FMTB-E BLK 5 ELO/TLO

Eyes are most effected by what categories of blasts?Secondary and TertiaryELO: identify the wounding effects of blast overpressure. Whats stress wave?supersonic, longitudinal pressure waves. These waves create high potential for injuries, especially in gas filled organs such as the lungs, ears and intestines.ELO: identify the wounding effects of blast overpressure. Whats Sheer wave?lower velocity transverse waves with longer duration than stress waves. These waves cause tissue in the body to move back and forth.What causes the most deaths due to overpressure?LungsWhats the most common injury due to overpressure?Perforation of the Tympanic Membrane.Whats the second common injury due to overpressure?Lung injuryLung blast PSI for the following: Possible at: 50% Possible at: Fatal at:30-40 PSI 80 PSI 200 + PSIwhat are signs and symptoms of blast lung?acute respiratory distress (dyspnea/apnea) bradycardia hypotension post-blast exposure hypoxia pneumothorax hemothorax Subcutaneous and mediastinal emphysema.Signs and symptoms of blast lung may appear in what time frame?Immediately of 24-48 hours later.Treatment for Blast Lung?Monitor the casualty for respiratory distress. oxygen, if available. fluid administration monitor the casualty for pneumothorax Do not remove impaled objects. prevent movement.Suspicion of overpressure can be increased due to what injury?Perforation of eardrumThe Tympanic Membrane can rupture at what PSI?5-15 PSISigns and symptoms of Tympanic Membrane rupture?Sudden deafness tinnitus (ringing in the ears) vertigo (dizziness) Bleeding from EarIf dirt or debris is found in the ear, what additional treatment can you provide?AntibioticsWhat blast injury is common in a indoor setting?Intestine perforationSigns and symptoms of GI overpressure injury?Pain in the Groin, Abdomen, TestesSolid organs are mostly affected in what setting?UnderwaterAll blast injuries must be referred to who?Medical OfficerELO: identify the mandatory events requiring TBI evaluation.a. Involvement in a vehicle blast event, collision, or rollover. b. Presence within 50 meters of a blast (inside or outside). c. A direct blow to the head or witnessed loss of consciousness. d. Exposure to more than one blast event (the Service member's commander shall direct a medical evaluation).What are the two categories of a TBI?Primary Brian Injury Secondary Brain InjuryWhats a primary brain injury?Direct trauma to the brain and associated structures (Contusions, hemorrhages, lacerations)Whats a secondary brain injury?The ongoing injury process from primary injury - Management of TBI is focused to limit or stop these secondary mechanisms (ICP, hypoxia, hypotension and inadequate cerebral blood flow)Describe a Mild TBI and recovery- Loss of consciousness is brief, usually a few seconds/minutes. - 90% of individuals recover within 6-8 weeksDescribe Moderate TBI and recovery- Loss of consciousness lasts from a few minutes to a few hours - Confusion lasts from days to weeks - Physical, cognitive, and/or behavioral impairments last for months or are permanent - EEG/CAT/MRI are positive for brain injuryDescribe Severe TBI and RecoveryProlonged unconscious state or coma lasts days, weeks or months - Categories include: o Coma o Vegetative State o Persistent o Minimally Responsive State o Locked-in SyndromeWhat does I.E.D stand for in regards to TBI?Injury Evaluation DistanceWhen using the IED, whats the acronym used for evaluation?H.eadache Vomiting E.ars ringing A.mnesia, Altered LOC, Loss of Consciousness D.ouble vision, dizziness S.omething doest feel right or somethings wrongWhat does a MACE Exam encompass?1. Demographics 2. Sequence of events (What happened, did you hit your head, see stars, dazed) 3. What caused it? 4. Where you wearing a helmet 5. Amnesia (events leading up to it) 6. Loss of consciousness 7. Witness loss of consciousness 8. Symptoms 9. Orientation 10. Short term memory 11. Neurogenic Screening (eyes, motor, verbal) 12. Concentration (numbers 123-321/months) 13. Long term memorySigns and symptoms of a MACE exam found?Headache Memory problems Dizziness Balance Nausea Vomiting Visual disturbances Trouble concentrating IrritabilityMax score on a MACE exam?30What are the diagnosis's of a MACE exam?No Concussion 850.0 Concussion without loss of consciousness 850.1 Concussion with loss of consciousnessWhats the time frame that a SIGACT report must be completed in?24 hoursWhat makes up a SIGACT report?a. Date of potentially concussive event. b. Type of potentially concussive event triggering evaluation. c. SIGACT number (if applicable). d. Personal identifier (e.g., DoD identification number or