COMMENTARY

MILITARY MEDICINE, 186, 5/6:123, 2021

Prolonged Field Care Research Approach and Its Relevance

to Civilian Medicine

Downloaded from https://academic.oup.com/milmed/article/186/5-6/123/5917413 by guest on 04 September 2022

Adam B. Cohen, MD*,†; COL Michael Davis, MD, USA‡; Sarah E. M. Herman, PhD*

ABSTRACT In early March 2020, Johns Hopkins University Applied Physics Lab hosted an Association of Mili-
tary Surgeons of the United States regional conference to address medical demands of the future battlefield for which
prolonged field care is expected. Arising from this conference, we propose here an approach to prolonged field care
research—and also summarize the major concepts discussed at the conference. We draw parallels to prolonged field care
investments and advancements that apply beyond the combat environment. The exceedingly daunting medical challenges
of the future battlefield, on land and at sea, must be addressed to maintain an effective force able to compete with modern
highly capable adversaries. Since the human element, and its health, will allow future mission success, we propose here
an approach to making soldier health-related research most impactful.

INTRODUCTION to hours of injury. Soldiers equipped with Tactical Combat

The conference focused on medical technology; however,
other components will be needed to optimize prolonged field
care, including doctrine, organization, training, materiel,
leadership, education, personnel, and facilities. The confer-
ence aimed to highlight prolonged field care gaps—and req-
uisite areas of innovation to address the gaps across the array
of expected combat-related injuries and illnesses (Table I).
The speakers and panelists (Table II) spanned military and
academic research, technology, operational, and research
domains.
Prolonged field care refers to “field medical care, applied
beyond ‘doctrinal planning time-lines’ by a Special Opera-
tions Combat Medic or higher, in order to decrease patient
mortality and morbidity. Utilizes limited resources, and is
sustained until the patient arrives at an appropriate level of
care.”1 It is a state of care in which the patient remains in the
field beyond the time when capabilities to evacuate and care
for the patient are severely limited. Recent battlefield medi-
cal evacuations are typically rapid, occurring within minutes
* National Health Mission Area, Asymmetric Operations Sector,
The Johns Hopkins University Applied Physics Laboratory, Laurel,
MD, 20723, USA
† Department of Neurology, Johns Hopkins Hospital, Baltimore,
MD, 21287, USA
‡ U.S. Army Medical Research & Development Command, Frederick,
MD, 21702
The views expressed are solely those of the authors and do not reflect the
official policy or position of the Johns Hopkins University, U.S. Army, U.S.
Navy, U.S. Air Force, the Department of Defense, or the U.S. Government.
doi:10.1093/milmed/usaa352
© The Association of Military Surgeons of the United States 2020.
All rights reserved. For permissions, please e-mail: journals.
permissions@oup.com.
Casualty Care (TCCC)2 skills can manage common casualty
conditions during this typical field care window. They pro-
vide immediate lifesaving care while temporarily stabilizing
the patient until evacuation to equipped care facilities that pro-
vide more definitive care. Denied or unavailable evacuation
typically results in a prolonged field care scenario. In that
situation, the patient’s clinical condition demands capabili-
ties unavailable in the field, thereby increasing morbidity and
mortality risk.
The evolution of civilian care from the hospital and clinic
toward the patient draws important parallels to prolonged field
combat care, which aims to bring effective care closer to the
solider. Such parallels must be recognized in order to identify
areas of overlap whereby innovation and research investments
in one domain will benefit the other. For the military, in par-
ticular, civilian and industry interest may be required in order
to garner the degree of investment and resources needed to
sustain desired innovations.
Although much of U.S. civilian medicine occurs in well-
resourced settings, much does not. Further, with rapid
advancements in digital and mobile health, in concert with
other aspects of health technology, medicine will increasingly
move toward patients in their own settings, progressively out-
side hospitals and clinics. Such advancements offer patients,
families, and available providers more capability to manage
health. For example, the coronavirus pandemic produced sce-
narios in which patients and clinicians required support that
could not be delivered within the current healthcare paradigm.
Capability brought to the forward environment, via new meth-
ods and modes of communication, for example, have been
necessary.

