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Journal of Special Operations Medicine - Article Index

The Journal of Special Operations medicine peer-reviewed article index displays all of our articles listed in alphabetical order. Simply click on the article that interests you, and you will be taken to the abstract for that article. We hope that you find this list of peer-reviewed tactical medicine journal articles to be a useful tool in your research.

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"Evita Una Muerte, Esta en Tus Manos" Program: Bystander First Aid Training for Terrorist Attacks

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Pajuelo Castro JJ, Meneses Pardo JC, Salinas Casado PL, Hernandez Martin P, Montilla Canet R, del Campo Cuesta JL, Incera Bustio G, Martin Ayuso D. 17(4). 133 - 137. (Journal Article)

Abstract

Background: The latest terrorist attacks in Europe and in the rest of the world, and the military experience in the most recent conflicts leave us with several lessons learned. The most important is that the fate of the wounded rests in the hands of the one who applies the first dressing, because the victims usually die within the first 10 minutes, before professional care providers or police personnel arrive at the scene. A second lesson is that the primary cause of preventable death in these types of incidents involving explosives and firearms is massive hemorraghe. Objective: There is a need to develop a training oriented to citizens so they can identify and use available resources to avoid preventable deaths that occur in this kind of incidents, especially massive hemorrhage. Methods: A 7-hour training intervention program was developed and conducted between January and May 2017. Data were collected from participants' answers on a multiple-choice test before and after undertaking the training. Improved mean score for at least 75% of a group's members on the posttraining test was considered reflective of adequate knowledge. Results: A total of 173 participants (n = 74 men [42.8%]; n = 99 women [57.2%]) attended the training. They were classified into three groups: a group of citizens/ first responders with no prior health training, a group of health professionals, and a group of nursing students. Significant differences (ρ < .05) between mean pre- and post-training test scores occurred in each of the three groups. Conclusion: There was a clear improvement in the knowledge of the students after the training when pre- and post-training test scores were compared within the three groups. The greatest improvement was seen in the citizens/first responders group

Keywords: tourniquet; hemostatic; compression bandage; terrorism; mass-casualty event

PMID: 29256213

DOI: TVAX-4JCE

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"Follow Admiral William Halsey's advice: Look around and see what needs to be done. Then do it."

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Kragh JF. 15(4). 130 - 132. (Interview)

Abstract

-Frank Butler on serving the operational medicine community

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"I always wanted to be part of something bigger than myself. Even more so if I could make a small contribution to the bigger effort."

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Kragh JF. 15(3). 124 - 125. (Interview)

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-MSG Harold "Monty" Montgomery on a Career as a Special Operations Forces Medic

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"It Always Starts With the Heart.": Ricardo "FLO" Flores on personal pushes in moving current care toward best care.

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Kragh JF. 16(3). 87 - 92. (Interview)

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PMID: 27734451

DOI: W66O-6KA8

"It was a special, pivotal time; the stars were aligned."

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Kragh JF. 16(1). 118 - 121. (Interview)

Abstract

-Rob Miller on Changing Trauma Care

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"It's exciting and important to have a journal so focal and unique."

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Kragh JF. 14(3). 123 - 123. (Interview)

Abstract

- COL (Ret.) Craig Llewellyn on Five Decades of Special Operations Forces Medicine

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"It's What Color?"

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Banting J, Meriano T. 15(2). 97 - 101. (Journal Article)

Abstract

The series objective is to review various clinical conditions/ presentations, including the latest evidence on management, and to dispel common myths. In the process, core knowledge and management principles are enhanced. A clinical case will be presented. Cases will be drawn from real life but phrased in a context that is applicable to the Special Operations Forces (SOF) or tactical emergency medical support (TEMS) environment. Details will be presented in such a way that the reader can follow along and identify how they would manage the case clinically depending on their experience and environment situation. Commentary will be provided by currently serving military medical technicians. The medics and author will draw on their SOF experience to communicate relevant clinical concepts pertinent to different operational environments including SOF and TEMS. Commentary and input from active special operations medical technicians will be part of the feature.

Keywords: muscle, fatigue; muscle, soreness; rhabdomyolysis; workout

PMID: 26125171

DOI: 0LN4-50LG

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"My name, F., just that one letter."

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Kragh JF. 13(4). 127 - 127. (Interview)

Abstract

SGM F. Bowling on Being a Special Operations Medic and Leader Today

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"Now, more than ever": The Virtual Combat Medical Care Conference 2021 in a Pandemic Setting

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Weber S, Josse F. 21(4). 83 - 84. (Classical Conference)

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PMID: 34969132

DOI: N4Y0-X7O2

"People who say 'No!' irritate me; we should say 'yes'"

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Kragh JF. 14(4). 143 - 143. (Interview)

Abstract

- COL Russ Kotwal of the Joint Trauma System on Improving Prehospital Medicine

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PMID: 27290747

DOI: HKX8-SW6H

"Rationale for Use of Intravenous Acetaminophen in Special Operations Medicine"

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Bowling F. 15(4). 81 - 81. (Letter)

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PMID: 27280218

DOI: 9E0W-POVR

"Rationale for Use of Intravenous Acetaminophen in Special Operations Medicine": Reply

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Vokoun ES. 15(4). 82 - 82. (Letter)

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PMID: 27280219

DOI: L7SW-6P42

"SWAT Is a Lifestyle; It's a Way of Life"

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Kragh JF. 16(2). 108 - 110. (Interview)

Abstract

Ray Casillas on a Career in Operational Medicine

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"Testing of Junctional Tourniquets by Military Medics to Control Simulated Groin Hemorrhage"

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Schwartz RB, Reynolds BZ, Gordon RD, Shiver SA, Lyon M, Holsten SB. 15(2). 94 - 95. (Letter)

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PMID: 27280211

DOI: FB5B-9YSP

"Testing of Junctional Tourniquets by Military Medics to Control Simulated Groin Hemorrhage": Reply

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Kragh JF, Parsons DL, Kotwal RS, Kheirabadi BS, Aden JK, Gerhardt RT, Billings S, Dubick MA. 15(2). 96 - 96. (Letter)

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PMID: 27280212

DOI: 3D4H-83UR

"The central theme is helping the men become the best Operators they can be."

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Kragh JF. 15(2). 152 - 153. (Interview)

Abstract

-Steve Rush on US Air Force Pararescue and Pararescuemen Today

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PMID: 27280212

DOI: JOGL-QJVX

"The Gun & the Scythe" and "The First Marauder": The Passions of an Army Ranger

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Esposito A. 19(3). 130 - 131. (Book Review)

Abstract

Ryan L. The Gun & the Scythe: Poetry by an Army Ranger. Independently published (April 17, 2019). ISBN-10: 1717858341. ISBN-13: 978-1717858344. Ryan L. The First Marauder: Book I of III. Independently published (August 3, 2018). ISBN-10: 1091476454. ISBN-13: 978-1091476455.

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"There I Was": A Cup of Improvisation

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Hubbard B, Freeman C. 19(4). 120 - 122. (Journal Article)

Keywords: improvisation; tourniquets

PMID: 31910487

DOI: MWP4-5N9Q

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"We had the benefit of walking in those shoes, so let's make it better for these guys."

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Kragh JF. 15(1). 133 - 135. (Interview)

Abstract

-The 17th Surgeon General of the United States, Dr Richard Carmona, on a Life of National Service, Including Being a Special Forces Medic

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PMID: 27280265

DOI: RVUM-AF7R

10 Years of SOF Rotary Wing CASEVAC Missions, Training and Equipment: A Retrospective View from the 160th SOAR (A)

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Faudree LK. 12(3). 14 - 18. (Journal Article)

Abstract

On 3 October 2001, the first chalk of Night Stalkers left Campbell Army Airfield enroute to Uzbekistan in support of what would become our nation's longest war. The vast majority of Soldiers were untested in war and would quickly have the opportunity to meet with the enemies of our nation in close combat. The two Special Operations Task Forces (TF), TF Dagger to the north in Uzbekistan and TF Sword in the south (aboard the USS Kitty Hawk) were our nation's first strike options against Al Qaeda and Taliban forces in Afghanistan. Due to the inherent nature of forced entry operations (restrictive terrain, lack of medical infrastructure, etc.) TF Dagger and TF Sword utilized 160th Special Operations Aviation Regiment (Airborne) [SOAR (A)] rotary wing aircraft solely for the Casualty Evacuation (CASEVAC) operations during the first months of Operation ENDURING FREEDOM.

