Combat casualty care nursing research and the joint combat casualty research team.
Subject: Nursing (Military aspects)
Soldiers (Military aspects)
Behavioral health care (Military aspects)
Stress management (Military aspects)
Nursing (Research)
Authors: Feider, Laura L.
Platteborze, Lynn S.
McClinton, Annette R.
Garner, Betty K.
Pub Date: 10/01/2012
Publication: Name: U.S. Army Medical Department Journal Publisher: U.S. Army Medical Department Center & School Audience: Professional Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2012 U.S. Army Medical Department Center & School ISSN: 1524-0436
Issue: Date: Oct-Dec, 2012
Topic: Canadian Subject Form: Behavioural medicine
Accession Number: 309980598
Full Text: The Mayo brothers are quoted as saying, "the only winner in war is medicine." (1) Research within theaters of operations occurred in World War I, World War II, the Korean War, and the Vietnam War. There were no formal research teams during those wars, only healthcare providers seeking better ways to care for the wounded Soldiers. Many advances in medical care have been and are continuing to be made as a result of wars and conflicts--management of shock, psychology of combat stress, blood transfusions, resuscitation, behavioral health, and en route care just to name a few. However, there have been many shortcomings in evaluating and developing healthcare practices during these conflicts. Most advances were not based on formal research, they involved on-the-spot innovation and trial-and-error, and were based on personal experience and skills. New ideas were not easily or speedily shared, and often ideas were adopted after the conflict, not in real time.

Combat casualties from Iraq and Afghanistan are provided world-class healthcare through innovative research. Combat casualty care in Operations Iraqi Freedom, New Dawn, and Enduring Freedom is better than or comparable to trauma systems in the United States. (2) This article highlights the overall importance and effect on nursing of combat casualty care nursing research by the Joint Combat Casualty Research Team (JC2RT) since 2006.

The nurse members of the JC2RT directly support the mission of military nursing--the Nurse Corps of the US Army, Navy, and Air Force. All actions and tasks must lead and work toward promoting the wellness of Warriors and their Families, supporting the delivery of Warrior and Family healthcare to all those entrusted to our care, and ultimately positioning military nursing as a force multiplier for the future of military medicine. The JC2RT nursing team members consistently achieve performance excellence, foster innovation, build knowledge and capabilities, and ensure organizational credibility and sustainability.

TEAM DEVELOPMENT

In October 2006, the first Deployed Combat Casualty Research Team (DC2RT) was deployed to Baghdad. The initial team consisted of one Army physician, one Army nurse (PhD), 3 Army nurses functioning as data collectors, and one noncommissioned officer-in-charge (lab technician) functioning in an administrative role. The team expanded to the Air Force Theater Hospital in Balad, Iraq, in 2008 when Air Force members joined the team. Figure 1 shows the locations of military hospitals in Iraq in 2006.

Six DC2RTs deployed to Iraq in support of Operation Iraqi Freedom from 2006 to 2009. One team deployed every 6 months to an Army theater combat support hospital, an Air Force theater hospital, or an Army forward operating base. In August 2009, the DC2RT formally transitioned to the Joint Combat Casualty Research Team with the headquarters moving from Baghdad, Iraq, to Bagram, Afghanistan, and satellite offices opened in Balad, Iraq, and Kandahar, Afghanistan. The JC2RT now includes 12 military professionals from the Army, Air Force, and Navy medical departments as delineated by the US Central Command (USCENTCOM) Assurance and Joint Manning Document. (3) The JC2RT 12 currently has 3 offices in Afghanistan: Bagram, Kandahar, and Camp Leatherneck (Figure 2).