Battle Roster Number). e. Service member's name. f. Unit name, unit identification code, and home duty station. g. Combatant Command in which the event occurred. h. Service member's distance from the blast when applicable. i. The disposition following the medical evaluation (return to duty after 24 hours, commander's justification to return to duty prior to 24 hours, or did not return to duty after 24 hours).Whats the purpose of triage?ensures the greatest care for the greatest number and the maximal utilization of medical personnel, equipment, and facilities, especially in a mass-casualty incident (MCI). (care for the most likely to survive and then those who are not with what you have left-over).What are the categories of triage?Immediate, Delayed, Minimal, ExpectantWhat are the colors associated to triage categories?Immediate RED Delayed YELLOW Minimal Green Expectant BlackImmediate Category- require immediate LSI and/or surgery. - airway obstruction, chest or abdominal injuries, massive external bleeding, or shock.Delayed Category- may need surgery, but whose general condition permits a delay in surgical treatment - large soft tissue wounds, fractures of major bones, intra-abdominal and/or thoracic wounds, or burns to less than 20% of total body surface areaMinimal Category- "walking wounded." These casualties have minor injuries and can usually care for themselves with self-aid or buddy aid. - small burns, lacerations, abrasions, and small fractures.Expectorant Category- wounds that are so extensive that even if they were the sole casualty and had the benefit of optimal medical resources, their survival would be highly unlikely. - unresponsive casualties with injuries such as penetrating head trauma with obvious massive damage to the brain.Whats a key component to ensure that triage categories are being maintained?Constant re-assessment of casualties that can either move them up or down in category.What are priorities for a Mass Casualty?- Secure the area and ensure scene safety - Establish Command Post (CP), Casualty Collection Point (CCP) and routes of access - Estimate initial number, severity and additional hazards (e.g. smoke, NBC, etc) - Assign initial triage categories - Perform life -saving interventions (LSIs) - Re-triage with an extended secondary survey as time permitsPatients who can ambulate and follow instructions usually will fall into what category.MinimalPatients with obvious signs of death can be initially placed in what category.ExpectorantPatients that can obey simple commands, possess a normal radial pulse, and are not in respiratory distress.DelayedCategory: Obvious LSI required?ImmediateCategory: Casualty does not obey commands?ImmediateCategory: Abnormal Radial pulse character?ImmediateCategory: Casualty in respiratory distress?ImmediateWhich category would each of the following injuries be triaged in: 1) Airway Obstruction 2) Penetrating head trauma 3) Burns less than 20% 4) Small fractures1) Immediate 2) Expectorant 3) Delayed 4) MinimalMission of Aid StationWhile in a field/combat environment, the mission of the Aid Station is to minimize the effect wounds, injuries, and diseases have on a unit's effectiveness, readiness and morale. while in garrison is to keep the Marines assigned ready for deployment.Large aid stations consist of what medical personnel and support how many personnel.- 2 MO - 65 Corpsmen - Support 1000 MarinesWhat are the two MO's for a aid station?Battalion Surgeon Assistant Battalion SurgeonEach BAS is assigned one RMT consisting of what?1 Chaplin 1 RPHow many corpsmen are part of a aid station?21 corpsmen led by a chiefHow many Corpsmen are assigned to Line Companies?44 Corpsmen divided into four groups of 11 corpsmenBAS RESPONSIBILITIES IN GARRISON-Maintain medical and dental readiness -Conduct sick call -Administration -Supply -Provide medical coverage as needed for training -Provide training to non-medical personnel to enhance self/buddy aid and litter team responsibilitiesWhat components make up sick call procedures?Check In Patient Encounter Discharge Binnacle List Disease Non Battle InjuryWhats a Binnacle list?each morning a Binnacle List (Report of the Sick and Injured) is sent to the company office detailing individuals who had been seen that day. It also lists Marines who are Sick in Quarters or currently on Light Duty.Whats a Disease non Battle Injury (list)?