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PMID: 23032315

DOI: 76HZ-GKIO

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160th Soar(a) Flight Medic Specialized Training: The Special Operations Aviation Medical Indoctrination Course

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Faudree LK. 10(2). 4 - 6. (Journal Article)

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PMID: 21256209

DOI: 2IOT-MQ8G

2016 Special Operations Medical and Scientific Assembly Abstracts

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Anonymous A. 16(2). 71 - 77. (Letter)

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2018 Combat Medical Care (CMC) Conference Abstracts

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Anonymous A. 18(4). 115 - 122. (Classical Conference)

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PMID: 30566736

DOI: 9Z62-ZXQV

2018 Combat Medical Care Conference Abstracts: Overview of the Combat Medical Care (CMC) Conference 2018

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Josse F. 18(4). 111 - 112. (Classical Conference)

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PMID: 30566734

DOI: 96TX-Z2IW

2018 Research Abstracts Selection for Podium or Poster Presentation

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Anonymous A. 18(3). 79 - 85. (Classical Conference)

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PMID: 30222843

DOI: HP36-8ZG4

2019 Recommended Limb Tourniquets in Tactical Combat Casualty Care

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Montgomery HR, Hammesfahr R, Fisher AD, Cain JS, Greydanus DJ, Butler FK, Goolsby C, Eastman AL. 19(4). 27 - 50. (Journal Article)

Abstract

Military and civilian trauma can be distinctly different but the leading cause of preventable trauma deaths in the prehospital environment, extremity hemorrhage, does not discriminate. The current paper is the most comprehensive review of limb tourniquets employable in the tactical combat casualty care environment and provides the first update to the CoTCCC-recommended limb tourniquets since 2005. This review also highlights the lack of unbiased data, official reporting mechanisms, and official studies with established criteria for evaluating tourniquets. Upon review of the data, the CoTCCC voted to update the recommendations in April 2019.

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PMID: 31910470

DOI: HQDV-7SXN

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2019 SOMSA Research Abstract Selection for Oral or Poster Presentation

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Anonymous A. 19(3). 94 - 99. (Classical Conference)

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PMID: 31539441

DOI: R6D0-NXPF

2021 Combat Medical Care (CMC) Conference Abstracts

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Anonymous A. 21(4). 85 - 89. (Classical Conference)

Keywords: mental health; military psychology; military personnel; emergency responders; stigma; partners; health services accessibility

PMID: 34969133

DOI: 56ET-DQUF

2021 Scientific Assembly Research Award Winners and Presentations

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Anonymous A. 21(3). 100 - 106. (Classical Conference)

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PMID: 34529815

DOI: I8J3-87F6

2022 Scientific Assembly Research Award Winners and Presentations

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Anonymous A. 22(3). 109 - 117. (Classical Conference)

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20th SFG(A) Non-Trauma Module (NTM) Course

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Walker LH, Godbee DC, Palmer LE, Share MP, Mouri M. 22(2). 29 - 34. (Journal Article)

Abstract

The authors describe the 20th Special Forces Group-Airborne Non-Trauma Module refresher training for Special Forces medical sergeants and Special Operations combat medics.

Keywords: 20th Special Forces Group-Airborne Non-Trauma Module refresher training; training

PMID: 35639889

DOI: 2V6K-AKQN

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23.4% Hypertonic Saline: A Tactical Option for the Management of Severe Traumatic Brain Injury With Impending or Ongoing Herniation

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DeSoucy ES, Cacic K, Staak BP, Petersen CD, van Wyck D, Rajajee V, Dorsch J, Rush SC. 21(2). 25 - 28. (Journal Article)

Abstract

There are limited options available to the combat medic for management of traumatic brain injury (TBI) with impending or ongoing herniation. Current pararescue and Tactical Combat Casualty Care (TCCC) guidelines prescribe a bolus of 3% or 5% hypertonic saline. However, this fluid bears a tactical burden of weight (~570g) and pack volume (~500cm3). Thus, 23.4% hypertonic saline is an attractive option, because it has a lighter weight (80g) and pack volume (55cm3), and it provides a similar osmotic load per dose. Current literature supports the use of 23.4% hypertonic saline in the management of acute TBI, and evidence indicates that it is safe to administer via peripheral and intraosseous cannulas. Current combat medic TBI treatment algorithms should be updated to include the use of 23.4% hypertonic saline as an alternative to 3% and 5% solutions, given its effectiveness and tactical advantages.

Keywords: traumatic brain injury; TBI; military medicine; hypertonic saline; Tactical Combat Casualty Care; TCCC

PMID: 34105117

DOI: 5B5V-W2CK

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A Brief Introduction to Phases of Clinical Medical Research for the SOF Medic

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Merkle A, Randles J. 21(2). 112 - 114. (Journal Article)

Abstract

This is the first of an ongoing series to provide a background into reading medical research literature for the SOF medic.

Keywords: medics; research; research, medical

PMID: 34105134

DOI: BL33-6YZ6

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A Call for Innovation: Reflective Practices and Clinical Curricula of US Army Special Operations Forces Medics

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Rocklein Kemplin K. 14(4). 70 - 80. (Journal Article)

Abstract

Background: Special Operations Forces (SOF) medics have written and published numerous practice reflections that intricately describe their practice environments, clinical dilemmas, and suggestions for teaching and practice. The lack of translation of SOF medics' experiential evidence to their curriculum has created a gap in evidence-based curriculum development. This study analyzed SOF medics' learning and practice patterns and compared it to the evidence in the interdisciplinary clinical literature. After framing the problem, the literature was reviewed to determine appropriate tools by which perceptions and attitudes toward reflection-centered curricula could be measured. Methods: A recognizable practice reflection was extracted from the published SOF clinical literature and presented in writing to self-identified SOF medics and medic instructors via a descriptive crossover design, to ensure possible biases were mitigated. To measure SOF medics' perceptions of reflection-based curricula, the Dundee Ready Education Environment Measure survey instrument was used, as it has validated psychometric properties and is used worldwide. Results: SOF medics' averaged scores of perceptions of their medic education indicated positive but not completely statistically significant preferences toward reflection-based curricula over traditional curriculum.

Keywords: Special Operations; medics; reflective practice; curricula

PMID: 25399371

DOI: 9VLP-C9MS

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A Case for Improvised Medical Training

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Hetzler MR. 19(4). 123 - 125. (Journal Article)

Abstract

The hyperresourced, uber-controlled, ultrareactive, constant environment that we have come to know in the past 20 years should not be mistaken as the norm in conflict. In truth, unrealistic expectations of both commanders and systems in resourcing is presently being reinforced almost daily. Only in the past few years of this decade have the majority of allied forces experienced challenge in resupply and support in contingency operations. When logistical lines are cut, limited, or untimely, we must know and exercise other means of providing the highest level of medical care possible-if not with indigenous ways and means, then by improvisation. History has proved that improvised medicine can be capable, professional, and ethically sound if practiced properly and to standards, the price being time, education, and investment in the requirement. Most often, these are already time-honored means of care.

Keywords: military medicine; environment; equipment design; unconventional medicine

PMID: 31910488

DOI: W9R5-ZFWB

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A Case of Prehospital Traumatic Arrest in a US Special Operations Soldier: Care From Point of Injury to Full Recovery

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McKenzie MR, Parrish EW, Miles EA, Spradling JC, Littlejohn LF, Quinlan MD, Barbee GA, King DR. 16(3). 93 - 96. (Journal Article)

Abstract

During an assault on an extremely remote target, a US Special Operations Soldier sustained multiple gunshot and fragmentation wounds to the thorax, resulting in a traumatic arrest and subsequent survival. His care, including care under fire, tactical field care, tactical evacuation care, and Role III, IV, and V care, is presented. The case is used to illustrate the complex dynamics of Special Operations care on the modern battlefield and the exceptional outcomes possible when evidence-based medicine is taken to the warfighter with effective, farforward, expeditionary medical-force projection.

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PMID: 27734452

DOI: 69HW-YWF9

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A Case Of Reactive Arthritis In A Ranger Indoctrination Program (RIP) Student

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Hart RS, Detro JF. 09(2). 22 - 28. (Journal Article)

Abstract

Musculoskeletal complaints comprise the majority of cases encountered by military physicians when evaluating young active duty Soldier-athletes. This is a case of reactive arthritis in a 19-year-old active duty Soldier-athlete whose failure to improve with conservative therapy initiated further investigation. When evaluating what appear to be routine overuse injuries, it is important to actively include other potential causes of musculoskeletal complaints in the differential diagnosis. Further investigation of disease in patients whose symptoms and complaints do not improve with routine conservative care is paramount. Reactive arthritis, though self-limiting in two-thirds of those affected, can become a chronic disabling disease affecting as many as 40 out of 100 patients. Current theories suggest the persistent presence of non-culturable bacteria and bacterial antigens residing in the joint synovia as the etiology of the disease state. There is no curative therapy for reactive arthritis and management is focused on the treatment of symptoms with non-steroidal anti-inflammatory drugs (NSAIDs), immunomodulator therapy, and antibiotics if an infectious source is suspected.