MILITARY MEDICINE, Vol. 186, May/June 2021 123

 Prolonged Field Care Research

TABLE I. Example Combat Casualty Conditions: Past, Current, and Future Battlefields

Abdominal trauma Musculoskeletal injury

Airway compromise Nerve injury

Burn Ocular and optic nerve trauma
Complex chest trauma Pain
Complex extremity trauma Pelvic and genitourinary trauma
Directed energy weapon injuries Pneumothorax
Environmental exposure (e.g., Arctic, subterranean, prolonged sea) Sleep disorders
Hearing loss and tinnitus Spinal cord trauma
Hemorrhage Spine injury
Infection Toxic exposure

Downloaded from https://academic.oup.com/milmed/article/186/5-6/123/5917413 by guest on 04 September 2022

Maxillofacial trauma Traumatic brain injury
Mental health conditions Wounds

TABLE II. Speakers and Panelists From the AMSUS Regional Conference on Prolonged Field Care Technology Needs, Listed in Order
of Presentations

Speaker/panelist Affiliation

Brigadier General (retired) John Cho
Adam Cohen, MD
Colonel Mike Davis, MD
Colonel Stacy Shakleford, MD
Sarah Herman, PhD
Brian Telfer, PhD
Colonel Vikhyat Bebarta, MD
Colonel (retired) Ronald Poropatich, MD
Scott Gearhart
Colonel Jerome Buller, MD
Colonel Robert O’Connell, MD
Lieutenant Colonel Sean Hipp, MD
Kathy Berst
Association of Military Surgeons of the USA
The Johns Hopkins University Applied Physics Laboratory
U.S. Army Medical Research and Development Command, Combat Casualty Care Research Program
Joint Trauma System
The Johns Hopkins University Applied Physics Laboratory
Massachusetts Institute of Technology Lincoln Laboratory
Colorado University Anschutz Center for Combat Medicine and Battlefield (COMBAT) Research
University of Pittsburgh Center for Military Medicine Research
The Johns Hopkins University Applied Physics Laboratory
U.S. Army Institute of Surgical Research
Walter Reed Army Institute of Research
U.S. Army Medical Department Brooke Army Medical Center
Defense Health Agency

In varied military and civilian scenarios, patient needs
may exceed available capabilities—because of limited skills,
experts, or resources. Researches to develop new technolo-
gies to improve care across these domains require similar
approaches.
The future battlefield is projected to be different than
what was experienced in prior conflicts because of a rapidly
changing adversary. Our future military will less likely face
small, disorganized armies in rural settings. It will more likely
face large, well-organized, and well-resourced armies in both
remote and congested urban settings or new environments,
such as extreme cold, subterranean domains, and prolonged
maritime engagements.3 In addition to contested air superi-
ority, the combat zone may be different in other ways, as
well. There may be evolving and highly mobile battlefields,
dispersed operations, large casualty volumes (e.g., > 10,000
over 60 days), more lethal weapons producing new injury
patterns such as those from directed energy, disrupted com-
munications, highly challenging logistics and resupply issues,
and more rapid attrition and movement of medical assets.4
This perfect storm of challenges will extend field care from
the current duration of hours to a future period of days, indi-
cating a need for a paradigm shift for combat casualty care
strategy.
CURRENT PRACTICE AND IMPLICATIONS FOR
PROLONGED FIELD CARE
Tactical Combat Casualty Care, first introduced in the 1990s
by U.S. Special Operations Command, refers to a standard
of care for prehospital battlefield medicine.5 The provider is
typically a field medic or a casualty “buddy.” Conditions span
common forms of combat-related injury and illness, includ-
ing compressible and noncompressible hemorrhage, loss of
airway, tension pneumothorax, and burn, some of which
represent causes of potentially survivable death.6
In the field, available resources include the provider’s
skills, acquired through training, experience, and review of
the TCCC Guideline2 and the limited number of medical
supplies able to fit into a medical backpack. Depending on
telecommunications availability, remote experts may also
assist by telemedicine.
Prolonged field care data remain scarce since medical doc-
umentation and other forms of data capture during combat
and transport are limited or absent. To address this, DeS-
oucy and colleagues collected recall-based surveys on 54 such
experiences occurring between 2001 and 2016.7 In that study,
prolonged field care referred to care delivered on the battle-
field (role-of-care 1) or prehospital environment that lasted