- information from the Sick Call log is also transferred into a Disease Non Battle Injury (DNBI) Report. This report breaks down the categories of injuries and illness for the unit. It is forwarded up the chain and collected for the major unit. This information can be used to track the spread of disease or identify injury trends.BAS RESPONSIBILITIES IN THE FIELD/COMBAT ENVIRONMENT- Conduct sick call - Conduct Triage - Treat casualties to minimize mortality, prevent further injury, and stabilize for further evacuation. - Record all casualties received and treated, and report them to the appropriate unit section for preparation of casualty reports. - Provide temporary shelter in conjunction with emergency treatment. - Return patients to duty when possible. - Transfer evacuees from the BAS to ambulance, helicopter, or other evacuation transportation. - Initiate treatment of combat stress casualties. - Maintain deployment health records (DHR) of battalion personnel. - Provide personnel replacement and medical re-supply for company level Hospital Corpsmen.Whats "Leap Frogging" when utilizing a BAS in a combat scenario?Alpha BAS advances with the battalion, Bravo BAS will remain behind and continue to provide medical care/evacuations until all patients have been evacuated, or until relieved by medical support elements such as Medical Battalion Shock Trauma Platoon (STP). Once the STP assumes all casualties, Bravo BAS, personnel and supplies will rejoin Alpha BAS to form the complete BASWhat makes up the BAS?Internal Security Triage Treatment Area Evacuation Area Expectant AreaWhats not allowed in the BAS?AT NO TIME will any weapon or ammunition be allowed into the medical treatment areaResponsibilities of Battalion Surgeon- Supervising patient treatment, planning, and organization. - Education of the battalion medical staff. - Other duties as the battalion commander may direct.Responsibilities of Assistant Battalion Surgeon- Direct, manage, and supervise the operation of the BAS. - Perform such additional duties as may be assigned by the Battalion Surgeon.Responsibilities of Battalion Chief- Administration, personnel, and logistical matters. - Ensures that all battalion HSS commitments and operational requirements have the appropriate medical and logistical support. - Advises the Battalion Surgeon on all matters relating to the BAS or battalion medical personnelResponsibilities of the Battalion Surgeon/Chief- Organizing/Assignment of medical platoons personnel. - Preparing HSS appendix to battalion's operational plan. - Supervising and assisting in the collection, treatment, and evacuation of the sick and injured. - Develop HSS Standard Operation Procedures (SOP) - Conduct medical sanitation inspections. - Maintaining and submitting appropriate records and reports. - Train medical personnel in subjects relating to HSS. - In the absence of a Preventive Medicine Technician, supervise instruction for nonmedical personnel in personal hygiene, preventive medicine, and field sanitation. - Ensuring medical supplies and equipment are properly managed, and that a responsive re-supply system is established to ensure adequate re-supply at garrison and combat levelsWhat class of supply is for medical?Class VIIIAMAL 635Battalion Aid Station EquipmentAMAL 636Battalion Aid Station SupplyADAL 662Field Dental ItemsDD-1348Used to order standard stock itemsLine itemsitem having a National Stock Number (NSN)Items in a Table of Equipment (T/E)- Tentage - Vehicles - Tools - Communication equipment - Nuclear, biological and chemical (NBC) gear - Office equipment and suppliesonly permanent medical/dental supply source in a Marine Expeditionary Force (MEF).Medical Logistics Company (MEDLOG), Supply BN -Whats the purpose of the Naval Medical and Dental Material Bulletin (NMDMB)monthly publication which provides information on medications, supplies, equipment and authorizes additions or deletions to the AMALs and ADALsChain of re-supply under combat situations:Unit Corpsman BAS Logistics Command Element MEDLOG, Supply Battalion, MLGWhat are the layers of the skin?Epidermis Dermis Subcutaneous TissueThe dermis is comprised of what?Blood vessles, nerves, sweat glands, and sebacceous glands.What makes up the epidermis?Epitheal cellsWhat makes up the Sub-qElastic and fibrous tissue and fat deposits.Whats the most common type of burn on modern battlefield?ThermalWhat body part is most concerning for loss of life?FaceSigns and symptoms of thermal facial burns?Stridor Oropharyngeal Swelling Hoarseness Difficulty Swallowing Carbonacceous sputum (blackened sputum) Signed nasal/facial har DyspneaWhat is a easy identifier of electrical burns and what are we concerned about?Entry wound on where the body made contact Exit wound on where the ground was at Deep layers of tissue are destroyed and increased chance of cardiac arythmias.What does potassium do during electrical shock?Increase serum levels and cause cardiac