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PMID: 19813516

DOI: 0AWI-L34A

A Case of Rhabdomyolysis Caused by Blood Flow-Restricted Resistance Training

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Krieger J, Sims D, Wolterstorff C. 18(2). 16 - 17. (Case Reports)

Abstract

Blood flow-restricted resistance (BFRR) training is effective as a means to improve muscle strength and size while enduring less mechanical stress. It is generally safe but can have adverse effects. We present a case of an active duty Soldier who developed rhabdomyolysis as a result of a single course of BFRR training. He was presented to the emergency department with bilateral lower extremity pain, was admitted for electrolyte monitoring and rehydration, and had an uncomplicated hospital course and full recovery. This is an increasingly common mode of rehabilitation in the military, and practitioners and providers should be aware of it and its possible adverse effects.

Keywords: rhabdomyolysis; blood flow restricted training; ischemic training

PMID: 29889951

DOI: 1YXC-IZH1

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A Case Of Tapework Infestation

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Kacoroski J, Bonk C, Gilpatrick S. 10(3). 46 - 48. (Case Reports)

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PMID: 21049435

DOI: HG9G-FO26

A Case Series of Air Force Pararescue Long-Range Ocean Rescues

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Mix JW, DeSoucy ES, Hilser A, Houser DJ, Mhayamaguru KM, Dorsch J, Gaither JB, Rush SC. 20(3). 122 - 127. (Journal Article)

Abstract

Background: US Air Force (USAF) pararescuemen (PJs) perform long-range ocean rescue missions for ill or injured civilians when advanced care and transport are not available. The purpose of this case series is to examine the details of these missions, review patient treatments and outcomes, and describe common tactics, techniques, and procedures for these missions. Methods: Cases in which the USAF PJs preformed long-range ocean rescue for critically ill or injured civilians between 2011 and 2018 were identified. Case information was obtained, including patient demographics, location, infiltration/exfiltration methods, diagnoses, treatments, duration of patient care, patient outcome, and lessons learned. Results: A total of 14 pararescue missions involving 22 civilians were identified for analysis. Of the 22 patients, 10 (45%) suffered burns, six (27%) had abdominal issues, four (18%) had musculoskeletal injuries, one had a traumatic brain injury, and one had a necrotizing soft-tissue infection. Medical care of these patients included intravenous fluid and blood product resuscitation, antibiotics, analgesics, airway management, and escharotomy. The median duration of patient care was 51 hours. Conclusion: This case series illustrates the complex transportation requirements, patient and gear logistical challenges, austere medicine, and prolonged field care (PFC) unique to USAF PJ open-water response.

Keywords: pararescue; open-water rescue; prolonged field care; search and rescue

PMID: 32969017

DOI: MD7K-AVF1

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A Case Study of Long-Range Rotary Wing Critical Care Transport in the Battlefield Environment

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Eastman J, Dumont J, Green K. 21(2). 77 - 79. (Journal Article)

Abstract

Military medical evacuation continues to grow both in distance and transport times. With the need for long-range transport of greater than 2 hours, crews are having to manage critical care patients for longer trips. This case study evaluates one specific event in which long-range transport of a sick noncombat patient required an enroute critical care team. Medical electronics and other equipment require special attention. Oxygen bottles and batteries for medical devices become the limiting factor in transport from point to point. Having to juggle multiple data streams requires prioritization and reassessment of interventions. Using the mnemonic "bottles, bags, batteries, battlefield environment" keeps the transport paramedic and enroute care nurse on track to effectively deliver the patient to the next level of care. Consideration should be given to such mnemonics for long critical care transports.

Keywords: enroute care; MEDEVAC; medical evacuation; Golden Hour; critical care transport

PMID: 34105126

DOI: NO8C-ALZC

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A Case Study of MEDCANGRO Relative to RAND Conceptual Framework*

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Scott A, Hogan R. 15(2). 123 - 131. (Journal Article)

Abstract

The 2010 Department of Defense (DoD) Instruction 6000.16, Military Health Support for Stability Operations, established medical stability operations as a core military mission. National military leaders appreciated that to better manage risks for US military personnel operating in far forward locations, reduce cost and footprint requirements for operations, and aid partner nations with providing service to relevant populations in underserviced/undergoverned the US military would need to be employed strategically in efforts to build partner nation medical capacity. Medical Stability Operations has evolved into Global Health Engagement in the lexicon of planners but the goal is still the same. This article used a technical report authored by the RAND Corporation as the basis of a case study of a Special Operations Command Africa (SOCAF) Mission to the country of Niger to build a casualty evacuation capability. The case study evaluates the utility of a hypothetical framework developed by the RAND researchers relative to the actual events and outcomes of an actual mission. The principal finding is that the RAND technical report is of value to planners, Operators, and trainers as a systematic approach to successful building partner capacity in health (BPC-H) missions. The article also offers several examples of metrics that aid leadership in making better decisions as to when corrective actions might be required.

Keywords: building partner capacity in health (BPC-H); global health engagement (GHE); international health mission; medical stability operations (MSO)

PMID: 26125176

DOI: DB51-9PMQ

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A Comparison Of Direct Versus Indirect Laryngoscopic Visualization During Endotracheal Intubation Of Lightly Embalmed Cadavers Utilizing The Glide Scope®, Storz Medi Pack Mobile Imaging Systemt™ And The New Storz C-MAC™ Videolaryngoscope

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Boedeker BH, Nicholas TA, Carpenter J, Leighton S, Bernhagen MA, Murray WB, Wadman MC. 11(3). 21 - 29. (Journal Article)

Abstract

Background: Studies indicate that the skills needed to use video laryngoscope systems are easily learned by healthcare providers. This study compared several video laryngoscopic (VL) systems and a direct laryngoscope (DL) view when used by medical residents practicing intubation on cadavers. The video devices used included the Storz Medi Pack Mobile Imaging SystemTM, the Storz CMAC® VL System and the GlideScope®. Methods:After Institutional Review Board (IRB) approval, University of Nebraska Medical Center, Department of Emergency Medicine (UNMC EM) residents were recruited and given a brief pre-study informational period. The cadavers were lightly embalmed. The study subjects were asked to perform intubations on two cadavers using both DL and VL while using the three different VL systems. Procedural data was recorded for each attempt and pre and post experience perceptions were collected. Results: N=14. All subjects reported their varied previous intubation experience. The average airway score using DL: for the Storz VL was 1.54 (SD = 0.576) and for the C-MAC was 1.46 (SD = 0.637). Success in intubation of the standard airway using DL was 93% versus a 100% success rate when intubating with indirect VL visualization. Conclusion: Based on our data, we believe that the incorporation of VL into cadaver airway management training provided an improved learning environment for the study residents. In our study, the resident subjects were 93% successful with DL intubation even though 50% had less than 30 intubations. As well, there was a 100% success rate when intubating with indirect VL visualization. In conclusion, the researchers believe this cadaver model incorporated with VL is a powerful tool which may help improve the overall learning curve for orotracheal intubation.

Keywords: videolaryngoscopy; prehospital; direct laryngoscopy; indirect laryngoscopy; intubation; cadaver

PMID: 21706458

DOI: VLGO-AL6B

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A Comparison of Prehospital Versus Emergency Department Intubations in Iraq and Afghanistan

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Schauer SG, April MD, Tannenbaum LI, Maddry JK, Cunningham CW, Blackburn MB, Arana AA, Shackelford S. 19(2). 87 - 90. (Journal Article)

Abstract

Background: Airway obstruction is the second most common cause of potentially preventable death on the battlefield. We compared survival in the combat setting among patients undergoing prehospital versus emergency department (ED) intubation. Methods: Patients were identified from the Department of Defense Trauma Registry (DODTR) from January 2007 to August 2016. We defined the prehospital cohort as subjects undergoing intubation prior to arrival to a forward surgical team (FST) or combat support hospital (CSH), and the ED cohort as subjects undergoing intubation at an FST or CSH. We compared study variables between these cohorts; survival was our primary outcome. Results: There were 4341 intubations documented in the DODTR during the study period: 1117 (25.7%) patients were intubated prehospital and 3224 (74.3%) were intubated in the ED. Patients intubated prehospital had a lower median age (24 versus 25 years, p < .001), composed a higher proportion of host nation forces (36.1% versus 29.1%, p < .001), had a lower proportion of injuries from explosives (57.6% versus 61.0%, p = .030), and had higher median injury severity scores (20 versus 18, p = .045). A lower proportion of the prehospital cohort survived to hospital discharge (76.4% versus 84.3%, p < .001). The prehospital cohort had lower odds of survival to hospital discharge in both univariable (odds ratio [OR] 0.60, 95% confidence interval [CI] 0.51-0.71) and multivariable analyses controlling for confounders (OR 0.70, 95% CI 0.58-0.85). In a subgroup analysis of patients with a head injury, the lower odds of survival persisted in the multivariable analysis (OR 0.49, 95% CI 0.49-0.82). Conclusions: Patients intubated in the prehospital setting had a lower survival than those intubated in the ED. This finding persisted after controlling for measurable confounders.

