War at Sea: Burn Care Challenges—Past, Present and Future

Round 1

Reviewer 1 Report

This is an interesting review of the history of naval burn injuries. One significant criticism is that they rely too much on secondary references. For instance references 1 and 2 are both reviews written this year. More effort to find original documents would add credibility to their manuscript.

In general this just reads as an reenumeration of events (that are probably documented in other references that they have cited) rather than a comprehensive analysis about how we have learned from sequential naval fires etc. Much of the narrative is very superficial without critical assessment. For instance  it is disappointing that  details about the 40 sailors and 23 civilians injured in the Bonhomme Richard explosion are so brief. What happened to these individuals? return to service? Disabled? Where were they triaged - local civilian facilities? Burn Centers? This relates to each of the narratives about victims of other conflagrations as well. It would be especially useful to outline the transition of care that these individuals receive. Did MMAMC deploy air evactuation? Were they treated by field medics? Did they require transfer to Landstuhl Regional Medical Center. This is the type of information that would be especially interesting to this burn specialty audience.

Sections 6.1/.2 and .3 (The good the Bad and the Ugly) begin to undertake what I have suggested is needed throughout the entire manuscript. Perhaps integrating their SWOT assessments into each section or alternatively utilizing the specific catastrophic events to highlight their opinions about the strengths and weaknesses of naval combat casualty care would strengthen their paper. 

They emphasize large life threatening burns that require resuscitation but they could also address the many small burns sustained on ships that relate to cooking at sea for instance. Or smoking. They may be small burns but may render sailors disabled due to location of burn etc.

Since this is a review article for the civilian medical audience - an international one at that they should better define the Tactical combat Casualty principles rather than just citing a reference - perhaps a table summarizing the . It seems critical to the readers understanding of naval responses. As such Figure 3 is the most valuable takeaway from the entire paper.

They repeatedly cite limited freeze dried plasma access as a problem for resuscitation at sea but they should provide more evidence that plasma resuscitation is optimal since it is still under investigation as a feasible and safe intervention.

Author Response

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Author Response File: Author Response.pdf

Reviewer 2 Report

The authors have completed a thorough, comprehensive review of burn casualties at sea, from the age of sail through modern conflicts.  They also include recommendations for manning, training, and equipping forces for near-future conflicts given predicted casualty patterns.  The manuscript is well-written and direct.  It is relevant to both military and non-military providers, as burns sustained at sea are by no means limited to times of war or ships of war.  To make the article perhaps more relevant and readable for a broader population, I have some questions and suggestions.  Minor editing suggestions are flagged in the following list as “MINOR EDITING.”

11.       MINOR EDITING: Consider moving the first sentence of page 1, lines 44-47, to the first paragraph of the Introduction.  [While medical care, especially burn care, is not its primary purpose of the warship, it becomes a priority once a casualty producing event occurs.  In addition, the risk of thermal… remains an ever-present threat.] The paragraph discussing the Walker Dip could then have a more direct opening sentence.

22.       Military jargon and acronyms are often well-defined immediately after their introduction, but not always.  This risks alienating some readers if even basic terms are not immediately explained.  Examples include: “orlop deck” referring to the lowest deck on a multi-deck sailing ship (page 2, line 61); “flash gear” (page 2, line 85) which is not really explained until later in the manuscript; “damage control” (page 3, line 120) – while readily recognized in surgical literature, exactly what maneuvers comprise damage control on a naval vessel are not defined, and the Ten Commandments of DC do not actually define the term, either; “amphibious assault ships” (line 165); “DMO” and “MDO” (see item #8 below).

33.       Casualty flows during general quarters on ships can be extremely difficult.  While this is mentioned on page 4, lines 137-140, I suggest expanding a description of the DC Center and how “safe routes” are created, including how the DC efforts are prioritized and patient movement is secondary.  This section could also include a brief overview of conditions on a ship during GQ and how litter bearers must transit hatches, ladder-wells, scuttles, etc, further slowing movement.

44.       MINOR EDITING: Consider changing “electrocution” to “electrical injuries” for additional precision (page 4, line 179)

55.       MINOR EDITING: In all tables referring to mortality, please include a caption or other footnote indicating that the % refers to mortality among casualties as opposed to the total n of the crew

66.       MINOR EDITING: The subtitle preceding “The Falklands War” should be “4.3” (page 7, line 262).

77.       Page 7, lines 265-266 refer to medical providers preparing for an Indo-Pacific conflict, but this concept has not been previously introduced.  The reasoning behind the statement does not appear until section 5.2 (line 307), and medical providers are constantly preparing for a wide range of contingency and LSC operations.

88.       Section 5.1 (line 291) is factually accurate but not related to the material of the paper until a mention the following page: “During current and future contested DMO, rapid medical evacuation is unlikely to be available.” (lines 354-355).  Section 5.1 should be reworked to explain the term MDO (not currently defined) and how DMO differs from previous force distributions.  The phrase “geographically distributed but integrated through an architecture of new and developing technologies to synchronize operations across all domains” (line 296), while adequate to explain DMO in military doctrinal terms, will not convey an adequate explanation to non-military readers.  The geographic dispersion of DMO should then be explicitly linked to the increased need for PCC (including a definition) and reliance on ERC teams.