arythmias.What does Myoglobin do during electrical shock?Can cause kidney failures.Due to the nature of electrical shocks, what intervention should we perform?C-Spine immobilization.What does a circumferential burn do?Cause full burns around a portion of the body that will have increased swelling and potentialy create a tourniquet effect causing loss of limb.Radiation burns occur how and what may also be present?First and second degree burns from items that catch on fire but if doses of radiation are high enough, other related radiation effects will overshadow burns.Chemical burns are affected by what?Type of chemical and duration of exposure.What are three types of chemical burns?Acid Bases (alkali) OrganicAcid burns have what PH and are found in what?7-0 PH, found in cleaners and acidifiers.Bases PH levels and are found where?7-14 Fertilizer, Industrial Cleaners, batteries used in radios.Organic chemical burns contain what and are found where?Carbon, found in phenols, creosote, petroluem products.Degrees of burns are based on what?Depth and extent (TBSA)How many degrees of burns are there?4Whats the effect of first degree burns and signs?- first-degree burns involve only the epidermis and are characterized as being red and painful. - Dry, red and inflamed skin - Painful to touch - The burned area blanches with pressure - Minimal swelling (if present)Whats the effect of second degree burns and signs?-involve the epidermis and varying portions of the underlying dermis. - Skin is moist, with reddened areas - Blisters or open weeping wounds - Deep, intense pain - Edema will be moderate - Fluid loss may be significant depending on the extent of the burnWhats the effect of third degree burns and signs?- involve all three layers of skin and may have several appearances. - Skin has a dry, leathery appearance - The skin can range in color from white, yellow, cherry red, brown, or charred - Severe pain around periphery of burn, but little to no pain near center of burn. - No capillary refill at affected areaWhats the effect of fourth degree burns and signs?- fourth-degree burns are those that not only burn all layers of the skin, but also burn underlying fat, muscles, bone or internal organs.Whats the percentages for the rules of nine?Head 9% Torso 9% Abdomen 9% Upper back 9% Lower Back 9% Arms 4.5% front (9% for the total arm) Arms 4.5 % back (9% for the total arm) Legs 9% front (18% for total leg) Legs 9% back (18% for total leg) Groin 1%Whats the rule of palms?Patients hand is used to calculate burn percentage. One hand = 1%.How do you treat burns?1) stop the burning process 2) Monitor airway and O2 saturation for complications. 3) Monitor respiration for failure and perform intervention. 4) Get IV access to maintain a pulse and blood pressure. 5) Continue with detailed assessment of more important wounds. 6) Estimate TBSAWhats the rule of ten?TBSA x10cc (add 100 per 10kg over 80kg)Signs and symptoms of burns to the eyes?- Blurry vision - Vision loss - Pain - Tearing - Conjunctival erythemaThermal eye injury treatment?- Irrigate with large amounts of water - Cover eyes with a dry sterile dressing. In a tactical situation, if the patient can partially see out of the affected eye and can otherwise ambulate, defer dressing the eye. Avoid dressing both eyes if only one eye is injured.Acid/alkali eye injury treatment?- Flush acid for 5-10 minutes - Flush alkali for 20 minutes - Cover eyes with a dry sterile dressing. In a tactical situation, if the patient can partially see out of the affected eye and can otherwise ambulate, defer dressing the eye. Avoid dressing both eyes if only one eye is injured.What are the four/five levels of TAXONOMY OF CARE?First Responder Capability Forward Resuscitation Capability Theater Hospitalization Capability Definitive Capability En Route Care CapabilityWhats is First Responder Capability?- first aid and emergency care rendered at the point of initial injury are the primary objectives of care at this level. (Immediate care and stabilization for next level) ex. Self Air/Buddy Aid, BAS.What is Forward Resuscitative Capability?- performing advance emergency medical treatment as close to the point of injury as possible, stabilizing the patient, and saving life and limb. Stabilization ensures the patient can tolerate evacuation.Forward Resuscitative Capability; Medical Battalion.surgical care for the MEF. Provides stabilizing surgical procedures. Capable of holding patients up to 72 hours.Forward Resuscitative Capability; Casualty Receiving & Treatment Ships (CRTS).Expeditionary Strike Group (ESG). They provide additional medical capabilities for receiving a mass casualty (up to 50 casualties).Forward Resuscitative Capability; Shock Trauma Platoon (STP).