Nurse-performed ultrasonography in combat operations: a perspective for the future?

Background In current French military operations, it is not uncommon for the military nurses (MNs) to be required to support soldiers alone in isolated areas. At a time when advanced practice nurses in the civilian sector develop extended skills, we asked MNs about their willingness to be trained in point-of-care ultrasound (POCUS). Methods We conducted a web-based survey from 1 November 2018 to 1 December 2018, including all MNs deployed in the Barkhane operation. The questionnaire, sent by e-mail, aimed to describe the willingness of MNs to be trained in POCUS. Their opinion on the usefulness of this training, the situations and ultrasound targets that seemed most protable to them were also studied. Results 30 questionnaires out of 34 were completed. On average, MNs had 7.4 years of practice and had already carried out three military operations. Three MNs reported having been trained in POCUS and six had already performed POCUS on the eld. 96% of the untrained MNs wanted to be trained. Twenty-nine (96%) MNs felt that there was added value in knowing how to perform POCUS, especially in operations and in isolated posts without a military physician (MP). Focused assessment with sonography for trauma, pleural and urinary tract ultrasound were the targets considered most useful to them, in that order. Conclusion are interested in learning POCUS. A training before their departure on mission for simple and quick acquisition targets would be easy to implement and probably for the patient, the MN and the MP.


Abstract
Background In current French military operations, it is not uncommon for the military nurses (MNs) to be required to support soldiers alone in isolated areas. At a time when advanced practice nurses in the civilian sector develop extended skills, we asked MNs about their willingness to be trained in point-of-care ultrasound (POCUS).
Methods We conducted a web-based survey from 1 November 2018 to 1 December 2018, including all MNs deployed in the Barkhane operation. The questionnaire, sent by e-mail, aimed to describe the willingness of MNs to be trained in POCUS. Their opinion on the usefulness of this training, the situations and ultrasound targets that seemed most pro table to them were also studied.
Results 30 questionnaires out of 34 were completed. On average, MNs had 7.4 years of practice and had already carried out three military operations. Three MNs reported having been trained in POCUS and six had already performed POCUS on the eld. 96% of the untrained MNs wanted to be trained. Twenty-nine (96%) MNs felt that there was added value in knowing how to perform POCUS, especially in operations and in isolated posts without a military physician (MP). Focused assessment with sonography for trauma, pleural and urinary tract ultrasound were the targets considered most useful to them, in that order.
Conclusion MNs are interested in learning POCUS. A training course before their departure on mission for simple and quick acquisition targets would be easy to implement and probably bene cial for the patient, the MN and the MP.

Background
In military operations, the French defence health service is committed to provide emergency and routine health care as close to the operations as possible.
According to the anticipated combat operation duration, intensity and time-to-medical evacuation, medical support is normally provided by a military nurse-physician pair or by a military physician alone.
In the Barkhane operation (Additional le 1), the ght against terrorist armed groups in the Sahelo-Saharan band consists mostly in deploying small ghting units in remote areas, often with combat medics and a military nurse (MN) as the only medical support.
In the absence of a military physician (MP), an advanced level three training course in tactical combat casualty care, common for the MN and MP, allows the nurse to stabilise a wounded soldier alone while waiting for the medical evacuation team. The course assures the acquisition of a high level of knowledge in traumatology and the practice of specialised medical procedures. Responses were collected either electronically by return e-mail or in paper form after printing the questionnaire. After 15 days, a reminder e-mail was sent to the medical facilities that had not responded.
After a short explanation of the study objective, the rst part of the questionnaire collected demographic data aiming to describe the MN: nursing career, years of practice, number of missions and type of position held during the current mission.
The second part of the survey was designed to nd out: Their previous clinical US training and their willingness to be trained.
Their previous clinical US practice.
Their opinion on the added value of a MN trained in US.
The US targets they considered most useful to acquire.
The presence of an US scanner in their nurse-physician pair.
The questionnaires were all anonymised by a third party who collected them. This observational study was waived from ethics board approval.

Results
Of 34 MNs surveyed, 30 completed the questionnaires. On average, they had 7.4 years of practice and had already carried out three overseas missions. Seventy-three per cent had a curriculum exclusively in military units, 10% only in military teaching hospitals and 17% in both (Table 1).  In order of importance, targets considered most useful to them were the FAST (100%), pleural (79%) and urinary tract examination (67%), followed by the venous access guidance (38%), resuscitation evaluation (20%) and lower extremity deep vein examination (20%) (Fig. 2: Useful US targets according to the MNs surveyed).
Ninety per cent of physician-nurse pairs were already equipped with US scanners in the Barkhane operation.

Discussion
The aim of the military health system on the battle eld is to preserve the ghting force in an austere, resource-scarce environment in order to accomplish the military objective. In those conditions, medical care of injured and ill soldiers is a challenging task. Moreover, their evacuation to higher level of care requires manpower, use of limited resource and risk of injury or death to those involved in transporting the patient. Thus, any information that can be gleaned as close to the initial point of injury is critical in accomplishing the mission, conserving resources and preserving the ghting force.
A portable US scanner that ts in a backpack is a precious imaging modality which provides critical information, guiding diagnostic and therapeutic decisions as well as medical evacuation priorities.
The majority of MNs surveyed recognise the usefulness of US in isolated posts and would like to be trained to improve the management of their patients in deteriorated situations. Twenty per cent have already performed US examinations after learning it from the MPs they work with in metropolitan France and in foreign operations. They do not wish to become sonographers, but rather carry out certain targeted examinations after dedicated training and act within the framework of protocols. Given the accessibility of US scanners in foreign operations, training our MNs is a serious path we need to explore.
The FAST examination is recognised as the most useful target the nurses surveyed wanted to acquire.
The basic examination includes the upper right and left abdomen, cardiac and pelvic views. This rst line imaging assesses for intra-thoracic and intra-abdominal traumatic injury, providing information for guiding triage, treatment and evacuation priorities.
In a civilian setting, Bowra et al. (2) assessed the accuracy of nurse-performed FAST examination for the detection of free uid in the peritoneal cavity and pericardial space in patients brought to the emergency department following trauma after a 1-day training course and a minimum of 25 supervised validated scans. The results are encouraging, with an overall accuracy of 95%, similar to physician performance. In a military setting, Monti et al. (3) showed that a 4-hour introductory e-FAST training intervention among ultrasound-naïve U.S. military medics allows them to perform as well as previously trained emergency medicine physicians.
The pleural US examination considered as secondary target by the MNs presents a real added value in the noisy environment of a battle eld where physical examination is limited and X-ray often unavailable, in order to provide an early diagnosis of a tension pneumothorax and/or hemothorax. In various civilian and military studies, the ability of non-physicians to perform and interpret pleural US examination shows high level of sensitivity and speci city (4-6).
Renal US examination, venous access guidance, resuscitation evaluation and lower extremity deep vein examination are of interest in the diagnosis of pathologies caused by the operational constraints (dehydration and kidney stones linked to the hot desert climate, hypovolemia and intravascular volume evaluation to guide uid resuscitation in trauma related or medical pathologies, prolonged sitting in the convoys and thrombosis). As for the FAST and pleural examination, evidence from the available studies point out the ability and accuracy of non-physicians to perform speci c US examinations (7)(8)(9)(10) Figure 1 Added value situations for MN-performed POCUS.