99.       MINOR EDITING: Consider moving the RIMPAC 2022 burn patient description (lines 332-360) into a separate section preceding Section 6: Preparing for a Future War at Sea.

110.   Figure 3 (ADVISOR) appears low resolution quality, enough to interfere with legibility on the draft copy I was provided.

111.   Section 6.3 “The Ugly” is immediately followed (page 12, line 415) by “A provider unique to naval service is the Independent Duty Corpsman (IDC)…”  The optics alone are suboptimal.  The entire first paragraph is only two sentences and should be re-worked for clarity, perhaps after an introductory paragraph outlining the points being made by the section: training, resuscitative fluids, ERC, and triage.  Additionally, IDCs do receive burn care training, including cadaver-based training on fasciotomies and burn resuscitation didactics.  Whether this adequately prepares IDCs for prolonged care of multiple burn casualties is unlikely, but should be offered as an opinion.  The remainder of this Section is quite long, with no additional subtitles.  Potential sub-headings could include: Role 1, Role 2, resuscitation, ERC, triage.

a.       Consider moving the paragraph about crystalloid fluids (423-429) to Section 6.2, as they are available on all ships but could be improved/re-distributed.  This may help balance the sections, as well.

b.       Lines 492-501 similarly appear slightly beyond the scope of this article.  This discusses data regarding concomitant traumatic and burn injuries, which is likely assumed by all burn surgeons and could be shortened to a single sentence recognizing that burns often do not occur in isolation.

c.       Remove the paragraph describing radiation.  If the authors believe radiation deserves mention, a new section encompassing chemical burns would then necessitate inclusion.

d.       Triage, discussed in lines 530-540, deserves separation from the rest of the section.  Triage of large numbers of burn casualties in LSCO will present a significant deviation from current military instruction, and perhaps a total reversal of routine civilian triage practices.  I would request more specifics in this paragraph, including an example of unclassified casualty estimates from single ship classes vs the providers aboard those ships, perhaps in table format if the authors agree.  This triage section may also fit better in the Recommendations portion (Section 7) due to the number of recommendations made in the paragraph.

112.   The recommendation of a rotary wing physician-led critical care team appears twice (lines 484-488 and 552-553).  Rotary-based assets depend on air superiority and relatively short transits, neither of which can be expected in a theater such as the Indo-Pacific.  A comment should be included regarding this limitation.

Author Response

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Author Response File: Author Response.pdf

Reviewer 3 Report

In the manuscript “War at Sea: Burn Care Challenges – Past, Present and Future” investigators review medical, training and logistical challenges to burns sustained on ships. The context of wartime burns and logistical constraints is great and a perfect fit for this special issue. Largely, the authors present logical and well written content with historical context and should be congratulated. Some things to consider are given here:

-          The overall theme of learning from past experiences to better prepare for future LSCO is warranted; however, also warranted is a short conversation on burn care with resource limitations, which has been discussed previously, and referring to these types of reviews are warranted. For example, there is a growing body of knowledge from animal models about the effects of enteral resuscitation on burn pathophysiology, and even the possibility of rectally infused fluids. As it stands, this is only referred to superficially on line 429 to only mention that this strategy can be used. No discussion of how, why, or with what is included, and this subject should be explored more thoroughly.

-          Are the authors proposing to use whole blood for acute burn resuscitation? That would be against current doctrine, and this point should be clarified (i.e., use during excision surgeries) or provide references to its use. If mentioned for hemorrhagic shock, this should be clarified and deemphasized since this is manuscript is focused on burns.

-          The discussion on FDP is great- the authors may also want to consider current efforts to examine albumin (e.g., ABRUPT).

-          Box 2 could use some details- for example, authors may want to mention or give a reference to the Rule of 10s as a simple way to calculate fluid needs.

-          There is sometimes too much emphasis given to other injuries- for example, the discussion on casualties during WWII indicates the most common cause of death was penetrating wounds- this does not say much about burns, and should only be mentioned in the context of combined injury.

-          Similarly- is anything known about how many of the ~50% of injured service members on attacked ships were burned? The percentages of other casualties receiving fractures, TBI, etc. are not as pertinent, meaning Table 3 is not of general interest to burn providers.

-          The first paragraph of section 5 is a prime example of the extensive amount of abbreviations used. Some of these are used more than others, so I would consider how vital certain ones are and, at minimum, provide an abbreviations list. Another extreme example is medical emergency response team (MERT), which is abbreviated, but never used again.

-          Minor comments:

o   “apparently” in line 240 seems unnecessary

o   Figure 3 is fairly blurry in current form.

Author Response

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Author Response File: Author Response.pdf

Round 2

Reviewer 1 Report

The authors have addressed previous concerns sufficiently - though not completely. My only recommendation at this point is that their response about use of colloids was probably too long and detailed - especially since they conclude that ' high-quality data is needed to definitively answer the question regarding which colloid (plasma or albumin) should be utilized in acute burn resuscitation.'

Author Response

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Author Response File: Author Response.pdf