- small forward unit with one physician supporting the MEF specializing in patient stabilization and evacuation. No surgical capability.Forward Resuscitative Capability; Forward Resuscitation Surgical Suite (FRSS).8 to 10 personnel (two surgeons, one critical care nurse, one anesthesiologist, and four to six corpsmen). It consists of a two tent surgical system that provides a fully powered, climate-controlled environment with enough space for one operating room and one pre- and post-operative care room. The shelter is equipped with cutting-edge surgical gear and takes less than one hour to set up or break down.Theater Hospitalization Capability.Modular hospitals or ships that returns the patient to duty or stabilizes the patient to ensure they can tolerate evacuation to a definitive care facility. Inpatient and outpatient care, emergent care, and enhanced medical, surgical, and ancillary capabilities.Theater Hospitalization Capability. Fleet Hospitals.deployable ground asset that is located away from enemy threat providing up to 500 hospital beds, 80 ICU beds, and 6 OR's.Theater Hospitalization Capability. Hospital ships (USNS Mercy and USNS Comfort)deployable medical assets providing up to 1,000 beds, 100 ICU beds, and 12 OR's.Definitive Capability.capability generally leads to rehabilitation, return to duty, or discharge from the armed forces. Because this care is usually given outside the operational area, the most advanced health care can be made available and accessible to the patient.Definitive Capability; CONUS Military, Veteran's and selected civilian hospitals.- provide full convalescent, restorative, and rehabilitative care to all patients returned to the Continental United States (CONUS).Definitive Capability; Overseas Medical Treatment Facilities.- offers the surgical capability found in the theater hospitalization capability, along with further definitive therapy for those patients in the recovery phase who can be returned to duty within the theater evacuation policy. A patient who cannot be returned to duty will be evacuated through the en route care capability.En Route Care Capability. What are the three?MEDEVAC CASEVAC AeromedicalWhat is Aeromedical Evacuation?This type of evacuation is generally beyond the scope of TCCC but it is typically used when transferring patients between medical treatment facilities.What are the types of litters?Talon (Most common) Standard Army Litter Stokes Litter (Max Security) Pole-less Non-rigid Litter Miller (full body) Board (confined spaces/Vert Evac) Improvised LittersWhat are two category types of vehicles?Ground AirThe M997 Ambulance can transoirt how many litter or ambulatory patients? (key word is and / or)4 Litter 8 AmbulatoryThe M1035 Ambulance can carry how many litters and ambulatory. (key word is and / or)2 litter 3 ambulatoryMK 23 7 Ton can transport how many litter or ambulatory patient? (key word is and / or)10 litters 20 ambulatoryCH-46 Sea Knight can transport how many litter or ambulatory patient?carry 15 litters or 22 ambulatory patients.UH-1 Huey can transport how many litter or ambulatory patient?carry 6 litters or up to 10 ambulatory patientsMV-22 Osprey can transport how many litter or ambulatory patient?carry 12 litters or 24 ambulatory casualtiesCH-47 Chinook can transport how many litter or ambulatory patient?can carry 24 litter patients or 31 ambulatory patients.UH-60 Blackhawk can transport how many litter or ambulatory patient?carry up to 7 ambulatory patients or carry up to 6 litter patientsWhat are CASUALTY RECEIVING TREATMENT SHIPS? (types)LHD/LHA T-AH (hospital ships)LHD/LHA's have how many OR's and Beds?- 4 Operating Rooms - 15 ICU Beds - 45 Ward BedsT-AH have how many OR's and Beds?- Operating Rooms (12) - ICU Beds (100) - Intermediate Care Beds (400) - Ward Beds (500)What are the CASEVAC categories?Urgent Urgent Surgical Priority Routine ConvenienceDescribe CASEVAC Urgentcare is needed to save life or limb within 2 hoursDescribe CASEVAC Urgent SurgicalCare is needed to save life or limb within 2 hours and needs surgeryDescribe CASEVAC PriorityCare is needed or a patient will deteriorate into an urgent within 4 hoursDescribe CASEVAC RoutinePatient needs to be evacuated to complete treatment within 24 hours.Describe CASEVAC ConvenienceAdministrative patient movementWhats a brevity code?series of phonetic letters, numbers, and basic descriptive terminology used to transmit casualty information. These codes 5-48 indicate the standard information required for an evacuation commonly known as the "9 Line".Whats the nine line?1. Location 2. Radio