SPECIAL OPERATIONS MEDICINE 2026
Five Studies From the Journal of Special Operations Medicine That Deserve Immediate Attention
SOF selection, E-POCUS, hypochlorous acid, environmental CBRNE toxicology, and colorimetric confirmation of thoracostomy
By DrRamonReyesMD ⚕️
EMS Solutions International — Updated August 2026
EXECUTIVE OVERVIEW
The Summer 2026, Volume 26, Issue 2 edition of the Journal of Special Operations Medicine captures several important directions in contemporary operational medicine.
The common denominator is not simply technology.
It is doctrine.
Modern Special Operations medicine increasingly operates under conditions characterized by:
delayed evacuation, contested logistics, limited resources, environmental hazards, antimicrobial resistance, prolonged casualty care, and the need to move sophisticated diagnostic and therapeutic capability closer to the point of injury.
Five studies are particularly noteworthy:
- predictors of success in military Special Operations courses;
- Expeditionary Point-of-Care Ultrasound;
- hypochlorous acid for far-forward infection control;
- sewage-associated environmental toxicology and CBRNE awareness;
- colorimetric capnography for confirmation of thoracostomy placement.
Together they illustrate a fundamental evolution:
THE FUTURE OF OPERATIONAL MEDICINE IS MOVING CAPABILITY FORWARD.
1. PREDICTING SUCCESS IN SPECIAL OPERATIONS SELECTION
Tourinho and colleagues conducted a systematic review and meta-analysis examining factors associated with successfully completing military Special Operations courses.
The review included 23 studies from 10 countries, published between 1990 and 2022.
Course duration ranged from five days to twelve months, while individual study populations ranged from 11 to 1,138 participants.
Consistent positive associations with success included:
VO₂max,
pull-ups,
push-ups,
and
marching performance.
Body-fat percentage and sit-up performance were not consistently associated with successful course completion.
The authors also identified potential contributions from psychological characteristics, psychosocial resources, personality, anthropometric characteristics, and other variables.
OPERATIONAL INTERPRETATION
Success in Special Operations selection cannot be reduced to:
FITNESS ALONE.
The evidence supports a multidimensional model incorporating:
AEROBIC CAPACITY
MUSCULAR ENDURANCE
LOAD/MARCH PERFORMANCE
PSYCHOLOGICAL RESILIENCE
ADAPTABILITY.
However, an important limitation must remain visible:
GRADE certainty was LOW TO VERY LOW.
These are associations and candidate predictors—not a validated universal formula for selecting future operators.
Reference: Tourinho PM, et al. J Spec Oper Med. 2026;26(2):27-37.
DOI: 10.55460/J.Spec.Oper.Med.2026.MST7-23AU.
2. EXPEDITIONARY POCUS: BATTLEFIELD ULTRASOUND NEEDS ITS OWN DOCTRINE
Stevens and colleagues introduce an important operational concept:
EXPEDITIONARY POINT-OF-CARE ULTRASOUND — E-POCUS.
Civilian POCUS doctrine assumes conditions that may disappear during combat operations.
A hospital can provide:
power, multiple probes, lighting, specialists, maintenance, repeat examinations, and relatively controlled conditions.
A far-forward medic may instead face:
darkness, noise, extreme temperatures, limited battery capacity, limited training time, movement, enemy threat, prolonged evacuation, and severe logistical constraints.
Those are fundamentally different environments.
THE EVIDENCE
The authors performed a PRISMA-ScR scoping review and included 53 studies.
Approximately 34% of the evidence originated from civilian resource-limited environments, while only about 26% came from military zones.
Evidence quality varied substantially.
High-quality randomized evidence supported some applications involving AI-assisted image acquisition, whereas several trauma applications continued to rely on very low-quality animal evidence.
The authors therefore argue that Expeditionary POCUS requires a doctrine distinct from civilian ultrasound standards.
BEST — BETTER — MINIMUM
One of the paper's most useful concepts is a competency framework organized around:
BEST
Optimal capability.
BETTER
Intermediate operational capability.
MINIMUM
The minimum capability necessary to retain diagnostic utility.
This approach could help standardize:
training,
equipment acquisition,
credentialing,
maintenance
and
deployment of ultrasound capability.
THE CRITICAL QUESTION
The operational medic should not ask:
“CAN I PERFORM AN ULTRASOUND?”
The better question is:
“WILL THIS ULTRASOUND CHANGE WHAT I DO NEXT?”
That distinction separates technology from operational medicine.
Reference: Stevens RA, Ausman CE, Korb D, Hall B, Cunningham CW, Mitchell CA. J Spec Oper Med. 2026;26(2):50-60.