124 MILITARY MEDICINE, Vol. 186, May/June 2021

 Prolonged Field Care Research
longer than 4 hours and required evacuation of the patient to
a higher level of care.
Most prolonged field care (74%) was provided outdoors
or in hardened nonmedical structures. Cases were comprised
mainly of life-threatening injury or illness (67%). Fifteen
percent had limb or eyesight-threatening problems. There
was an even distribution of battle injuries (32%), nonbattle
injuries (33%), and medical illness (35%). Most cases (70%)
were attended by Air Force Special Operations Pararescue-
men, Special Forces Medical Sergeants, or Special Operations
Independent Duty Corpsmen. A physician was on the scene
24% of the time and teleconsultation occurred in 15% of
cases (typically by a remote surgeon) so 39% of patients had
physician consultation.
Potential gaps identified by the providers and authors in
this case series included contingency planning for medic
incapacitation, inadequate documentation (e.g., tourniquet
placement time), TCCC training (e.g., tourniquet conversion,
patient hygiene, pain medicine protocols), medical evacuation
planning and rehearsals, knowledge of in-country medical
assets, equipment shortfalls (e.g., oxygen concentrator, mon-
itors, blood products, intravenous fluids, field laboratory, or
ultrasound), and lacking teleconsultation.
PLANNING FOR FUTURE BATTLEFIELD AND
RESOURCE-CONSTRAINED MEDICINE
Best available care typically requires the delivery of patients
to capabilities housed within a medical facility. At the facility,
the full complement of resources, including trained medical
staff paired with ample equipment, some of which are bulky
and immobile, can easily deliver high-level care.
The prolonged field care setting, which by definition does
not allow casualty delivery to hospitals, requires capabilities
to be delivered to the patient. Thus, the major gaps in care and
research center on recreating hospital-like capabilities in the
field. Since most current hospital capabilities are impractical
for the field, the major innovations must replace or match tra-
ditional capabilities but with much smaller footprints and less
logistical burden.
Two additional driving features of the future prolonged
field care setting generate requirements. The first is the lack
of necessary medical personnel, who may be either physi-
cally or virtually unavailable. The second is the expectation
of mass casualties. With either challenge present, the avail-
able medical resources become overwhelmed and acceptable
alternatives must be fast, pervasive, and with some level of
automation. In essence, the great challenge is to provide effec-
tive care without doctors or traditional medical equipment.
Improving clinical outcomes in future battlefield casu-
alties, with the above challenges and constraints in mind,
depends on thoughtful planning now. Five tenets of planning
(Fig. 1) will maximize success.
First, determine and prioritize the specific problems to
be solved. There will be differences between the battlefield
medical problems of today and tomorrow. The future bat-
tlefield will see not only the medical problems we currently
MILITARY MEDICINE, Vol. 186, May/June 2021
face, but those related to emerging threats such as preci-
sion weapons, nuclear and nonnuclear strategic weapons, and
directed energy weapons, as well as new environments such
as dense urban, arctic, subterranean, and prolonged maritime
environments. It will also likely see the cascade of events and
complications that ensue not over hours, but over days from
the initial injury. Previously benign or mundane injuries, such
as varied types of musculoskeletal conditions, which could be
easily managed under historical settings, will draw more on-
site resources, potentially evolve into more grave conditions,
and adversely affect mission success. Further, a clinical cas-
Downloaded from https://academic.oup.com/milmed/article/186/5-6/123/5917413 by guest on 04 September 2022
cade may ensue, which would have been previously averted
or managed at higher echelons of care. Thus, modeling
clinical natural histories will reveal what needs to be pre-
vented or addressed in a prolonged care setting. The goal is to
identify what capabilities are most critical to push forward
into the future prolonged field care setting.
Because resources are limited, a constructive approach
identifies priorities, and what will not be pursued. A prior-
itization methodology should capture the importance of the
problems, but also the feasibility of solving them, cost, and
relevance to civilian matters. This latter military-civilian com-
ponent favors pursuits with industry interest, which makes the
solution more likely to last. Much of the ongoing innovation
in civilian healthcare, including that related to coronavirus
disease of 2019, also aims to bring care closer to the patient.
Thus, prolonged field combat care may draw from the inno-