The mission of the JC2RT is to "foster and facilitate combat relevant medical research within the USCENT COM Joint Area of Operations." The JC2RT's guiding philosophy is "Joint Military Medical Research ... Keeping the force ready and relevant." *

To fulfill this mission, healthcare providers and research scientists comprise the JC2RT. Typically, senior healthcare providers such as physicians and PhD-level nurses are selected for the key positions of director and deputy director within the team. As the leader of the JC2RT, the director provides executive-level leadership to coordinate assigned JC2RT staff to develop, implement, manage, and regulate research activities within the theater of operations, as well as direct guidance and assistance to investigators initiating new research protocols to ensure the feasibility of in-theater research projects. In addition, the director is responsible for maintaining open lines of communication with USCENTCOM, their subordinate commanders, and the Institutional Review Board (IRB) of the US Army Medical Research and Materiel Command (USAMRMC) providing them with status of research and performance improvement activities in all theater of operations. The deputy director assists investigators in developing protocols, processing their protocols through the theater approval, and submitting the protocols to scientific review and the IRB for approval. The deputy director acts as the main conduit of communication among the IRB, the US Army Institute of Surgical Research (USAISR), deployed researchers, and JC2RT members.

[FIGURE 1 OMITTED]

Healthcare providers and other professionals with research interest or backgrounds have the opportunity to serve on the JC2RT as researchers and research liaison officers. Depending on their experience and background, researchers serve as on-site principal investigators (PIs) for select protocols, assist with data collection efforts, and mentor other investigators in protocol writing and processing. * They work directly with the deputy director to develop, facilitate, and conduct research in the Joint Area of Operations. They facilitate communication among their PI counterparts, the director, and the deputy director during protocol development and review.

[FIGURE 2 OMITTED]

Although not technically a member of the JC2RT, the in-theater human protections administrator (HPA) plays an important role in overseeing research in theater and works very closely with the JC2RT. The position is held by a research scientist (PhD level) who is responsible for ensuring compliance with the Human Research Protection Program Management Plan for all research conducted in theater. The HPA reviews and screens protocols during development and implementation to ensure that they comply with applicable laws and regulations, and that PIs document their plans for human subject protection. The HPA audits studies conducted in theater and assists PIs to resolve and/or minimize adverse effects and protocol deviations.

Army nurses can serve on the JC2RT in any role. Since 2006, 37 Army Nurse Corps (ANC) officers have served in Iraq and/or Afghanistan in the following roles:

* Nine as deputy directors; six in the dual role of deputy directors and HPAs

* Five as senior researchers

* Twenty-three as researchers/data collectors

The nurse scientists and clinical experiences of Army nurses leverage the JC2RT's value by facilitating onsite medical research in the deployed theater. The nurse scientists who serve as deputy directors or senior researchers are Army nurses with a minimum of one year of postdoctoral and IRB experience. The skills set of nurse scientists are invaluable to facilitate a smooth approval process among both internal (deployed theater) and external (United States) customers. The ability to apply a knowledge of protocol development and evaluation of scientific rigor in the deployed setting ensures a high quality, realistic protocol implementation. Junior officer Army nurses who are interested in research serve as facilitators of protocols during various stages of the research approval process, and/or as data collectors in approved research protocols. These positions provide ANC officers opportunities to learn more about conducting research while performing data collection vital to the effort. The clinical expertise in various areas (eg, critical care, emergency room, medical-surgical, maternal child health, public health nursing, advanced practice) possessed by most nurses can be an important asset to investigators.

Appointment of Army nurses to the JC2RT involve both selective and nominative processes. The deputy director is selected by the nursing research consultant to The Surgeon General with concurrence from the officer's chain of command. All other Army nurses are selected for the JC2RT using the Army Medical Department Professional Officer Filler System. Army nurses must obtain written approval from their rater and all subsequent nursing leaders, and submit those approvals to the deputy commander for nursing or senior nurse executive who will forward recommendations for JC2RT membership to the regional nurse executive. The Commander, USAISR provides logistical and training support for the JC2RT, with operational support by the Command Surgeon, USCENTCOM. All JC2RT members may serve as deployed area PIs for researchers located in the United States. Additionally, team members spend approximately 20% of their time providing clinical care in the intensive care units, operating rooms, emergency rooms, clinics, and humanitarian outreach missions for the local Afghan people.

JC2RT RESEARCH SUBMISSION PROCESS

The necessity and feasibility of conducting a study in a combat zone are cornerstones of research in theater. Clearly, if a study can be conducted in the United States, it should not be conducted in the theater of operations. The individual PI (on-site or in the United States) works with the JC2RT deputy director and/or assigned researcher to develop the protocol using applicable templates. Once a draft protocol is developed, the JC2RT director, the deputy director, and the HPA review all protocols with a focus on the feasibility. The review evaluates the following:

* Whether the study is medically feasible within the operational area.

