OBJECTIVES: A significant proportion of patients with coronavirus disease 2019 requiring venovenous extracorporeal membrane oxygenation at our institution demonstrated heparin resistance, which in combination with a heparin shortage resulted in the transition to argatroban with or without aspirin as an alternative anticoagulation strategy. The optimal anticoagulation strategy for coronavirus disease 2019 patients requiring venovenous extracorporeal membrane oxygenation is unknown, and therefore, we sought to evaluate the efficacy and safety of argatroban with or without aspirin as an alternative anticoagulation strategy in this patient population. DESIGN: Retrospective cohort. SETTING: Single-center tertiary-care facility in Fort Sam Houston, TX, from 2020 to 2021. PATIENTS: Twenty-four patients who were cannulated for venovenous extracorporeal membrane oxygenation due to respiratory failure secondary to coronavirus disease 2019. INTERVENTIONS: Argatroban, with or without aspirin, was substituted for heparin in coronavirus disease 2019 patients requiring venovenous extracorporeal membrane oxygenation. MEASUREMENTS AND MAIN RESULTS: Eighty percent of our coronavirus disease 2019 patients requiring venovenous extracorporeal membrane oxygenation demonstrated heparin resistance, and patients who were initially started on heparin were significantly more likely to require a change to argatroban than vice versa due to difficulty achieving or maintaining therapeutic anticoagulation goals (93.4% vs 11.1%; p < 0.0001). The time to reach the therapeutic anticoagulation goal was significantly longer for patients who were initially started on heparin in comparison with argatroban (24 vs 6 hr; p = 0.0173). Bleeding and thrombotic complications were not significantly different between the two cohorts. CONCLUSIONS: Argatroban, with or without aspirin, is an effective anticoagulation strategy for patients who require venovenous extracorporeal membrane oxygenation support secondary to coronavirus disease 2019. In comparison with heparin, this anticoagulation strategy was not associated with a significant difference in bleeding or thrombotic complications, and was associated with a significantly decreased time to therapeutic anticoagulation goal, likely as a result of high rates of heparin resistance observed in this patient population.

Internal medicine residents across all post-graduate year (PGY) levels at our institution lacked confidence to independently perform core internal medicine procedures. Utilizing simulation-based medical education as an adjunct to clinical training is well accepted by internal medicine trainees, and resulted in significantly improved procedural confidence. This intervention was well received by trainees and could feasibly be replicated at other active-duty military internal medicine residency programs to assist with readiness. Research is currently in progress to correlate in-situ competency and evaluate clinical outcomes of this improved confidence.

Treatment of patients with severe burn injuries is complex, relying on attentive fluid resuscitation, successful management of concomitant injuries, prompt wound assessment and closure, early rehabilitation, and compassionate psychosocial care. The goal of fluid resuscitation is to maintain organ perfusion at the lowest possible physiologic cost. This requires careful, hourly titration of the infusion rate to meet individual patient needs, and no more; the risks of over-resuscitation, such as compartment syndromes, are numerous and life-threatening. Recognizing runaway resuscitations and understanding how to employ adjuncts to crystalloid resuscitation are paramount to preventing morbidity and mortality. This article provides an update on fluid resuscitation techniques in burn patients, to include choosing the initial fluid infusion rate, using alternate endpoints of resuscitation, and responding to the difficult resuscitation.

INTRODUCTION: Injury represents a hazardous event that can have long-lasting consequences for both the injured individual and their community. The Social Vulnerability Index (SVI) is a measure used in emergency preparedness to identify need for resources in the event of a disaster or hazardous event, ranking each census tract on 15 demographic/social factors. To inform clinical decision-making for trauma patients, we sought to evaluate SVI as a predictor of long-term trauma outcomes.METHODS: Moderate-severely injured patients (ISS 9) treated at one of three level-1 trauma centers were asked to complete a phone-based survey to assess outcomes 6-12 months post-injury. These data were matched at the census tract level with overall SVI and with the four SVI themes of socioeconomic status, household composition & disability, minority status & language, and housing type & transportation. Multivariable adjusted regression models were used to assess whether SVI factors were associated with long-term outcomes after injury.RESULTS: A total of 3,153 patients were included [54% male, mean age 61.6 (SD¼ 21.6) and mean ISS 14.2 (SD¼ 7.4)]. The median overall SVI percentile rank was 35 th (IQR: 16 th -65 th ) with higher values indicating greater community vulnerability. After adjusting for confounders, higher SVI rankings were associated with worse long-term outcomes. CONCLUSION:The SVI has potential utility in predicting individuals at higher risk for adverse long-term outcomes after injury. This measure may be a useful needs assessment tool for clinicians and researchers in identifying communities that may benefit most from targeted intervention and prevention efforts.

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Introduction Military internist and internal medicine (IM) subspecialist physicians must be prepared to function in both traditional inpatient and outpatient settings, as well as manage critically ill patients within a deployed austere environment. As many critical care procedures are not performed on a routine basis in general IM practice, many active duty IM physicians experience skills degradation and lack confidence in performing these procedures. In order to address this perceived deficiency, the U.S. Army and Air Force Internal Medicine Education and Skills Validation Course was developed to provide essential training in critical care procedures for active duty military IM physicians and subspecialists. Materials and Methods Staff internist and subspecialist physicians at multiple military treatment facilities participated in a 2-day simulation-based training course in critical care procedures included in the Army Individual Critical Task Lists and the Air Force Comprehensive Medical Readiness Program. Educational content included high-yield didactic lectures, multi-disciplinary Advanced Cardiac Life Support/Advanced Trauma Life Support high-fidelity simulation scenarios, and competency training/validation in various bedside procedures, including central venous and arterial line placement, trauma-focused ultrasound exam, airway management and endotracheal intubation, chest tube thoracotomy, and mechanical ventilation, among others. Results A total of 87 staff IM physicians participated in the course with an average of 2–4 years of experience following completion of graduate medical education. Upon course completion, all participants successfully achieved rigorous, checklist-based, standardized validation in all the required procedures. Survey data indicated a significant improvement in overall skills confidence, with 100% of participants indicating improvement in their ability to function independently as deployed medical officers. Conclusions Broad implementation of this program at military hospitals would improve pre-deployment critical care procedural readiness in military IM physicians.

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