vations with civilian and vice versa. These include advance-
ments toward autonomous care, reduction in care blind spots
(e.g., at home between clinical encounters), early interven-
tion, and empowerment of lower skilled providers or patients
themselves. Most of the sensors, artificial intelligence, and
other ingredients needed in the civilian sector are also required
with envisioned prolonged field care technologies.
Second, identify the clinical gaps by determining the spe-
cific concepts of operations in which the clinical problems are
being addressed. The gaps relevant to the hyperacute phase
of field care when physicians are unavailable include clinical
situational unawareness, diagnostic disability, limited equip-
ment, and limited expertise to perform procedures. These gaps
greatly differ from those applicable to other concepts of opera-
tions like the subacute phase of care in a fully staffed hospital.
Thus, the specific setting, available resources, and goal must
be understood in order to identify the clinical gaps and narrow
the research pursuits.
There are many clinical gaps and potential operational con-
cepts related to noncompressible hemorrhage, for example.
Research could explore new biomarkers to assess physiologi-
cal impact, new blood production methods or oxygen-delivery
fluids, automated means to collect vital signs, and an end-
less list of other potentially important and useful avenues.
To maximize impact, a directed approach isolates a high-
priority clinical gap, such as obtaining vascular access, for a
specific operational concept, such as for hyperacute manage-
ment by an inexperienced medic caring for many casualties
simultaneously. Then, research options are considered only
125
 Prolonged Field Care Research
FIGURE 1. Proposed approach to prolonged field care research. Steps 2 to 5 rely on successful output of prior steps.
against this specific gap and operational concept instead of
all potential clinical gaps and operational concepts related to
noncompressible hemorrhage.
Third, identify the research and technology development
gaps for which gap closure will address the specific chal-
lenge within an operational concept. For the aforementioned
hemorrhage example, such gaps include rapid and passive
means to detect and localize hemorrhage, hemorrhage source
localization, bleeding control (if tourniquets are inadequate
or unavailable), blood volume (or a physiological equivalent)
reconstitution, and downstream ischemia and reperfusion
injury avoidance. Note that these gaps are agnostic to a
solution approach or specific type of research undertaking.
Fourth, develop a research road map such that research and
technology development gaps are placed in order to sequen-
tially tackle each challenge. The sequence is dictated by
potential dependences whereby later gaps cannot (or should
not) be addressed before earlier gaps are closed. For exam-
ple, research to establish mild traumatic brain injury objective
standards and definitions should precede research to develop
new sensors to detect mild traumatic brain injury.
For each research and technology development gap, can-
didate research options are identified and prioritized. The
complete array of potential research approaches for each gap
should be explored. Then, only the ones most likely to be use-
ful and deployed are pursued. Again, pursuing all options will
126
Downloaded from https://academic.oup.com/milmed/article/186/5-6/123/5917413 by guest on 04 September 2022
hobble the most promising ones. Without such an approach,
endless dollars will be consumed with scores of disconnected
efforts without transitioning any to impact. Note that the gap
sequencing method identifies key requisite components of a
solution early in the research and development process such
as power and size requirements, which are considered from
the start to guide research selection.
In addition to a focused research road map, a higher-level
research plan establishes how successive focused research
road maps tackle increasingly difficult problems and produce
more complex solutions. For example, the higher-level
research plan begins with no autonomy, but proceeds through
the varied levels of autonomy, ultimately to achieve a fully
autonomous system. Thus, an early set of research objectives
may aim to improve a medic’s ability to cannulate the femoral
vein using telemedicine assistance. A later set of objectives
may focus on augmenting the medic’s effectiveness through
machine assistance to identify anatomic targets with aug-
mented reality, which also helps her navigate procedural and
clinical checklists with clinical decision support algorithms.
Research objectives at the end of the plan aim to cannulate the
femoral vein without human intervention, focusing on a fully
autonomous medical system that perceives the problem (e.g.,
via on-patient sensors), diagnoses the condition, and takes
