The Journal of High Threat and Austere Medicine

Submarine operations occur in one of the most austere medical environments in modern military practice. Once submerged, clinicians must provide care in a confined, isolated setting with limited diagnostic capability, finite medical supplies, and unpredictable timelines for evacuation or specialist consultation. A single medic is typically responsible for the health needs of more than fifty crew members while operating under conditions of fatigue, communication restrictions and significant operational constraints.

This editorial highlights the clinical, operational and psychological challenges associated with healthcare delivery in the submarine environment. Common presentations, such as chest pain, appendicitis, trauma and dental emergencies, carry heightened risk when definitive care may be days away. In addition, prolonged isolation, disrupted circadian rhythms and confined living conditions create ongoing mental health pressures for crew members.

Despite these complexities, submarine medicine remains poorly understood outside the submarine community. Increasing awareness of this uniquely austere clinical setting is important for ensuring that training, capability development and policy frameworks reflect the realities of healthcare delivery beneath the sea.

Background The increasing threat of intentional mass violence incidents in Australia necessitates an examination of paramedic preparedness and attitudes towards specialised response.

Aim To explore paramedic perspectives on the development of Mass Violence Paramedicine (MVP) as a sub-specialty and the readiness of ambulance services for mass violence incidents.

Method A 20 question, cross-sectional quantitative online survey was used. It was available from 1 September 2023 to 31 December 2023. Results were reported using the CROSS method. Data was analysed using thematic analysis.

Results Four main themes emerged: (1) Perceived threat and preparedness, (2) Support for specialised training, (3) Challenges in current practice, and (4) Ethical considerations of role expansion.

Conclusion Paramedics generally support the development of MVP as a sub-specialty but express concerns about organisational readiness and the ethical implications of expanded roles in high-risk scenarios.

Terrorism-related mass casualty incidents challenge conventional prehospital doctrine because clinical need, scene access and responder safety are contested simultaneously. In these incidents, the critical determinant of outcome is often not simply clinical capability, but whether casualties can be reached early enough for lifesaving interventions to occur. Tactical Emergency Casualty Care (TECC) provides a structured framework for civilian high-threat medical response by aligning treatment priorities with the operational environment and defining care by direct threat, indirect threat and evacuation phases. Current TECC guidance emphasises that civilian casualty care must be threat-adapted, dynamic and integrated with rescue and law-enforcement operations rather than treated as an extension of routine trauma practice.^1-3

This paper compares three broad approaches to medical response in civilian terrorism events: the United States model, which has strongly influenced early warm-zone care and layered hemorrhage-control practice; the United Kingdom and selected European interoperability model, which has historically placed greater emphasis on coordinated multi-agency command and structured risk management; and the Australian setting, which has robust national security guidance but a less explicit public doctrine for high-threat medical access. The central argument is that the most important comparative variable is not attack type alone, but how each system interprets and operationalises threat. That interpretation governs whether hemorrhage control, airway support, triage and extraction occur early or late and, therefore, materially affects survivability.^1,4

The paper argues that Australian preparedness would benefit from a clearer medical-response framework for terrorism and other high-threat incidents. Although Australia has strong crowded-place and counter-terrorism policy guidance, its publicly visible medical response architecture remains more fragmented than TECC-led models in the United States and less explicitly developed than post-incident learning in the United Kingdom and France. The paper concludes that Australian preparedness should evolve toward a more explicit doctrine of threat-adapted casualty access, supported by interagency training, medical after-action review, hospital surge planning and public hemorrhage-control capability.^5-7

Introduction Unconventional warfare medicine operates within the complex and covert nonpermissive environment of irregular conflict, where traditional systems of medical support are often untenable. This field encompasses medical care delivered through underground, auxiliary or guerrilla networks in denied or resource-limited settings. Despite its operational significance, unconventional warfare medicine remains poorly defined and underrepresented in the academic and policy literature. The aim of this review is to examine the existing evidence to provide an overview of what is known about unconventional warfare medicine in developed countries.

Methods This review will follow the Joanna Briggs Institute (JBI) methodology for scoping reviews. Databases, including Embase, MEDLINE, Web of Science, EBSCOhost, CINAHL, Google Scholar, JSTOR and Epistemonikos, will be searched from inception using defined descriptors and index terms related to unconventional warfare and medical support. Grey literature will also be searched using OpenGrey, Google, Bing and AI-assisted platforms to capture non-indexed materials. Two reviewers will independently conduct title, abstract and full-text screening, with a third reviewer consulted for consensus where required. Data extraction will be performed using a customised charting form and results will be presented narratively with reference to key themes, concepts and gaps in the literature

Background Prolonged on scene times for physiologically critical but logistically uncomplicated pre-hospital patients are associated with delayed access to definitive care and poorer outcomes. In volatile, uncertain, complex and ambiguous (VUCA) environments, cognitive overload, stress and workflow drift commonly produce excess scene time without clear clinical benefit.

Purpose This article outlines the conceptual development of OSCAR, a pragmatic cognitive framework designed to help pre-hospital clinicians prioritise time in critical care and progress efficiently toward definitive care in VUCA contexts.

Framework Description OSCAR (Oxygenation, Stretcher, Critical care interventions, Anticipated problems, Rotate wheels or blades) reframes the traditional “stay and play” versus “load and go” dichotomy into a structured, time-focused decision aid. It emphasises early correction of immediately life-threatening problems, rapid transfer to a controllable transport platform, selective performance of only outcome critical interventions, anticipatory preparation for deterioration, and prompt initiation of transport by road or air.

Implications OSCAR functions as a temporal and cognitive scaffold rather than a competing clinical algorithm. By externalising priorities, it reduces reliance on working memory and mitigates cognitive bias under pressure. The framework is applicable across medical and trauma presentations, road and aeromedical settings and levels of paramedic practice across diverse operational contexts.

Conclusion Embedding structured cognitive frameworks, such as OSCAR, into pre-hospital education and governance may reduce avoidable scene time, improve decision-making reliability, and support timely delivery of definitive care in high risk, resource-constrained environments.

An Australian male in his early fifties developed severe exertional heat stroke [EHS] trekking on the Kokoda Track in Papua New Guinea. The patient had been taking semaglutide (Ozempic), a glucagon-like peptide-1 receptor agonist for weight management. Initial presentation included generalised tonic-clonic seizures, altered consciousness, tachycardia, and tachypnoea in the field. Immediate creek immersion cooling was performed, as a presumptive diagnosis of EHS was made in the absence of rectal temperature measurement. The efficacy and practicality of cooling is irrespective of location and best-available attempts are a priority in EHS. Subsequent domestic then international medical evacuation was initiated due to multi-organ dysfunction after field cooling. The patient achieved complete neurological recovery without long-term sequelae. This case highlights GLP-1 agonist-induced dehydration as a modifiable risk factor for heat illness in austere trekking environments and underscores the critical importance of immediate field-based cooling and early recognition of heat stress.