Keywords:

PMID: 31201757

DOI: NRMI-FF0K

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A Comparison of the iGel Versus Cricothyrotomy by Combat Medics Using a Synthetic Cadaver Model: A Randomized, Controlled Pilot study

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Schauer SG, April MD, Fairley R, Uhaa N, Hudson IL, Johnson MD, Keen DE, De Lorenzo RA. 20(4). 68 - 72. (Journal Article)

Abstract

Background: Airway obstruction is the second leading cause of potentially preventable death on the battlefield. Prior to 2017, the Committee on Tactical Combat Casualty Care (CoTCCC) recommended the surgical cricothyrotomy as the definitive airway of choice. More recently, the CoTCCC has recommended the iGel™ as the supraglottic airway (SGA) of choice. Data comparing these methods in medics are limited. We compared first-pass placement success among combat medics using a synthetic cadaver model. Methods: We conducted a randomized cross-over study of United States Army combat medics using a synthetic cadaver model. Participants performed a surgical cricothyrotomy using a method of their choosing versus placement of the SGA iGel in random order. The primary outcome was first-pass success. Secondary outcomes included time-to-placement, complications, placement failures, and self-reported participant preferences. Results: Of the 68 medics recruited, 63 had sufficient data for inclusion. Most were noncommissioned officers in rank (54%, E6-E7), with 51% reporting previous deployment experience. There was no significant difference in first-pass success (P = .847) or successful cannulation with regard to the two devices. Time-to-placement was faster with the iGel (21.8 seconds vs. 63.8 seconds). Of the 59 medics who finished the survey, we found that 35 (59%) preferred the iGel and 24 (41%) preferred the cricothyrotomy. Conclusions: In our study of active duty Army combat medics, we found no significant difference with regard to first-pass success or overall successful placement between the iGel and cricothyrotomy. Time-to-placement was significantly lower with the iGel. Participants reported preferring the iGel versus the cricothyrotomy on survey. Further research is needed, as limitations in our study highlighted many shortcomings in airway research involving combat medics.

Keywords: combat, medic; airway; cricothyroidotomy; supraglottic; extraglottic

PMID: 33320315

DOI: A3RU-HNS9

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A Comparison of the Laryngeal Handshake Method Versus the Traditional Index Finger Palpation Method in Identifying the Cricothyroid Membrane, When Performed by Combat Medic Trainees

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Moore A, Aden JK, Curtis R, Umar M. 19(3). 71 - 75. (Journal Article)

Abstract

Background: The laryngeal handshake method (LHM) may be a reliable standardized method to quickly and accurately identify the cricothyroid membrane (CTM) when performing an emergency surgical airway (ESA). However, there is currently minimal available literature evaluating the method. Furthermore, no previous CTM localization studies have focused on success rates of military prehospital providers. This study was conducted with the goal of answering the question: Which method is superior, the LHM or the traditional method (TM), for identifying anatomical landmarks in a timely manner when performed by US Army combat medic trainees? Methods: This prospective randomized crossover study was conducted at Ft Sam Houston, TX, in September 2018. Two Army medic trainees with similar body habitus volunteered as subjects, and the upper and lower borders and midline of their CTMs were identified by ultrasound (US). The participants were also recruited from the medic trainee population. After receiving initial training on the LHM and refresher training on the TM, participants were asked to localize the CTMs of each subject with one method per subject. Success was defined as a marking within the borders and 5mm of midline within 2 minutes. Results: Thirty-two combat medic trainees participated; 78% (n = 25) successfully localized the CTM using the TM versus 41% (n = 13) using the LHM (p = .002). Conclusion: Findings of this study support that at present the TM is a superior method for successful localization of the CTM when performed by Army combat medic trainees.

Keywords: laryngeal handshake method; cricothyrotomy landmarks; cricothyroidotomy palpation; austere cricothyroidotomy

PMID: 31539436

DOI: R68T-D9IB

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A Comparison of Two Chronic Skin Conditions: Atopic Dermatitis and Psoriasis

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Conlon EG, Wright KT. 19(1). 125 - 127. (Journal Article)

Abstract

Atopic dermatitis (eczema) and psoriasis are two common chronic skin diseases that affect many people, including active- duty military Servicemembers and their families. Both conditions have significant psychosocial impacts and can lead to substantial morbidity if undiagnosed and left untreated. We compare and contrast atopic dermatitis and psoriasis in terms of epidemiology, etiology, presentation, diagnosis, and treatment. The goal is to help military medical providers distinguish between the two diseases and provide practical steps for treatment and long-term management.

Keywords: atopic dermatitis; dermatology; diagnostics; eczema; psoriasis; skin conditions; treatment

PMID: 30859539

DOI: RT22-4387

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A Comparison of Ventilation Rates Between a Standard Bag-Valve-Mask and a New Design in a Prehospital Setting During Training Simulations

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Costello JT, Allen PB, Levesque R. 17(3). 59 - 63. (Journal Article)

Abstract

Background: Excessive ventilation of sick and injured patients is associated with increased morbidity and mortality. Combat Medical Systems® (CMS) is developing a new bag-valve-mask (BVM) designed to limit ventilation rates. The purpose of this study was to compare ventilation rates between a standard BVM device and the CMS device. Methods: This was a prospective, observational, semirandomized, crossover study using Army Medics. Data were collected during Brigade Combat Team Trauma Training classes at Camp Bullis, Texas. Subjects were observed during manikin simulation training in classroom and field environments, with total duration of manual ventilation and number of breaths given recorded for each device. Analysis was performed on overall ventilation rate in breaths per minute (BPM) and also by grouping the subjects by ventilation rates in low, correct, and high groups based on an ideal rate of 10-12 BPM. Results: A total of 89 Medics were enrolled and completed the classroom portion of the study, with a subset of 36 evaluated in the field. A small but statistically significant difference in overall BPM between devices was seen in the classroom (ρ < .001) but not in the field (ρ > .05). The study device significantly decreased the incidence of high ventilation rates when compared by groups in both the classroom (ρ < .001) and the field (ρ = .044), but it also increased the rate of low ventilation rates. Conclusion: The study device effectively reduced rates of excessive ventilation in the classroom and the field.

Keywords: bag-valve-mask; BVM; hyperventilation; hemorrhage; traumatic brain injury; TBI; prehospital trauma

PMID: 28910470

DOI: 6Q5D-6CL6

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A Comprehensive Method of Assessing Body Composition Using Kinanthropometry in Human Performance Training

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Wentz LM, Webb PS, Burks K. 22(2). 37 - 41. (Journal Article)

Abstract

Nutrition is an essential component of Human Performance Optimization in Special Operations Forces (SOF) to enhance physical and mental performance, unit readiness, and mission success. Body composition is frequently used to monitor individual nutrition progress; however, using body fat percentage is limited both by the accuracy of the assessment method and its association with SOF relevant performance outcomes. Lower body fat and/or body mass index have generally, but not universally, been correlated with higher levels of physical performance, yet they poorly predict performance in military relevant tasks. As a complement to body fat, many performance dietitians in the SOF Human Performance Programs utilize the International Society for Advanced Kinanthropometry (ISAK) profile to assess body composition, proportionality, ratio of muscle to bone, and somatotype in combat Operators. Kinanthropometry is the study of human size, shape, proportion, composition, maturation, and gross function, and it is a helpful tool for monitoring nutrition and training progress in athletes and active individuals. The ISAK profile has been well established as an international method for talent identification, distinguishing characteristics between athletes across and within elite sports, and identifying predictors of sport performance that can be applied in the military setting. While some SOF dietitians are utilizing the ISAK profile, the challenge lies in translating sport data to military relevant outcomes. We present a series of four case studies demonstrating the utility of this method as a portable comprehensive assessment for cross-sectional and longitudinal body composition tracking in a military setting.