DOI: 10.55460/J.Spec.Oper.Med.2026.GOTR-RO8R.
Official JSOM — Expeditionary Point-of-Care Ultrasound
3. FROM ANTIBIOSIS TO HOCl ANTISEPSIS
Rasmussen and Makarov address an increasingly important problem in modern warfare:
FAR-FORWARD INFECTION CONTROL.
Combat wounds may be heavily contaminated while evacuation is delayed.
At the same time:
antimicrobial resistance,
biofilm,
devitalized tissue,
contaminated wounds
and
contested pharmaceutical logistics
can complicate conventional infection management.
The authors examine renewed interest in hypochlorous acid — HOCl.
WHY HOCl?
HOCl is not biologically foreign.
Human neutrophils generate hypochlorous acid as part of innate antimicrobial defense.
Modern manufacturing and electrochemical technologies can produce formulations designed to provide broad antimicrobial activity while maintaining tissue compatibility.
The operational proposition is compelling:
REDUCE MICROBIAL BURDEN AT OR NEAR THE POINT OF INJURY.
WHAT THE PAPER DOES NOT MEAN
HOCl should not be interpreted as a universal replacement for:
systemic antibiotics,
debridement,
irrigation,
source control
or
surgery.
Instead, it represents a potential additional tool for early wound management, particularly when definitive surgical care and evacuation are delayed.
The authors propose that HOCl deserves further evaluation for far-forward use, including potential incorporation into individual medical kits and future TCCC research.
That is a research and doctrinal proposition.
It is not yet equivalent to universal TCCC adoption.
Reference: Rasmussen ED, Makarov V. J Spec Oper Med. 2026;26(2):78-84.
DOI: 10.55460/J.Spec.Oper.Med.2026.KPUM-MM54.
PubMed — From Antibiosis to HOCl Antisepsis
4. SEWAGE SUFFOCATION: WHEN SANITATION INFRASTRUCTURE BECOMES A CBRNE THREAT
Fields and colleagues report a young Syrian man who accidentally fell into a sewage pit and rapidly developed:
altered mental status,
vomiting,
and
seizures.
He required emergency stabilization and intubation by a U.S. medical team at a Role 2 facility.
The case highlights an easily underestimated operational hazard.
A sewage pit is not merely a biological contamination problem.
It may become:
A TOXIC CONFINED SPACE.
THREE IMPORTANT HAZARDS
The authors discuss several sewage-associated gases, particularly:
METHANE — CH₄
A potential oxygen-displacing simple asphyxiant.
HYDROGEN SULFIDE — H₂S
A highly toxic gas capable of causing rapid neurological and respiratory collapse at sufficient exposure.
CYANIDE — CN⁻
Discussed as another potential toxicological contributor in these environments.
THE SECOND-VICTIM PROBLEM
The greatest operational lesson may involve the rescuer.
Personnel entering:
sewage pits, wells, tanks, sewers, or other confined spaces
without atmospheric assessment and appropriate respiratory protection can themselves become casualties.
Therefore:
CASUALTY ACCESS IS PART OF CASUALTY CARE.
The response may require integration of:
medicine, technical rescue, respiratory protection, atmospheric monitoring, toxicology, and CBRNE doctrine.
Reference: Fields A, Mitchell CA, Barbuto A, Thornton A, Ingram A.
DOI: 10.55460/J.Spec.Oper.Med.2026.XY8L-XE9S.
Official JSOM — Sewage Suffocation
5. COLORIMETRIC CAPNOGRAPHY TO CONFIRM THORACOSTOMY PLACEMENT
Topper and colleagues evaluated a novel colorimetric capnography device, Capnospot™, designed to provide visual confirmation of pleural entry during thoracic decompression.
The clinical problem is extremely important:
INSERTING A NEEDLE DOES NOT GUARANTEE EFFECTIVE PLEURAL DECOMPRESSION.
A catheter can fail to reach the pleural cavity or become displaced.
Failure may produce false reassurance while hypoxia and obstructive shock continue.
THE EXPERIMENT
The investigators created tension pneumothorax in a porcine model using transdiaphragmatic CO₂ insufflation.
Twenty-four thoracostomies were performed using needle or pigtail techniques.
Colorimetric confirmation was compared with ultrasound and radiographic confirmation.
For needle thoracostomy, reported confirmation times were approximately:
Capnospot: 1,030 ms
versus
ultrasound: 7,030 ms.
For pigtail thoracostomy:
Capnospot: 355 ms
versus
ultrasound: 22,355 ms.
The colorimetric method was also faster than radiographic confirmation in the experimental setting.
