The aim of the military health system on the battlefield is to preserve the fighting 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 fighting force.
A portable US scanner that fits 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 first 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 fluid 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 battlefield 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 specificity (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 fluid 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 specific US examinations (7–10).
Morgan et al. (11) showed that US examinations can be implemented in a deployment environment. Twenty-nine special forces medical sergeants performed 109 US examinations in a 1-year deployment period after an average of 16.7 hours didactic training and 8 to 52 hours of practical training over 2 years. That encouraging experience led the U.S. military physicians to develop a 24 hours curriculum of didactic and hands-on US training for special operations medics: The Special Operator Level Clinical Ultrasound (SOLCUS).
Similarly, we can expect our MNs to perform reliable US examinations after a brief training course. Several curricula should be assessed to introduce this skill.
Brief US theoretical training and practical examinations under the supervision of experienced physicians could be included in military nursing studies. Cazes et al. (12) assessed the number of US examinations required to perform reliable diagnosis on 10 novice military generalist practitioners without previous experience during their residency. After 2 hours of theoretical training, a minimum of 30 FAST and 20 pleural examinations were sufficient to assure optimal performance.
We also need to consider adapting and opening the complementary course on tactical US for MNs during their level three tactical combat casualty care training to ensure acquisition of quick and practical US targets. It could be a step towards the training of an upskilled workforce qualified in advanced practice, even though this new concept requires further work to define their operational role within military prehospital care (13).