Keywords: human performance optimization; performance nutrition; muscle mass; physical fitness; military

PMID: 35639891

DOI: VFOY-ZEG6

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A Dangerous Waste Of Time: Teaching Every Soldier Intravenous Line Placement

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Mabry RL, Cuenca PJ. 08(4). 55 - 57. (Editorial)

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DOI:

A Descriptive Analysis of Occupational Fatalities Due to Felonious Assault Among U.S. Law Enforcement Officers During Tactical Incidents, 1996-2014

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Thompson MS, Hartman TM, Sztajnkrycer MD. 17(3). 69 - 73. (Journal Article)

Abstract

Introduction: Little is known about occupational fatalities among tactical officers. A greater understanding of such injuries is needed to improve officer safety. The purpose of this study was to provide a descriptive analysis of line-of-duty deaths secondary to felonious assault during tactical incidents. Methods: Retrospective analysis was performed of open-source de-identified Federal Bureau of Investigation Uniform Crime Reporting Law Enforcement Officers Killed and Assaulted (LEOKA) data inclusive of the years 1996-2014. Officers were included if the fatal injury occurred during operations by a Special Weapons and Tactics (SWAT) team, fugitive task force, narcotics task force, or if the LEOKA narrative described the event as a tactical situation. Results: Of 1,012 officer deaths during the study period, 57 (5.6%) involved tactical officers. On average (± standard deviation), victim officers were 37.3 ± 7.8 years of age at the time of death, with 11.7 ± 6.6 years of law enforcement experience. High-risk warrant service accounted for 63.2% of fatalities. A single officer was killed in 91.2% of incidents; 49.1% of cases involved injuries to other officers. The majority of officers (59.6%) killed were the first officer(s) to enter the scene. The most commonly identified cause of death was head trauma (n = 28). Chest trauma accounted for 14 deaths; 10 (71.4%) sustained an entry wound via the ballistic vest armhole. Where recorded, 52.0% of officers died within the first hour of injury. The provision or nature of buddy care, tactical emergency medical services (EMS) care, or conventional EMS care was rarely noted. Conclusion: Tactical officer deaths most commonly occur during high-risk warrant service, and most often involve the first officer(s) to enter a scene, suggesting an opportunity for improved operational tactics. The frequency of fatal axillary penetration suggests the opportunity for ballistic protection redesign. Information is lacking regarding on-scene care, limiting the ability to determine optimal medical procedures for downed officers during tactical operations. Nearly 50% of victim officers survived more than 1 hour from time of injury, suggesting opportunities to intervene and potentially affect outcomes.

Keywords: tactical; Special Weapons and Tactics; SWAT; tactical emergency medical support; felonious assault

PMID: 28910472

DOI: AJYT-CIQA

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A Descriptive Analysis of US Prehospital Care Response to Law Enforcement Tactical Incidents

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Aberle SJ, Lohse CM, Sztajnkrycer M. 15(2). 117 - 122. (Journal Article)

Abstract

Background: Law enforcement tactical incidents involve high-risk operations that exceed the capabilities of regular, uniformed police. Despite the existence of tactical teams for 50 years, little is known about the frequency or nature of emergency medical services (EMS) response to tactical events in the United States. The purpose of this study was to perform a descriptive analysis of tactical events reported to a national EMS database. Methods: Descriptive analysis of the 2012 National Emergency Medical Services Information System (NEMSIS) Public Release research data set, containing EMS emergency response data from 41 states. Results: A total of 17,479,328 EMS events were reported, of which 3,953 events were coded as "Activation-Tactical or SWAT Specialty Service/Response Team." The most common level of prehospital care present on scene was basic life support (55.2%). The majority (72.3%) of tactical incident activations involved a single patient; mass casualty incidents occurred in 0.5% of events. The most common EMS response locations were homes (48.4%), streets or highways (37.0%), and public buildings (6.3%). The mean age of treated patients was 44.1 years ± 22.0 years; 3.5% of tactical incident activation patients were aged 8 years or less. Injuries were coded as firearm assault in 14.8% and as chemical exposure in 8.9% of events. Cardiac arrest occurred in 5.1% of patients, with the majority (92.2%) occurring prior to EMS arrival. The primary symptoms reported by EMS personnel were pain (37.4%), change in responsiveness (13.1%), and bleeding (8.1%). Advanced airway procedures occurred in 30 patients. No patients were documented as receiving tourniquets or needle thoracostomy. Conclusion: Approximately 11 EMS responses in support of law enforcement tactical operations occur daily in the United States. The majority occur in homes and involve a single patient. Advanced airway procedures are required in a minority of patients. Cardiac arrest is rare and occurs prior to EMS response in the majority of cases. Better understanding of the nature and location of EMS responses to tactical incidents is required to develop consistent EMS policies in support of law enforcement tactical operations.

Keywords: TEMS; emergency medical services; tactical; SWAT

PMID: 26125175

DOI: YCVJ-F6Z8

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A Herpes Zoster Outbreak on the Sinai Peninsula

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Acierto D, Savioli S, Studer NM. 16(2). 1 - 4. (Case Reports)

Abstract

Background: Infection with the varicella zoster virus, a type of herpesvirus, causes chickenpox in children and herpes zoster (commonly known as shingles) in adults. Case Presentation: Two 20-year-old male Soldiers returned from an outpost with a rash consistent with herpes zoster. Two other Soldiers with whom they were in close had had a similar rash 2 weeks earlier, which had since resolved at the time of initial presentation. Management and Outcome: Both Soldiers were started on an antiviral regimen and released to duty. They reported progressive relief, but both Soldiers redeployed to the United States before complete resolution. Conclusion: Herpes zoster cannot be transmitted from person to person. It is rare for young healthy people to become afflicted with it, let alone for two people to get it at the same time, which initially raised concern for infections mimicking herpes zoster. However, herpes zoster may be triggered by acute stress. Providers in deployed areas should consider the diagnosis in personnel who have had childhood varicella zoster infection (chickenpox).

Keywords: shingles; herpes zoster; operational medicine; Sinai

PMID: 27450594

DOI: TIMN-6UCN

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A Lost Opportunity: The Use of Unorthodox Training Methods for Prehospital Trauma Care

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McCarthy J, Lauria MJ, Fisher AD. 22(3). 29 - 35. (Journal Article)

Abstract

Prehospital trauma care guidelines and instruction have advanced significantly over the past 20 years. Although there have been efforts to create a standardized approach to instruction, the use of unorthodox techniques that lack supporting evidence persists. Many instructors use unrealistic scenarios, "no-win" scenarios, and unavoidable failing situations to train students. Doing so, however, creates student confusion and frustration and can result in poor skill acquisition. These training techniques should be reconsidered, with focus placed instead on the development of technical skills and far skill transfer. Knowing when to apply the appropriate type and level of stress within a training scenario can maximize student learning and knowledge retention. Furthermore, modalities such as deliberate practice, cognitive load theory (CLT), and stress exposure training (SET) should be incorporated into training. To improve delivery of prehospital trauma education, instructors should adopt evidence-based educational strategies, grounded in educational and cognitive science, that are targeted at developing long-term information retention as well as consistent, accurate, and timely life-saving interventions.

Keywords: training techniques; trauma care; education; teaching; military medicine

PMID: 35862849

DOI: AQU3-F0UP

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A Magnetic Resonance Imaging Study to Define Optimal Needle Length for Humeral Head IO Devices

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Rush SC, Bremer J, Foresto C, Rubin AM, Anderson PI. 12(2). 77 - 82. (Journal Article)

Abstract

Introduction: Intraosseous (IO) devices have gained popularity because of TCCC. The ability to gain access to the vascular system when intra venous access is not possible, and techniques such as central lines or cut-downs are beyond the scope of battlefield providers and tactically not feasible, has lead to the increased use of IO access. Since tibias are often not available sites in blast injury patients, the sternum was often used. Recently the humeral head has gained popularity because of ease of access and placement. The optimal needle length has not been defined or studied. Methods and Materials: Fifty consecutive shoulder MRIs among 18-40 year old patients were reviewed. Distances from the skin surface to the cortex from anterior and lateral trajectories were simulated and measured. Two different lateral trajectories were studied described as lateral minimum and lateral maximum trajectories, correlating with seemingly less and greater soft tissue. The cortical thickness was also recorded. Mean values and ranges for the measurements were determined. Results: The anterior trajectory represented the shortest distance. Mean anterior, mean lateral minimum and mean lateral maximum distances were 2.3, 3.0 and 4.7cm with corresponding ranges of 1.1-4.1, 1.6-5.7 and 2.8-7.4cm respectively. The cortical thickness was 4mm in all cases. Conclusions: Although this information was gathered amongst civilians, and many military members may have more soft tissue, these results indicate that needle length generally in the 40-50mm range should be used via the anterior approach. Use of a standard 25mm needle often used in the tibia would be inadequate in over half the cases, and may result in undue tissue compression or distortion.