AN IMPORTANT SCIENTIFIC CAUTION
These results are exciting.
But they remain:
PRECLINICAL.
The study does not establish clinical superiority in human combat casualties.
There is another important translational issue:
the experimental pneumothorax was generated using CO₂, precisely the gas detected by capnography.
Therefore, validation under conditions that more closely reproduce the gas composition and physiology of spontaneous or traumatic human pneumothorax is particularly important.
This technology should currently be regarded as:
A PROMISING PROOF OF CONCEPT.
Not yet as a replacement for established clinical assessment or current decompression doctrine.
Reference: Topper GV, Buonasorte M, Thange L, et al. J Spec Oper Med. 2026.
DOI: 10.55460/J.Spec.Oper.Med.2026.2XXI-YOOH.
PubMed — Novel Colorimetric Capnography for Thoracostomy Confirmation
6. FIVE PAPERS — ONE OPERATIONAL MODEL
| Study | Operational problem | Proposed capability | Current evidence |
|---|---|---|---|
| SOF selection | Attrition | Multidimensional prediction | Systematic review; low/very-low certainty |
| E-POCUS | Far-forward diagnostic uncertainty | Expeditionary ultrasound doctrine | 53-study scoping review |
| HOCl | Contamination + delayed evacuation | Early local antisepsis | Translational/clinical rationale |
| Sewage suffocation | Environmental toxic exposure | CBRNE recognition | Case report + pathophysiology |
| Capnospot | Unconfirmed pleural access | Immediate visual confirmation | 24-procedure porcine study |
7. THE BIGGER PICTURE
Read together, these papers describe an emerging architecture:
SELECT BETTER
↓
DETECT EARLIER
↓
INTERVENE EARLIER
↓
VERIFY THE INTERVENTION
↓
SUSTAIN THE CASUALTY
↓
SURVIVE DELAYED EVACUATION.
That is increasingly the operational challenge of modern warfare.
8. FROM GOLDEN HOUR TO CONTESTED EVACUATION
The traditional ideal remains:
POINT OF INJURY → RAPID STABILIZATION → RAPID EVACUATION → SURGERY.
When achievable, that remains extraordinarily valuable.
But future conflicts may impose:
POINT OF INJURY
↓
PROLONGED FIELD CARE
↓
CONTESTED OR DELAYED EVACUATION
↓
LIMITED SURGICAL CAPABILITY
↓
PROLONGED MOVEMENT THROUGH THE EVACUATION CHAIN.
The consequence is profound:
more medicine must occur before the casualty reaches the hospital.
9. THE FUTURE SOF MEDIC
The Special Operations medic of the future increasingly needs to integrate:
TCCC
DAMAGE CONTROL RESUSCITATION
POCUS
TOXICOLOGY
CBRNE
INFECTION CONTROL
TELEMEDICINE
PROLONGED CASUALTY CARE
MEDICAL LOGISTICS
CLINICAL DECISION-MAKING UNDER UNCERTAINTY.
Technology can extend the medic's reach.
It can also increase cognitive burden.
Training doctrine must therefore evolve alongside equipment.
CONCLUSION
The JSOM Summer 2026 issue provides an unusually clear snapshot of where operational medicine is moving.
The transformation is not defined by one device, drug, or procedure.
It is defined by a change in philosophy:
FROM PROCEDURE-CENTRIC CARE TO CAPABILITY-CENTRIC CARE.
The operational clinician must increasingly be capable of:
predicting, detecting, deciding, intervening, confirming, and sustaining.
E-POCUS may bring sophisticated diagnostics into the rucksack.
HOCl may broaden far-forward wound-management capability.
Environmental toxicology reminds us that invisible hazards can incapacitate both casualty and rescuer.
Colorimetric capnography may eventually provide a remarkably simple method of confirming critical thoracic interventions—if human validation supports the experimental findings.
And Special Operations selection research reminds us that despite every technological advance:
THE HUMAN OPERATOR REMAINS THE MOST IMPORTANT SYSTEM ON THE BATTLEFIELD.
The scientific standard must nevertheless remain uncompromising:
Promising technology is not doctrine. Association is not causation. Animal efficacy is not human effectiveness. Operational medicine advances when battlefield experience generates research, research survives critical appraisal, and validated evidence is finally translated into doctrine.
That is the enduring value of the Journal of Special Operations Medicine.
EXPERIENCE → EVIDENCE → DOCTRINE → SURVIVAL.
SUMMER 2026 EDITION
Journal of Special Operations Medicine — Summer 2026
By DrRamonReyesMD ⚕️
EMS Solutions International
Updated — August 2026
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