necessary actions by gathering and using appropriate tools.
In this way, the high-level research plan outlines the research
MILITARY MEDICINE, Vol. 186, May/June 2021
 Prolonged Field Care Research
FIGURE 2. Technology research pursuit areas for prolonged field care.
approach to achieve each level of autonomy whereby the first
research and technology development road map achieves a
low level of autonomy, and the later ones aim for higher levels
of autonomy.
Fifth, prioritize research undertakings that advance as
many high-priority problems (and clinical gaps) as possible.
If the problem relates to noncompressible hemorrhage, for
example, the development of a pertinent novel sensor may be
relevant to other high-priority problems such as small bone
fracture and pneumothorax. Thus, one research lane may cut
across problem spaces, potentially making it more preferable
to pursue. It is also preferable to design a research program
such that each successive research output provides real-world
use and clinical impact—instead of a program unlikely to
produce useful outputs until every related gap is closed.
The varied research pursuit areas of the prolonged field
care community were highlighted in our conference (Fig. 2).
At a basic level, the research pursuits follow the basic com-
ponents of patient care: assess, diagnose, treat, and reassess.
Each of these components, from the technology perspective,
falls into three broad categories: perceive, decide, and act
(Fig. 2).
Consider again a problem like extremity hemorrhage in
a setting without fully capable medical personnel whereby
the operational goal is a fully autonomous care system. First,
the problem must be perceived. In other words, the hemor-
rhage cannot be addressed without being recognized. Clinical
observation paired with physiological and lab data allow both
recognition of the hemorrhage and its initial complications
like hypotension and effect on patient function (e.g., cog-
nition). Second, the observer then must decide what to do.
Options include obtaining more data, gathering supplies, or
performing a clinical intervention like applying a pressure
dressing. Third, an action is taken that executes the decision.
A fully autonomous, intelligent field-based medical system
to manage acute traumatic hemorrhage is currently beyond
MILITARY MEDICINE, Vol. 186, May/June 2021
Downloaded from https://academic.oup.com/milmed/article/186/5-6/123/5917413 by guest on 04 September 2022
the horizon. Yet, the components are being developed. These
include small physiological sensors, intelligent robotics, arti-
ficial intelligence algorithms to detect clinical problems and
guide clinical actions, a standard20 architecture by which tech-
nologies interact, and computers powerful enough to store,
move, and process the data. Short of a fully autonomous
medical system, the individual components will first exist
on an earlier research road map that aims to team machines
with available onsite personnel, enhancing their capabilities
to enable effective care.
MILITARY-CIVILIAN CHALLENGES TACKLED
TOGETHER
Pertinent to prolonged battlefield care are various other
prolonged care environments. Research gaps cut across
these domains, which include wilderness care, space travel
medicine, and civilian care in remote settings or during
extended medical transport.8–12 Additionally, if material or
human resources become limited in standard civilian care set-
tings, such as during a pandemic, an effective prolonged field
care state emerges. Identifying research gaps relevant to both
prolonged battlefield and civilian care serves the interests of
both by: focusing strategy, funding, resources, investigators,
industry, and regulatory bodies.
Consider a soldier requiring urgent intubation and pro-
longed mechanical ventilation in the field whereby medi-
cal evacuation is unavailable or denied. Perhaps a medic is
available, but without intubation or mechanical ventilation
experience. His rucksack does not have an intubation kit or
ventilator. Thus, the medic needs supplies but even if on hand,
requires assistance with both intubation and managing the
ventilator.
Now consider a civilian hospital overwhelmed with
severely ill patients with coronavirus disease of 2019.13
Although anesthesiologists, critical care physicians, and high-
end medical equipment are on site, all have been consumed by
127
 Prolonged Field Care Research
the initial wave of admissions. Remaining personnel lack rel-
evant management skills and the ventilator supply is depleted.
In both scenarios, available providers need medical guid-
ance. If telemedicine is unavailable or unreliable, machine
sensing and decision assistance would be invaluable. For
ventilators, not only would low-cost, small, easy-to-use
versions be ideal in each environment, but closed-loop
autonomous machine-based control could replace skills nor-
mally contained within respiratory therapists and critical