Keywords:

PMID: 22707029

DOI: G6CY-1P5N

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A Man Who Put His Freedom to Use: A Story About Freedom and MSG (Ret) John Dominguez, Special Operations Combat Medic, That Took Place in Ethiopia in 2005

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Croushorn J. 22(2). 149 - 151. (Journal Article)

Keywords:

PMID: 35639906

DOI: CO7Y-F20V

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A Medical Training Event for Special Forces Medical Sergeants

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Hellums JS. 12(1). 56 - 61. (Journal Article)

Abstract

Special Forces Medical Sergeants (SFMS) are independent multidisciplinary medical personnel who possess unique medical skill sets that require regular practice in order to maintain proficiency. Due to high operational tempo, the windows of opportunity to practice these abilities are usually limited to short periods of required training to maintain credentials. A Special Forces (SF) Battalion allowed their medical section to orchestrate a weeklong medical training event that included emergency procedure lectures, human cadaver training, ultrasound familiarization, medical administration instruction, and behavioral health discussions. This training enabled the SFMS to hone their competencies and increase their clinical confidence while working and learning from each other and other medical providers. The training event was a great success.

Keywords: Special Forces; skills sustainment; cadaver training; ultrasound; emergency medical procedures

PMID: 22427050

DOI: MBOT-VT31

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A Modern Case Series of Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) in an Out-of-Hospital, Combat Casualty Care Setting

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Manley JD, Mitchell BJ, DuBose JJ, Rasmussen TE. 17(1). 1 - 8. (Case Reports)

Abstract

Background: Resuscitative endovascular balloon occlusion of the aorta (REBOA) is used to mitigate bleeding and sustain central aortic pressure in the setting of shock. The ER-REBOA™ catheter is a new REBOA technology, previously reported only in the setting of civilian trauma and injury care. The use of REBOA in an out-of-hospital setting has not been reported, to our knowledge. Methods: We present a case series of wartime injured patients cared for by a US Air Force Special Operations Surgical Team at an austere location fewer than 3km (5-10 minutes' transport) from point of injury and 2 hours from the next highest environment of care-a Role 2 equivalent. Results: In a 2-month period, four patients presented with torso gunshot or fragmentation wounds, hemoperitoneum, and class IV shock. Hand-held ultrasound was used to diagnose hemoperitoneum and facilitate 7Fr femoral sheath access. ER-REBOA balloons were positioned and inflated in the aorta (zone 1 [n = 3] and zone 3 [n = 1]) without radiography. In all cases, REBOA resulted in immediate normalization of blood pressure and allowed induction of anesthesia, initiation of whole-blood transfusion, damage control laparotomy, and attainment of surgical hemostasis (range of inflation time, 18-65 minutes). There were no access- or REBOArelated complications and all patients survived to achieve transport to the next echelon of care in stable condition. Conclusion: To our knowledge, this is the first series to demonstrate the feasibility and effectiveness of REBOA in modern combat casualty care and the first to describe use of the ER-REBOA catheter. Use of this device by nonsurgeons and surgeons not specially trained in vascular surgery in the out-of-hospital setting is useful as a stabilizing and damage control adjunct, allowing time for resuscitation, laparotomy, and surgical hemostasis.

Keywords: REBOA; endovascular balloon occulsion; shock, hemorrhagic; austere environments

PMID: 28285473

DOI: 9H3H-5GPS

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A Multiyear Analysis of the Clinical Encounters of the ATF Tactical Medical Program

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Tang N, Kubit J, Berrett OM, Levy MJ. 14(3). 102 - 106. (Journal Article)

Abstract

Background: The Bureau of Alcohol, Tobacco, Firearms and Explosives (ATF) Tactical Medical Program provides tactical medical support for ATF's tactical Special Response Teams (SRTs) and investigative National Response Teams (NRTs) through the deployment of specially trained ATF Agent-Medics. All patient care activities are centrally coordinated through ATF Headquarters. Methods: A retrospective analysis of de-identified patient care reports (PCRs) from the ATF Tactical Medical Program from 2009 to 2012 was performed. Clinical and operational data were extracted from PCRs and were entered into a database by the research team. Descriptive and summative analyses were performed to assess patient type, law enforcement incident type, chief complaint, and interventions performed. Results: Analysis was performed on the 254 charts. Nearly half (114; 44.9%) of patients encountered during the study period were law enforcement officers. High-risk warrant service was associated with one third (85; 33.5%) of the ATF medics' clinical encounters. The most common chief complaints of patients encountered were musculoskeletal pain/injury (57; 22.4%) and wounds/lacerations (57; 22.4%), followed by heat illness (17; 6.7%). The most common intervention was wound care (61; 26.9%), followed by control of bleeding with direct pressure (43; 18.9%). The most common medications administered were ibuprofen (28; 25.2%), topical antibiotic (12; 10.8%), and acetaminophen (12;10.8%). Conclusion: This multiyear analysis represents an important contribution to the growing body of scientific literature surrounding tactical medicine. The results of this analysis demonstrate a continued need for expanded scope of practice training, as well as enhanced treatment protocols for tactical medics.

Keywords: tactical emergency medical support; tactical medicine

PMID: 25344717

DOI: 5NW9-ECZ1

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A New Look On Civil Military Operations

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Johnston MJ, Shearer J, Wilson W. 08(4). 36 - 37. (Journal Article)

Abstract

Civil Affairs has a long history of helping ease the impact of war on a civilian population. To this end, providing medical care and education to a civilian population is beneficial. When these can be provided by host nation assets instead of solely by U.S. Forces, the benefits are exponential. Examined here is a summary of how a Civil Affairs team accomplished these goals in the Philippines during the spring of 2007.

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A New Plan For The 800-pound Guerrilla: Perinatal Mortality. A 21st Century Medical Counterinsurgency Model For Afghanistan

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Johnson TC. 11(4). 52 - 55. (Journal Article)

Abstract

Afghanistan has the highest perinatal mortality rate in the entire world. One Afghani woman dies every 30 minutes from perinatal- related event. One of eight Afghani women will die from perinatal events. Maternal mortality is (use percentage, not fractions) 1600/100,000 vs 13 /100,000 in the United States. Afghanistan is one of the only countries in the world in which the average woman's life expectancy is shorter than a males- despite the active, nationwide combat fought primarily by Afghani males. Meaning, women in Afghanistan are not routinely involved in combat, yet are more likely to die than a man of the same age. This article presents an alternative model Medical Seminar (MEDSEM) for a successful Special Forces (SF) medical counterinsurgency (COIN) plan that can obtain real results by addressing the mission of the Afghan Ministry of Health versus clinging to old notions. This model forms around the medical capabilities of the SF Operational Detachment (ODA)- Alpha (A) and preventinmaternal- infant complications.

Keywords:

PMID: 22173597

DOI: 846X-RANO

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A New Standard for Battlefield Trauma Care in the US Military

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Butler FK. 18(2). 153 - 153. (Classical Conference)

Keywords:

PMID: 29889976

DOI: X864-XO4Q

A Nontraditional Role as a Physical Therapist in the Quality of Life Plus Program (QL+)

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Springer B. 19(1). 31 - 33. (Journal Article)

Keywords: Quality of Life Plus Program (QL+); physical therapist; sports and orthopedic physical therapy; veterans

PMID: 30859523

DOI: TPH3-ROUR

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A Novel Application Of Hydrogel To Improve The Asherman Chest Seal® In A Deployed Environment

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Nowrouzzadeh F. 07(4). 38 - 42. (Journal Article)

Abstract

There are many challenges when practicing medicine in an operational environment. These challenges can be compounded with multiple traumatic injuries and extreme environments. The Asherman chest seal® has been issued to the U.S. Navy as a standard piece of medical equipment used to treat thoracic injuries. In the austere setting, there have been a number of case reports of the device failing to maintain a seal. By using an adhesive material called hydrogel, a water based polymer compound, with the chest seal, successful seal of penetrating chest wounds have been reported. This combination provides a way to improve the effectiveness and efficiency of medical personnel's live-saving gear.