* Whether the study could hinder combat operations or clinical support of combat operations.

* Whether the study can only be conducted in theater.

* Whether the study has the potential to improve healthcare.

* Whether there are any local or cultural factors that may affect execution of the protocol.

The HPA conducts a review of all protocols to ensure that investigators document plans for human subject protection. The HPA or the JC2RT deputy director obtains letters of support and institutional official signatures from the appropriate commanders on behalf of the PI. The deputy director forwards the protocol and supporting documents to the USAMRMC Office of Research Protection and the IRB for scientific and ethical review and approval.

The protocol is expected to adhere to sound research and scientific principles, the USCENTCOM Human Research Protection Program, and all Department of Defense (DoD) and other US regulatory requirements. Formal scientific reviews are managed through the USAISR and are conducted by subject matter experts throughout DoD. Upon passing scientific review, the protocol is referred to the IRB for ethical review. The IRB may review protocols via full board or expedited review. Once the IRB approves the protocol, the USCENTCOM institutional official issues the study start letter. Table 1 lists the steps and typical timeline for completing a research protocol. Table 2 presents the checklist of items for the PI to review prior to submitting a theater protocol.

NURSING RESEARCH PROTOCOLS AND THEMES

The type and complexity of in-theater research has evolved since 2005 when studies were mainly retrospective reviews. Research now covers the span from simple retrospective chart reviews to prospective observational and/or interventional studies. Data is collected by the PI or a designated on-site PI, who could be a member of the JC2RT, or other medical personnel working at the combat support hospital. Approximately 173 protocols have been reviewed since 2006, with 153 receiving IRB and institutional official approval. As of this writing, 54 protocols remain open in ongoing or data analysis status. The JC2RT research priorities in the combat zone have evolved, but continue to focus on trauma care, concussion/traumatic brain injury, preventive medicine, and behavioral health.

Since the inception of DC2RT/JC2RT in 2006, 39 nursing research protocols have been submitted, representing 28% of the JC2RT protocols submitted as of this writing. Prior to the 2010 nursing research agenda, * many of the protocols focused on the nurse's area of interest or expertise and ability to conduct a feasible study in the combat zone based on the theater research priorities. The current nursing research agenda priorities set forth by the ANC include leadership, health promotion and wellness, human capital, patient-centered and family centered systems of care, deployment, anesthesiology, and informatics. Many of these research protocols fit into the 2010 ANC research agenda focusing on improving Warrior care from the point of injury to arrival at medical facilities in the United States. The predominant themes of the JC2RT nursing research protocols (Table 3) address 39 elements of military healthcare, with focus on Warrior care, in the numbers indicated:

Warrior Care

* Healthcare delivery (11)

* Soldier health (7)

* Trauma (3)

* Behavioral health (3)

* Nursing/healthcare professional issues (15)

EFFECT OF JC2RT NURSING RESEARCH INITIATIVES AND LESSONS LEARNED

The effect of nurses serving on the JC2RT has been very beneficial for newly wounded Warriors. Some examples include improved delivery of fluid resuscitation of trauma patients, standardization of tourniquet use, damage control laparotomy, development and implementation of clinical practice guidelines (ie, burns, hypothermia, pelvic fractures, trauma airway management, vascular injury), and the development of 39 nursing-driven research initiatives affecting war-wounded in real time. Additional evidence-based practice and performance improvement projects were also initiated. Nursing-driven research initiatives include "back-to-basics" clinical practices such as oral care for ventilated patients, documentation of pain management, and hand hygiene in an austere environment. Other important aspects of nursing-driven research protocols are the experiences and outcomes of nurses providing care to both wounded Warriors and Afghan local nationals, including insurgents. These studies are rich in data from the perspective of asymmetric warfare in a generation of nurses who have no experience in any previous combat environments. However, as the war continues with multiple deployments, these studies provide knowledge as a platform from which nurses can further build current nursing knowledge and clinical practices.

