article-abstract/38/1/e269/4568937?redirectedFrom=fulltext

3. https://www.sciencedirect.com/science/article/abs/pii/S0305417917300359

4. https://www.sciencedirect.com/science/article/abs/pii/S0305417918305680

5. https://cdmrp.army.mil/mbrp/pdfs/MBRP%20Strategic%20Plan.pdf

6. https://cdmrp.army.mil/mbrp/awards/19idaawards.aspx

7. https://academic.oup.com/milmed/article/182/11-12/e2021/4661646

8. https://academic.oup.com/jbcr/article/38/1/e158/4568924

9. https://www.sciencedirect.com/science/article/abs/pii/S0305417918307605

10. https://www.sciencedirect.com/science/article/abs/pii/S0305417919302657

11. https://www.sciencedirect.com/science/article/abs/pii/S0305417918301773

12. https://www.jtraumainj.org/journal/view.php?doi=10.20408/jti.2017.30.4.145