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A Novel Cryotherapy Compression Wrap in the Management of Acute Ankle Sprains: Potential Use for Special Operators on the Battlefield

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Boland M, Mulligan I, Payette J, Serres J, O'Hara R, Maupin G. 12(4). 17 - 23. (Journal Article)

Abstract

Objective: Musculoskeletal injuries related to training and operational missions frequently affect military personnel. A common treatment for these injuries is the PRICE (protection, rest, ice, compression, and elevation) method, which is time consuming and impractical in the field. Therefore, the primary objective of this study was to determine the effectiveness of the cryotherapy wrap compared to a traditional treatment in the management of acute ankle sprains. Methods: A randomized controlled clinical trial was conducted in a university research laboratory with 13 subjects (9 males and 4 females) with the following physical characteristics: age (yr) 20.6 ± 2.2, height (cm) 177.0 ± 14.3, weight (kg) 76.6 ± 20.6, and body mass index (kg/m2) 24.1 ± 3.7. Participants were instructed to perform PRICE with a traditional ice pack and compression wrap (control group) or with an Arctic Ease® cryotherapy wrap (test group) for 48 hours following enrollment in the study. The Numeric Pain Scale, Foot and Ankle Ability Measure, and ankle/foot volumetric measurement were performed at initial presentation and 24-hour, 48-hour, and 7-day follow-up intervals. Results: While the comparison of the Numeric Pain Scale scores, Foot and Ankle Ability Measure scores, and volumetric changes between groups revealed no statistically significant differences (ρ > 0.01), there was an 86% compliance rate for subjects in the cryotherapy wrap group compared to a 17% compliance rate of subjects in the control group. Conclusions: The cryotherapy wraps performed comparably to ice therapy and therefore may be especially applicable to military personnel required to operate in austere and hostile environments where traditional therapies are unrealistic. Although this pilot study did not demonstrate that the cryotherapy wraps produce statistically superior results, trends emerged in the data suggesting that subject compliance rate may be improved by using an alternative form of cryotherapy compression, which could lead to better management of pain, edema, and functional recovery. Future research should include a larger sample size to verify this claim.

Keywords: crytotherapy; ankle sprain; ice; edema; compression

PMID: 23536452

DOI: WVY0-TRTS

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A Novel Ultrasound Transmission Gel for Resource-Constrained Environments

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Monti JD. 17(1). 22 - 25. (Journal Article)

Abstract

Ultrasound represents an ideal diagnostic adjunct for medical personnel operating in austere environments, because of its increasing portability and expanding number of point-of-care applications. However, these machines cannot be used without a transmission medium that allows for propagation of ultrasound waves from transducer to patient. This article describes a novel ultrasound gel alternative that may be better suited for resource-constrained environments than standard ultrasound gel, without compromising image quality.

Keywords: ultrasound; austere; ultrasound gel; military; POCUS

PMID: 28285477

DOI: J84X-IT77

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A Novel, Perfused-Cadaver Simulation Model for Tourniquet Training in Military Medics

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Grabo DJ, Polk T, Strumwasser A, Inaba K, Foran CP, Luther C, Minneti M, Kronstedt S, Wilson A, Demetriades D. 18(4). 97 - 102. (Journal Article)

Abstract

Background: Exsanguinating limb injury is a significant cause of preventable death on the battlefield and can be controlled with tourniquets. US Navy corpsmen rotating at the Navy Trauma Training Center receive instruction on tourniquets. We evaluated the effectiveness of traditional tourniquet instruction compared with a novel, perfused-cadaver, simulation model for tourniquet training. Methods: Corpsmen volunteering to participate were randomly assigned to one of two tourniquet training arms. Traditional training (TT) consisted of lectures, videos, and practice sessions. Perfused-cadaver training (PCT) included TT plus training using a regionally perfused cadaver. Corpsmen were evaluated on their ability to achieve hemorrhage control with tourniquet(s) using the perfused cadaver. Outcomes included (1) time to control hemorrhage, (2) correct placement of tourniquet(s), and (3) volume of simulated blood loss. Participants were asked about confidence in understanding indications and skills for tourniquets. Results: The 53 corpsmen enrolled in the study were randomly assigned as follows: 26 to the TT arm and 27 to the PCT arm. Corpsmen in the PCT group controlled bleeding with the first tourniquet more frequently (96% versus 83%; p < .03), were quicker to hemorrhage control (39 versus 45 seconds; p < .01), and lost less simulated blood (256mL versus 355mL; p < .01). There was a trend toward increased confidence in tourniquet application among all corpsmen. Conclusions: Using a perfused- cadaver training model, corpsmen placed tourniquets more rapidly and with less simulated-blood loss than their traditional training counterparts. They were more likely to control hemorrhage with first tourniquet placement and gain confidence in this procedure. Additional studies are indicated to identify components of effective simulation training for tourniquets.

Keywords:

PMID: 30566731

DOI: 3Q37-3P0A

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A Painful Rash in an Austere Environment

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Hellums JS, Klapperich K. 15(1). 113 - 117. (Journal Article)

Abstract

Dermatologic complaints are common in the deployed environment. Preventive medicine and knowledge of indigenous flora and fauna are cornerstones for forward deployed medical personnel. This article describes a case of Paederus dermatitis in an austere environment, reviews dermatologic terminology, and provides a reminder of the importance of exercising good preventive medicine procedures.

Keywords: Africa; dermatology; Special Operations medic; Paederus dermatitis

PMID: 25770808

DOI: SLRR-UKUI

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A Perspective on the Potential for Battlefield Resuscitative Endovascular Balloon Occlusion of the Aorta

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Knight RM. 17(1). 72 - 75. (Journal Article)

Abstract

Resuscitative endovascular balloon occlusion of the aorta (REBOA) has a place in civilian trauma centers in the United States, and British physicians performed the first prehospital REBOA, proving the concept viable for civilian emergency medical service. Can this translate into battlefield REBOA to stop junctional hemorrhage and extend "golden hour" rings in combat? If yes, at what level is this procedure best suited and what does it entail? This author's perspective, after treating patients on the battlefield and during rotary wing evacuation, is that REBOA may have a place in prehospital resuscitation but patient and provider selection are paramount. The procedure, although simple in description, is quite complicated and can cause major physiologic changes best dealt with by experienced providers. REBOA is incapable of extending the golden hour limiting the procedure's utility.

Keywords: REBOA; resuscitative endovascular balloon occlusion of the aorta; battlefield resuscitation; junctional hemorrhage

PMID: 28285483

DOI: JI27-4D3H

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A Pilot Study of Four Intraosseous Blood Transfusion Strategies

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Auten JD, Mclean JB, Kemp JD, Roszko PJ, Fortner GA, Krepela AL, Walchak AC, Walker CM, Deaton TG, Fishback JE. 18(3). 50 - 56. (Journal Article)

Abstract

Background: Intraosseous (IO) access is used by military first responders administering fluids, blood, and medications. Current IO transfusion strategies include gravity, pressure bags, rapid transfusion devices, and manual push-pull through a three-way stopcock. In a swine model of hemorrhagic shock, we compared flow rates among four different IO blood transfusion strategies. Methods: Nine Yorkshire swine were placed under general anesthesia. We removed 20 to 25mL/kg of each animal's estimated blood volume using flow of gravity. IO access was obtained in the proximal humerus. We then autologously infused 10 to 15mL/kg of the animal's estimated blood volume through one of four randomly assigned treatment arms. Results: The average weight of the swine was 77.3kg (interquartile range, 72.7kg-88.8kg). Infusion rates were as follows: gravity, 5mL/min; Belmont rapid infuser, 31mL/min; single-site pressure bag, 78mL/min; double-site pressure bag, 103mL/min; and push-pull technique, 109mL/min. No pulmonary arterial fat emboli were noted. Conclusion: The optimal IO transfusion strategy for injured Servicemembers appears to be single-site transfusion with a 10mL to 20mL flush of normal saline, followed immediately by transfusion under a pressure bag. Further study, powered to detect differences in flow rate and clinical complications. is required.

Keywords: blood transfusion; operational medicine; intraosseous infusion; intraosseous transfusion; hemorrhagic shock

PMID: 30222837

DOI: 6SU5-H23M

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A Prehospital Trauma Registry for Tactical Combat Casualty Care

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Kotwal RS, Montgomery HR, Mechler KK. 11(4). 127 - 128. (Previously Published)

Previously published in AMEDD Journal, Prehospital Combat Casualty Care - The Starting Point of Battlefield Survival. April June 2011

Abstract

Many combat-related deaths occur in the prehospital environment before the casualty reaches a medical treatment facility. The tenets of Tactical Combat Casualty Care (TCCC) were published in 1996 and integrated throughout the 75th Ranger Regiment in 1999. In order to validate and refine TCCC protocols and procedures, a prehospital trauma registry was developed and maintained. The application of TCCC, in conjunction with validation and refinement of TCCC through feedback from a prehospital trauma registry, has translated to an increase in survivability on the battlefield.