Nursing practice in the combat zone has changed, reflecting advancements in Warrior care from research and performance improvement efforts. Numerous publications and presentations have been provided at national and international conferences. Many protocols are in data analysis, manuscript publication, or in-press phases. Innovations from JC2RT research protocols have had an effect on hemorrhage control, tourniquet use, damage control resuscitation, en route care during medical evacuation, critical care air transport, extremity care, and conversion of evidence into practice. (5)

FUTURE COMBAT CASUALTY CARE NURSING RESEARCH PROTOCOLS

Nursing research to improve combat casualty care during Operations Iraqi Freedom, New Dawn, and Enduring Freedom is unprecedented. Future combat casualty care nursing research may include topics that have an effect on trauma care provided in real time prehospital phases, and to compare with and translate to the civilian sector. Nursing research should also stimulate longitudinal outcome studies that support Warrior care, leader development, human capital, and evidence-based care. Their recommendations should be prioritized by the ANC and Army Medical Department as the next steps in combat casualty care nursing research.

Some of the future combat casualty care nursing research topics which have high or medium priority according to the nursing research agenda are listed in Table 4. Army nurses will continue to serve on the JC2RT in a variety of roles, significantly assisting combat casualty care. Army nurses will remain at the tip of the spear, leading the path for medical innovations in real time--remembering the past, engaging the present, and envisioning the future.

[ILLUSTRATION OMITTED]

REFERENCES

(1.) Haberman TM, Ziemer RE, Beck CS. The Mayo Brothers' Heritage: Quotes and Pictures. Rochester, MN: Mayo Clinic Scientific Press;20021:6.

(2.) Eastridge BJ, Costanzo G, Jenkins DM, et al. Impact of joint theater trauma system initiatives on battlefield injury outcomes. Am J Surg. 2009;198:852-857.

(3.) Brosch L, Holcomb J, Thompson J, et al. Establishing a human research protection program in a combatant command. J Trauma. 2008;64(suppl 2):S9-S13.

(4.) Clark S, Brewer R. Building the Army nursing campaign plan. US Army Med Dept J. October-December 2011: 10-17.

(5.) Bridges E, Biever K. Advancing critical care: joint combat casualty research team and joint theater trauma system. AACNAdv Crit Care. 2010;21(3):260-276.

* JC2RT STRATCOM, US Army Medical Command, February 2011. Internal military document not readily accessible by the general public.

* The PI and assigned researchers must have current curriculum vitae and completed the human subject protection training of the University of Miami's online Collaborative Institutional Training Initiative (for information see http://it.med. miami.edu/x1654.xml).

* The nursing research agenda is an annual priority listing derived by the ANC Corps Chief's Office Campaign Plan. (4) The priority list provides recognition of gaps in knowledge and the actions necessary to fill them. The policy outlines the plan to deliver evidence for decision making and formulation of solutions.

LTC Laura L. Feider, AN, USA

Lynn S. Platteborze, MS, RAC

Annette R. McClinton, RN, MA

LTC Betty K. Garner, AN, USA

AUTHORS

LTC Feider is Regional Chief, Center for Nursing Science and Clinical Inquiry, Brooke Army Medical Center, Fort Sam Houston, Texas.

Ms Platteborze is Human Protections Administrator, Brooke Army Medical Center, Fort Sam Houston, Texas.

Ms McClinton is Chief, Regulatory Compliance, US Army Institute of Surgical Research, Fort Sam Houston, Texas.

LTC Garner is Deputy Chief, Center of Nursing Science and Clinical Inquiry, Landstuhl Regional Medical Center, Landstuhl, Germany.
Table 1. Typical timeline to complete a research protocol.

Step                                Average Time

Develop and write protocol          Variable
PI/AIs completion of                Variable
CITI/curriculum vitae
JC2RT Executive Steering            3-7 days
Committee review
Scientific review of protocol       2 weeks *
Review by USCENTCOM MRMC IRB        2-3 weeks ([dagger])
2nd-level review and start letter   1-3 days
Approving Official Start letter     1-3 days
Average total time required         2-3 months ([double dagger])

AI indicates assigned researcher.

CITI indicates Collaborative Institutional
Training Initiative (University of Miami).

* Time spent in scientific review also dependent on
the amount of time required for PI revisions.

([dagger]) Review time dependent on the type of protocol,
the IRB schedule, and the amount of time required
for PI revisions.

