Enhancing Critical Care Through a Military, Trauma, and Disaster Nursing Lens

Many health care professionals around the globe, including those in the civilian and military sectors, are increasingly affected by warfare, trauma, and disaster.^1–4  This special issue of Critical Care Nurse is dedicated to articles specific to military, trauma, and disaster nursing. There is considerable conceptual overlap among these nursing practices, including the following:

• Mass casualties: an influx of patients with varying degrees of injuries, requiring rapid triage and prioritization of nursing care

• High-pressure situations: stressful, chaotic environments that require health care workers to perform under pressure and make rapid clinical decisions

• Unconventional settings: nontraditional settings such as field hospitals, evacuation centers, or shelters that require health care workers to adapt to limited equipment and resources and unfamiliar environments

• Psychological trauma: exposure to human suffering and large-scale morbidity and mortality that can lead to compassion fatigue, emotional distress, and symptoms of posttraumatic stress disorder

• Finite resources: a scarcity of personnel, medical supplies, and other resources, especially in the first stages of disaster response or wartime settings, making the efficient allocation of precious resources and resourcefulness essential

We introduced the idea for this special issue during a presentation at the American Association of Critical-Care Nurses National Teaching Institute in May 2023 and began to solicit manuscripts. The flood of responses from potential authors was a clear indication that many health care professionals have been exposed to at least one of these stressful environments and that the opportunity to tell their stories resonated with them. Climate change and weather-related events are just one type of disaster that affects health care professionals and our communities, especially underserved populations, exposed workers, persons with disabilities, and vulnerable populations. Disasters, such as the Fukushima nuclear reactor accident in Japan, Hurricane Ian in Cuba and the southeastern United States, and the current health care crisis in Gaza, highlight the need for health care professionals to remain focused on disaster preparedness. We invited both civilian and military experts to share major health care–related crisis and disaster response initiatives. We hope this collection of feature articles and compelling stories will both inspire and inform the journal’s readers.

Armon et al⁵  discuss skill atrophy, which is not exclusive to military nursing. The authors describe a unique military-civilian partnership to help develop and maintain competencies by military nurses in high-risk, low-frequency skills such as intra-aortic balloon pump treatment, temporary heart pump management, and continuous renal replacement therapy, when caring for high-acuity patients.

Carpenter and colleagues³  stress that mass shooting incidents can occur in any environment, including the acute care setting. A rapid surge of both victims and surrounding hospital staff can lead to health care workers feeling “overrun.” Nursing roles during a mass shooting are similar to roles during other disasters, and the authors discuss functions specific to this type of disaster.

Hickey et al⁶  provide best practices for caring for patients with injuries from violence. Themes discovered in their integrative review include recognizing those who were exposed to intimate partner violence or child abuse, collecting forensic evidence, providing emotional support of patients and their loved ones, supporting health care professionals caring for patients with injuries from violence, preventing further violence, and caring for patients with injuries from violence and with concurrent substance use disorders. The authors highlight identification of those at risk, forensic evidence preservation, use of sexual assault nurse examiners, and the need for psychosocial and other resources.

Bhatta and colleagues⁷  discuss the challenges of providing medical care at the US Army’s Landstuhl Regional Medical Center in Landstuhl, Germany, following a mass casualty event that took place during the COVID-19 pandemic. The authors describe the high-level coordination, communication, and medical care delivered by everyone involved. This mass casualty response involved both civilian and military medical personnel from multiple countries.⁸ 

During military conflicts in Iraq and Afghanistan, the US military faced logistical challenges in providing blood transfusions to injured civilian and military personnel in remote environments. These challenges led to the adoption of low-titer O-positive whole blood (LTOWB) as a frontline resuscitation strategy. O’Hollearn et al⁸  discuss how the military’s successful experience with LTOWB demonstrated it to be a viable alternative to traditional component therapy, especially when rapid transfusion is critical. The authors describe the simplicity of LTOWB, which eliminates the need for extensive pretransfusion screening and storage of blood supplies. Inspired by the military’s success, rural hospitals across the United States have begun using LTOWB in civilian health care. Additional benefits of LTOWB include access to platelets, reduced risk of fluid overload, and exposure to fewer donors compared with administration of multiple blood components.

Flarity and colleagues⁹  discuss the importance of supporting the psychological health of military critical care nurses and ways to ensure their well-being and readiness for future combat and military disaster response. The authors describe the effectiveness of educational and peer support programs to enhance resiliency and prevent burnout. Using a stress classification tool may help identify at-risk health care workers so individuals most likely to benefit from resiliency interventions can be identified.

Agyenim-Boateng et al¹⁰  describe their experience in Sierra Leone, responding as a US team to a burn mass-casualty incident to provide care and educate the host provider team who had no previous burn care experience. The US team overcame many challenges including working with supply shortages, establishing clean environments, and adapting to cultural differences under austere conditions. Providing optimal burn care and education in the host country required cultural humility and understanding of cultural norms.

Wheeler-McAnally¹¹  tells the story of a disaster response during a hospital fire. The author, who was a novice administrator at the time of the fire, shares takeaways that may help others in similar situations avoid potential delays and negative consequences. Successful evacuation of the acute and critical care units was facilitated by frontline staff and management who were empowered to make safety decisions for their units; these decisions involved providing continuous updates to building infrastructure, establishing protocols for fire and life safety, ensuring emergency equipment training and availability, and using clear communication to reduce silos.

Although military, trauma, and disaster nursing experiences can be chaotic and stressful, potentially increasing health care providers’ risk for mental health complications, positive psychological growth can occur from these experiences. Nurses involved in military, disaster, or trauma nursing care gain valuable hands-on experience that builds upon foundational clinical practice. They may develop resilience and adaptability in high-pressure scenarios, become proficient with patient triage, increase resourcefulness, and learn rapid decision-making skills. These experiences can foster psychological growth, providing health care professionals with confidence and composure to handle future experiences. In addition, this psychological growth can enhance nurses’ professional skills, health care organizations; ability to respond to future disasters, and patient outcomes.

This special issue is dedicated to nurses, both civilian and military, who care for patients, their families, and communities in times of great need, such as during a mass casualty or disaster response. Military nurses focus their careers and training to deploy when their communities or nations face crisis, responding to everything from natural disasters to the point of injury on the battlefield. Both civilian and military nurses gain invaluable perspective when responding to a trauma, mass casualty, or disaster situation. Insights that nurses can gain from disaster and wartime experiences can lead to the following actions:

• Improve clinical practice: Nurses contribute their expertise in crisis management and improvisation to optimize clinical practice guidelines and policy.^8,10,11 

• Promote a culture of preparedness: Experienced nurses provide leadership to inspire a culture of disaster preparedness in their health care organization, make sure their teams and staff stay informed about emergency response procedures, schedule routine disaster response drills, and instill a proactive approach to risk management.^3,11 

• Inform training and education: Nurses experienced in disaster or wartime response can contribute a crucial role in developing and delivering training for the interprofessional team to build a health care workforce ready to respond to future crises and needs. The team can build realistic disaster scenarios, reinforce triage skills, and provide guidance and insight on managing the psychological impact of traumatic events.^6,7 

The articles in this issue bring awareness about some of the important and life-altering events of our time. Nurses are leading the way to make a difference in prevention, planning, treatment, and policy change, which will ultimately improve patient outcomes. We hope that you find inspiration in the collection of articles in this special issue to both inform and enhance your professional journey.