care physicians. Recent research is exploring all such
potential solutions in the form of automated respiratory
physiology sensors, computerized clinical decision support
algorithms, artificial intelligence to guide sensing and deci-
sions, and autonomous intubation and closed-loop ventilatory
systems.14–17 Many more military-civilian overlap scenarios
exist, including mobile diagnostic imaging, and remote and
autonomous triage and management.18,19
The problems in the combat arena that require prolonged
care are analogous to those across civilian healthcare beyond
pandemics and the scenarios already outlined. Medicine is
quickly becoming increasingly digital, whereby care will
be increasingly delivered to the patient—instead of patients
being delivered to the source of care.
The trend is toward continuously more capabilities of for-
ward personnel (and patients themselves), which enables
more care to be delivered out of traditional care facilities and
less on-site expert dependency. Given the great magnitude
of resources required to tackle the challenges facing pro-
longed battlefield care, identifying and collaborating on those
that extend outside the battlefield are imperative to future
missions.
ACKNOWLEDGMENTS
The authors thank the AMSUS regional conference organizers and lead-
ers, including Susan Bachenheimer and Lori Lawrence and Dr. John Cho.
They also thank the conference speakers; Johns Hopkins University Applied
Physics Laboratory staff Sarah Toth Johnson, Theresa Myers, and Suzy
Kennedy; and U.S. Army Combat Casualty Care Research Program staff
Dr. Therese West and LTC David Johnston.
FUNDING
This effort received no grant support.
CONFLICT OF INTEREST STATEMENT
None declared.
128
REFERENCES
1. Keenan S, Riesberg JC: Prolonged field care: beyond the “golden
hour”. Wilderness Environ Med 2017; 28(2S): S135-9.
2. TCCC guidelines 2019; Available at: https://books.allogy.com/web/
tenant/8/books/b729b76a-1a34-4bf7-b76b-66bb2072b2a7/; accessed
July 10, 2020
3. Summary of the 2018 National Defense Strategy of the United States
of America; 2018. Department of Defense, Washington DC
4. Command USATAD: The U.S. Army in Multi-Domain Operations
2028; 2018. Department of Defense, Washington DC
5. Butler FK, Hagmann J, Butler EG: Tactical combat casualty care in
special operations. Mil Med 1996; 161(Suppl Chapter 1): 3-16.
6. Eastridge BJ, Mabry RL, Seguin P, et al: Death on the battlefield (2001-
Downloaded from https://academic.oup.com/milmed/article/186/5-6/123/5917413 by guest on 04 September 2022
2011) implications for the future of combat casualty care. J Trauma
Acute Care Surg 2012; 73(Suppl 6): S431-7.
7. DeSoucy E, Shackelford S, DuBose JJ, et al: Review of 54 cases of
prolonged field care. J Spec Oper Med 2017; 17(1): 121-9.
8. Thibeault C, Evans AD, Pettyjohn FS, Alves PM: AsMA medical
guidelines for air travel: in-flight medical care. Aerospace Med Hum
Perform 2015; 86(6): 572-3.
9. Stepanek J, Blue RS, Parazynski S: Space medicine in the era of
civilian spaceflight. Reply. N Engl J Med 2019; 380(11): e50.
10. Bogomolov VV, Castrucci F, Comtois J-M, et al: International space
station medical standards and certification for space flight participants.
Aviat Space Environ Med 2007; 78(12): 1162-9.
11. Scoles S: A new kind of space camp teaches the art of Martian
medicine. Available at: https://www.wired.com/story/a-new-kind-of-
space-camp-teaches-the-art-of-martian-medicine/. Published June 25,
2019; accessed May 2, 2020.
12. Langford S: The Leading Edge. Apollo Books; 2015. UWA Publish-
ing; Crawley, Western Australia
13. Grasselli G, Pesenti A, Cecconi M: Critical care utilization for the
COVID-19 outbreak in Lombardy, Italy: early experience and forecast
during an emergency response. JAMA March 2020. 323:1545-1546
14. Johannigman JA, Muskat P, Barnes S, Davis K, Branson RD:
Autonomous control of ventilation. J Trauma 2008; 64(4 Suppl):
S302-20.
15. Morris AH: Treatment algorithms and protocolized care. Curr Opin
Crit Care 2003; 9(3): 236-40.
16. Tehrani FT, Roum JH: Intelligent decision support systems for
mechanical ventilation. Artif Intell Med 2008; 44(3): 171-82.
17. Carlson JN, Das S, la Torre De F, et al: A novel artificial intelligence
system for endotracheal intubation. Prehosp Emerg Care 2016; 20(5):
667-71.
18. Vetrugno L, Bove T, Orso D, et al: Our Italian experience using lung
ultrasound for identification, grading and serial follow-up of sever-
ity of lung involvement for management of patients with COVID-19.
Echocardiography 2020; 37(4): 625-7.
19. Swaminathan S, Toro B, Wysham N, Mark N: CovidX: Remote screen-
ing, surveillance, triage, and management of novel Coronavirus. https:/
/covidx.vironix.ai. covidxvironixai
20. The Johns Hopkins Applied Physics Laboratory. April 2020. Med-
ical Device Interoperability Reference Architecture. Accessed on
September 10, 2020. https://secwww.jhuapl.edu/mdira.
MILITARY MEDICINE, Vol. 186, May/June 2021