([double dagger]) Estimate, may be shorter or longer.

Table 2. Example of a checklist used by a Principal Investigator to
ensure that the proposed protocol meets all requirements.

Complete   N/A   USAMRMC Institutional Review Board: Human Subjects
                 Research Initial Protocol Application

                                      Protocol

                 Prepared using the current version of the
                 templates provided by RLNO

                                       Part A

                 1. Study Contacts: Principal Investigator, Onsite
                 Investigator, Associate Investigator, Consultants,
                 and (if needed) Medical Monitor

                 2. Key Study Personnel: must provide all of the
                 following information: names, addresses, rank &
                 position, phone numbers, department work area,
                 e-mail, unit, redeployment date

                 3. Study Facilities

                 4. Multisite Research

                 5. Scientific Review

                 6. Additional Approvals

                 7. Funding Information

                 8. Drugs, Dietary Supplements, Biologics,
                 and Devices

                 9. Clinical Trial Registration

                 10. Target Population(s)

                 11. Waiver/Alterations of the Informed
                 Consent/Assent Process

                 12. HIPAA Authorization

                 a. Request for HIPAA Waiver signed by principal
                 investigator (if applicable)

                 b. Completed HIPAA Authorization for use and
                 disclosure of protected health information

                 c. Completed HIPAA Application for Waiver

                                       Part B

                 1. Responsibilities of the Principal
                 Investigator in Human Subjects

                                       Part C

                 1. Protocol Title

                 2. Abstract

                 3. Background and Significance

                 4. Military Relevance

                 5. Objectives/Specific Aims/Research Questions

                 6. Research Design

                 7. Research Plan/Human Subjects Protection

                 a. Clearly and comprehensively describes the
                 database are and how the data from the data
                 collection measures transferred into an electronic
                 or hard copy database.
                 Use of audio and/or visual tapes and their
                 disposition is explained.

                 b. Describes what HIPAA identifiers that permit
                 the association of the data with the individual
                 are being collected.

                 c. Describes the method for maintenance of
                 confidentiality and security. Clearly delineates
                 measures for coding of measures so that individual
                 subject data is not identified by name but by a
                 coded system, the security of electronic data
                 through use of password-protected and encrypted
                 files, and the storage of paper records in locked
                 file cabinets and rooms with access to only
                 authorized personnel, both in theater
                 and in transit.

                 d. Describes the method for transmission of data
                 through use of password-protected and
                 encrypted files.

                 e. Describes the status of data (ie, deletion
                 of data) after completion of the research study.

                 f. Describes the risks and benefits from the study.
                 If there were any identifiers collected, discusses
                 how the risk to potential loss of
                 privacy/confidentiality of data will be minimized.

                 g. If greater than minimal risk, Medical Monitor-
                 identified. Cannot be a subordinate in the PI's
                 rating chain. The IRB determines requirement.

                 8. Risks/Benefits Assessment

                 9. Adverse Events, Unanticipated
                 Problems, and Deviations

                 a. Definition of adverse event

                 b. Reporting of unanticipated problems

                 c. Medical Monitor

                 10. Withdrawal From Study Participation

                 11. USAMRMC Volunteer Registry Database

                 12. References-Review of Literature

                 a. Identified date of search, period searched,
                 sources searched, and key words of search.

                 b. Literature supports the theoretical
                 framework of the study.

                 c. Interventions are supported by the literature.

                 d. Use of chosen measurements/instruments are
                 documented/validated in the literature.

                 13. Time required to complete study (expected start
                 and end dates) (including data analysis)

                                     Attachments

                                   Signature Pages

                 1. Signature block entered for all PI(s), AI(s),
                 medical monitor, and unit Commander; use following
                 example for format:

                 John Doe

                 MAJ, MC

                 2. Signed and dated by principal investigator,
                 associate investigator(s), unit commander,
                 FOB/COB/garrison commander