frequency/call sign 3. Patient category (Urgent etc but ABCDE from urgent to admin) 4. Equipment 5. Number of patients by type (litter/ambu) 6. Security of site 7. Method of marking 8. Patients nationality 9. NBC contaminantWhat is M.O.U.T stand for?Military Operations in Urban TerrainWhat is Military Operations in Urban Terrain?military actions planned and conducted on a terrain where man-made structures impact the tactical options available to the commander. This terrain is characterized as a four-dimensional (air, buildings, streets, and subways) battlefield with the following features: - Considerable rubble. - Ready-made fortified fighting positions. - An isolating effect on all combatants.What are basic health risks or considerations in a M.O.U.T?-Parallel planning for medical. -Securing a good location for casualty collection -Injuries are very high due to blasts so medical training is essential for Sailors and Marines -Isolation and reduced response to casualties -Imposition of civilian casualties and refugees -Undefined lines of battle that delay medical treatment -Mass casualty/casualty overload situations -Communicable disease endemic to the area -Lack of water and sanitation -Combat stress -NBC environmentWhat are three types of communicable diseases for a M.O.U.T?- Animals carrying diseases - People carrying diseases - Lack of Potable (clean) waterIdentify the predominant factors that lead to combat stress casualties in a MOUT environment- Long duration of being on the alert - Fear of IED's or sniper fire - Exposure to death or dyingIdentify some events that may lead to complicated CASEVAC efforts in a MOUT environment.- Finding your patient - Collapsed structures - Vehicles crashing or being shot atWhat type or terrain makes operating (combat related) hard in a MOUT?- Enemy observation positions are likely in high, isolated structures such as steeples or lone high-rise buildings. - Assaulting forces can become quickly isolated, confused and cut-off by a tangle of unfamiliar structures. - Small assaulting units are at a great disadvantage due to multiple floors, rooms, stairways, and doors. The enemy may make great use of these obstacles to inflict serious losses.What are rules of engagement(ROE) designed for?- Avoid alienation of the local population. - Reduce the risk of adverse world opinion. - Preserve structures and facilities for future use. - Preserve vital cultural facilities and grounds.Whats the purpose of OSCAR Team members?prevent, identify, and manage COS(Combat operational stress) problems as early as possible.What makes up a OSCAR team?Mentors Extenders Mental Health PersonellWhats the role of Mentors?Marines with combat zone deployment experience, who are strong role models and are willing to assist and montor other Marines with COS problems.Whats the role of Extenders?bridging the gap between MHPs and Marine mentors. Counselling, Sleep treatment etc.Whats the role of Mental Health Personnel?provide not only direct clinical services, but also spend a significant portion of their time in the field with the Marines they support during training and deployment.Whats operational stress?Changes in physical or mental functioning or behavior resulting from the experience or consequences of military operations other than combatWhat is combat stress?Changes in physical or mental functioning or behavior resulting from the experience of lethal force or its aftermath. "Shell Shock" "Combat Fatigue"What are the five leadership functions of COSC?Strengths (Unit cohesion, Mind resiliency, training) Mitigate (Reduce non required stress) Identify (Know your people and assist) Treat ReintegrateWhat are the four zones of stressGREEN (READY) YELLOW (REACTING) ORANGE (INJURED) RED (ILL)Describe the green zone.Not stress-free, but mastering stress with good coping skills. Ready to go!Describe the yellow zone.Reacting to life's normal stressors. Mild and reversible!Describe the orange zone.Stress injuries damaging the mind, body or spirit. Temporarily non-mission ready!Describe the red zone.Stress injuries that become stress illnesses. Only diagnosed by health professionals!What are seven first aid steps to stress?Check to see if action is required Coordinate the next steps Seek cover and get to safety Calm the Marine Connect with the Marine Restore competence and ability Restore confidenceWhats the importance of an after action review?Marines are afforded the opportunity to discuss with their peers and immediate supervisors, in an atmosphere of trust and honesty, perceptions and reactions after significant operational or training events to prevent them from developing into long-term issues.