                 3. Theater signature page (to be completed by ESC)

                 4. Signed by all other individuals approving study

                                    Consent Form

                 1. Informed Consent Document, unless a waiver is
                 requested in the protocol

                                  HIPAA Form/Waiver

                 1. HIPAA Form, unless a waiver is requested
                 in the protocol

                                     Appendices

                 1. Recruitment Flyer/Email/Script

                 2. Study Instruments

                 3. Data Use Agreements

                 4. Product Information

                 5. Investigational Brochure

                 6. Device Manual

                 7. Database/Data Collection Sheets
                 (how you will record your results)

                 8. Letter(s) of Support as appropriate

                 9. All applicable Impact Statements

                                  CITI, CV, and COI

                 1. Current Curriculum Vitae for each
                 investigator (including Medical Monitor)

                 2. Documentation of CITI within the
                 last 3 years for each investigator
                 (including Medical Monitor)

                 3. Conflict of Interest form for each
                 investigator (including Medical Monitor)

Table 3. Current ANC nursing research protocols of the
Joint Combat Casualty Team.

Protocol                                                      ANC
                                                            Research
                                                            Priority

Evaluating the presence of compassion                       High
fatigue among healthcare providers

Use of paralytic agents during helicopter                   Medium
aeromedical transport during Operation Iraqi Freedom

Perceived readiness of healthcare providers to              Medium
deliver palliative care in a combat environment

Evaluating pain management by examining documentation       High
of pain relief interventions in a combat support hospital

Evaluating hand hygiene compliance in a combat              High
support hospital

Evaluating compliance of semirecumbent head of bed          Medium
positioning in mechanically ventilated patients in
a combat support hospital

Early detection of combat operational stress                High
among deployed Soldiers

Chlorine exposure during Operation Iraqi Freedom            Low

Variables to consider in assessing deployment-related       Medium
health of combat support hospital nurses who are
unexpectedly extended

Army Nurse Corps officers' experience of nursing            High
care and a nursing care evidence-base during
deployment in support of combat operations

Medical-surgical nursing at a combat support                Medium
hospital-Operation Iraqi Freedom

A women's health intervention to decrease                   Medium
gynecologic problems in the deployed environment

Carbon monoxide exposure                                    Low

Oral care practices for the deployed military               Medium
critical care nurse in orally intubated Soldiers

Burnout: measurement in a deployed                          Medium
combat hospital setting

Compassion fatigue in nurses caring for                     High
detainees in a deployed environment

Deployment nursing research priorities                      Medium
in a mature battlefield: a Delphi study

Taking care of Iraqis: Army nurses' perception              Medium
of nursing care for host nation patients at
a combat support hospital

The use of a meditation intervention in deployed            Medium
military medical personnel to decrease stress
and anxiety and promote resilience: a pilot study

Dimensions of deployed nurses' experiences                  Medium
at a combat support hospital

Organizational properties of the self-concept:              Medium
a cognitive vulnerability to PTSD symptoms in
deployed military nursing personnel exposed to
combat-related trauma and stressors

Factors related to healthcare delivery among                High
US military medical personnel at
3 different hospitals

Trauma team healthcare culture at Craig                     Low
Joint Theater Hospital

Arterial based and noninvasive functional                   Medium
hemodynamic indices in combat trauma resuscitation

Sleep disturbance in deployed Soldiers                      Medium

Use of NIRS [S.sub.1][O.sub.2] to detect occult             Medium
hypoperfusion under field conditions

Military women's health and illness behaviors               Medium
in deployed settings

Iron status of deployed military members                    Low

Use of N.O. Xplode by service members                       Low
deployed in support of Operation Enduring Freedom

Interpersonal safety of US military women in the            Medium
deployed environment of Bagram,
Afghanistan: a grounded theory approach

US military nurses in Afghanistan: anticipatory             High
concerns about returning home

Descriptive analysis of resuscitation and early             High
clinical outcomes as a function of aeromedical
platform in Afghanistan

The immediate effects of yoga on wounded                    Medium
warriors in a deployed setting: a pilot study

Assessment of fatigue in deployed critical                  Medium
care air transport team crews

Sleep and the use of energy products                        Medium
in a combat environment

Patient safety in en route care survey                      Medium

Readiness and resilience in National                        High
Guard Soldiers project

Protocol                                                    Status

Evaluating the presence of compassion                       Closed
fatigue among healthcare providers

Use of paralytic agents during helicopter                   Closed
aeromedical transport during Operation Iraqi Freedom

Perceived readiness of healthcare providers to              Closed
deliver palliative care in a combat environment

Evaluating pain management by examining documentation       Closed
of pain relief interventions in a combat support hospital

Evaluating hand hygiene compliance in a combat              Closed
support hospital

Evaluating compliance of semirecumbent head of bed          Closed
positioning in mechanically ventilated patients in
a combat support hospital

Early detection of combat operational stress                Closed
among deployed Soldiers

Chlorine exposure during Operation Iraqi Freedom            Closed

Variables to consider in assessing deployment-related       Closed
health of combat support hospital nurses who are
unexpectedly extended

Army Nurse Corps officers' experience of nursing            Closed
care and a nursing care evidence-base during
deployment in support of combat operations

Medical-surgical nursing at a combat support                Closed
hospital-Operation Iraqi Freedom

A women's health intervention to decrease                   Closed
gynecologic problems in the deployed environment

Carbon monoxide exposure                                    Closed

Oral care practices for the deployed military               Closed
critical care nurse in orally intubated Soldiers

Burnout: measurement in a deployed                          Closed
combat hospital setting

Compassion fatigue in nurses caring for                     Closed
detainees in a deployed environment

Deployment nursing research priorities                      Closed
in a mature battlefield: a Delphi study

Taking care of Iraqis: Army nurses' perception              Closed
of nursing care for host nation patients at
a combat support hospital

The use of a meditation intervention in deployed            Closed
military medical personnel to decrease stress
and anxiety and promote resilience: a pilot study

Dimensions of deployed nurses' experiences                  Closed
at a combat support hospital

Organizational properties of the self-concept:              Open
a cognitive vulnerability to PTSD symptoms in
deployed military nursing personnel exposed to
combat-related trauma and stressors

Factors related to healthcare delivery among                Closed
US military medical personnel at
3 different hospitals

Trauma team healthcare culture at Craig                     Closed
Joint Theater Hospital

Arterial based and noninvasive functional                   Closed
hemodynamic indices in combat trauma resuscitation

Sleep disturbance in deployed Soldiers                      Closed

Use of NIRS [S.sub.1][O.sub.2] to detect occult             Open
hypoperfusion under field conditions

Military women's health and illness behaviors               Open
in deployed settings

Iron status of deployed military members                    Open

Use of N.O. Xplode by service members                       Open
deployed in support of Operation Enduring Freedom

Interpersonal safety of US military women in the            Open
deployed environment of Bagram,

Afghanistan: a grounded theory approach

US military nurses in Afghanistan: anticipatory             Open
concerns about returning home

Descriptive analysis of resuscitation and early             Open
clinical outcomes as a function of aeromedical
platform in Afghanistan

The immediate effects of yoga on wounded                    Closed
warriors in a deployed setting: a pilot study

Assessment of fatigue in deployed critical                  Open
care air transport team crews

Sleep and the use of energy products                        Open
in a combat environment

Patient safety in en route care survey                      Open

Readiness and resilience in National                        Open
Guard Soldiers project

NIRS indicates near infrared spectroscopy.

[S.sub.1][O.sub.2] indicates skeletal muscle
tissue oxygenation.

Table 4. Topics for future protocols of combat casualty care
nursing research.

En route care provided for nurses

Critical care nurse for intratheater evacuation patient outcomes

Outcomes of evidence-based clinical practice guidelines

Combat nurse survey of required and sustained go-to-war skill sets

Hemorrhage resuscitation: nursing implications and care

Prevention, burn care implications for nursing, trauma

Trauma resuscitation: nursing implications and care

Damage control resuscitation and surgery nursing implications

Burn Flight Team: nursing care implications

Pressure ulcer prevention from point of injury to the United States

Incidence and distribution of decubitus ulcers in civilian versus
global transport of combat wounded

Complex battle wound healing

Traumatic brain injury research

Outcomes evaluation of Joint Theater Trauma Registry clinical
practice guidelines

Predeployment nursing training and preparation

Stresses of flight

Longitudinal and rehabilitation nursing outcomes

Behavioral health of the care provider and Warriors

Outcomes information that may be applicable to civilian trauma
setting and improvement of combat casualty care
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