Keywords:

PMID: 22173603

DOI: ZGTC-RJQZ

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A Prospective Randomized Controlled Two-Arm Clinical Study Evaluating the Efficacy of a Bioelectric Dressing System for Blister Management in US Army Ranger Recruits

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Housler GJ, Cross S, Marcel V, Kennedy DO, Husband M, Register A, Roberts T, Grubbs S, Dudewicz D, Setka n, Bay C, Wendelken ME, Izadjoo MJ. 17(2). 49 - 58. (Journal Article)

Abstract

This study focused on a clinically relevant healthcare problem in the military: acute soft tissue wounds, or blisters. The trial was a prospective, controlled, randomized two-arm study evaluating the efficacy of a bioelectric dressing, Procellera®, applied topically two to three times per week for 2 weeks to blisters developed in Ranger trainees during training at Fort Benning, Georgia. A total of 80 US Army Ranger recruits with blister wounds below the knee were randomly assigned to one of two treatment groups (n = 40/group). The primary goal was to assess the clinical efficacy (rate of healing) of administered Procellera in conjunction with the standard-of-care (SOC) treatment, moleskin and Tegaderm ®, on the healing rate of blisters compared with the SOC treatment alone. The secondary end points for efficacy were the quantities of wound fluid biomarkers and bacterial bioburden. The tertiary end point was assessment of pain in the treatment group compared with that of the control group during the 2-week study. The results showed no statistical difference between the SOC and SOC+Procellera groups in wound healing and pain. Wound fluid was reported for 24 participants (64.9%) in the SOC group and 21 participants (56.8%) in SOC+Procellera group at the baseline measurement (ρ = .475); however, the wounds were devoid of fluid on follow-up visits. The mild nature of the wounds in this study was apparent by the low pain scores at the beginning of the study, which disappeared by the follow-up visits. The average wound sizes were 2.2cm2 and 1.5cm2 for the SOC and SOC+Procellera groups, respectively. This trial protocol should be conducted on open softtissue wounds in severe heat. To our knowledge, this is the first clinical study conducted within the US Army Rangers training doctrine.

Keywords: canines; K9s; Operational K9s; Tactical Emergency Casualty Care; Procellera®; dressing, bioelectric; wound, acute; Rangers

PMID: 28599034

DOI: BUPV-PAVD

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A Prospective, Feasibility Assessment of a Novel, Disposable Video Laryngoscope With Special Operations Medical Personnel in a Mobile Helicopter Simulation Setting

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Schauer SG, Mendez J, Uhaa N, Hudson IL, Weymouth WL. 21(4). 26 - 29. (Journal Article)

Abstract

Background: Video laryngoscopy (VL) is shown to improve first-pass success rates and decrease complications in intubations, especially in novice proceduralists. However, the currently fielded VL devices are cost-prohibitive for dispersion across the battlespace. The novel i-view VL is a low-cost, disposable VL device that may serve as a potential solution. We sought to perform end-user performance testing and solicit feedback. Methods: We prospectively enrolled Special Operations flight medics with the 160th Special Operations Aviation Regiment at Hunter Army Airfield, Savannah, Georgia. We asked them to perform an intubation using a synthetic cadaver model while in a mobile helicopter simulation setting. We surveyed their feedback afterward. Results: The median age of participants was 30 and all were male. Of those, 60% reported previous combat deployments, with a median of 20 months of deployment time. Of the 10, 90% were successful with intubation, with 60% on first-pass success with an average of 83 seconds time to intubation. Most had a grade 1 view. Most agreed or strongly agreed that it was easy to use (70%), with half (50%) reporting they would use it in the deployed setting. Several made comments about the screen not being bright enough and would prefer one with a rotating display. Conclusions: We found a high proportion of success for intubation in the mobile simulator and a high satisfaction rate for this device by Special Operations Forces medics.

Keywords: i-view; medic; airway; intubation; flight; helicopter; laryngoscopy

PMID: 34969123

DOI: 581V-SWP2

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A Review of Acute Kidney Injury

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Weidner DA, Yoo MJ. 22(3). 70 - 74. (Case Reports)

Abstract

Acute kidney injury (AKI) is a serious, often silent, medical condition with diverse etiologies and complex pathophysiology. We discuss the case of a patient injured in a single vehicle rollover. Included is a discussion of prevention and supportive care, with a focus on electrolyte repletion, fluid correction, minimization of nephrotoxic exposures, and identification and treatment of the root cause.

Keywords: acute kidney injury; supportive care; nephrotoxic exposures

DOI: 9AQ9-XEXQ

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A Review of Reduction Techniques for Anterior Glenohumeral Joint Dislocations

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Dannenbaum J, Krueger CA, Johnson AE. 12(2). 83 - 92. (Journal Article)

Abstract

This review article aims to describe the techniques, success rates, advantages and disadvantages of commonly used anterior shoulder reduction maneuvers. Methods: A review of literature was performed and each article was reviewed for the reported success rates, advantages, disadvantages and technical notes for each anterior shoulder reduction technique. Results: There are a wide variety of very successful shoulder reduction maneuvers, each with their own specific set of advantages and disadvantages. Conclusion: While there are some situations that may favor one of these anterior shoulder reduction techniques over another; it is largely left up to the healthcare provider to determine which maneuver is best on a patient-to-patient basis.

Keywords: shoulder dislocation; shoulder subluxation; shoulder reduction; orthopaedics; emergency medicine

PMID: 22707030

DOI: Z3ES-2TE9

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A Review of the Use of Early Hypothermia in the Treatment of Traumatic Brain Injuries

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Arcure J, Harrison EE. 09(3). 22 - 25. (Journal Article)

Abstract

Traumatic brain injury (TBI) is an assault to the brain that disrupts neurological activity. Known as the signature wound of combat during Operations Iraqi Freedom (OIF) and Enduing Freedom (OEF), it has become one of the most common injuries to American Soldiers. While affected Soldiers may remain stable after the primary injury, progressing secondary mechanisms can produce neurological degeneration. Hypothermic medicine is the treatment of injuries by cooling the core body temperature below normal physiological levels. Such treatment may be indicated to improve neurological outcomes after traumatic brain injuries by reducing the evolving secondary deterioration. To date, clinical trials have reached mixed conclusions. Trials have used unique temperature goals for treatment, different methods and times to reach such goals, and different durations at therapeutic temperature. Such variances in procedure and experimental populations have made it difficult to assess significance. In the article written by Markgraf et al. in 2001, research in animals showed the effect of hypothermic treatment within rats. Their results suggest that early initiation of hypothermic medicine after an induced traumatic brain injury (TBI) improved neurological outcomes when the body was cooled to 30°Celsius (C) within four hours. An ongoing study by Clifton et al., on adults diagnosed with TBI, is examining the neurological outcome of early hypothermic medicine by centrally cooling the body to 33°C and maintaining that temperature for 48 hours. While previous hypothermic devices were unable to cool rapidly, new technology allows achievement of the goal temperature within 20 minutes. Implementation of such new treatment may show an improvement in neurological outcomes for patients when treatment target temperature is reached within a four-hour window. We recommend that the use of hypothermic medicine should be re-evaluated for its indication in TBI due to the capabilities of a new extremely rapid cooling device.

Keywords:

PMID: 19739473

DOI: 6EAQ-Z4AP

A Salmon Thrombin-Fibrinogen Dressing Controls Hemorrhage in a Swine Model Compared to Standard Kaolin-Coated Gauze

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Floyd CT, Rothwell SW, Martin R, Risdahl J, Olson CE. 12(1). 49 - 55. (Journal Article)

Abstract

Battlefield hemorrhage remains the primary cause of death in potentially survivable combat injuries with noncompressible hemorrhage. Fibrin dressings have great potential for reducing mortality, however are limited by cost, availability, and disease transmission. Methods: Dressings comprising a soluble dextran dressing with lyophilized salmon thrombin and fibrinogen (STF) were tested against Combat Gauze (CG) as a control in a standard swine femoral artery hemorrhage model. Ten female swine were used in each arm of the study. Results: Survival, blood loss, and time to hemostasis were similar between the two dressings. Two of the CGtreated animals that survived exsanguinated during the simulated walking maneuver. Three CG-treated animals formed a clot within the wound, but the clot did not adhere to the femoral artery injury. All ten of the STFtreated animals formed a clot in the wound that adhered and sealed the arterial injury site, even in three animals that did not survive. None of the STF-treated animals bled following the simulated walking maneuver. Three of five STF-treated animals reestablished blood flow distal to the injury as demonstrated by angiography. Conclusions: The STF dressing is as efficacious as CG in treating hemorrhage in this model of a lethal injury. Further, the STF dressing formed a fibrin sealant over the injury, whereas CG achieved hemostasis by occlusive compression of the artery. The sealant property of the STF dressing allowed reestablishment of antegrade blood flow into the distal limb, demonstrating that this dressing has the potential of limb salvage in addition to control of life-threatening hemorrhage.

Keywords: hemorrhage control; Fibrin dressing; Fibrinogen; Combat Gauze™; animal model

PMID: 22427049

DOI: 3JN8-YUB5

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A Sampling of TCCC and ERCCC Journal Watch Abstracts From 2021

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Montgomery HR, Rich TA, Drew B, Cunningham CW, Butler FK. 22(3). 136 - 142. (Classical Conference)

Keywords:

DOI: ASS8-AGQR

A Series Of Special Operations Forces Patients With Sexual Dysfunction In Association With A Mental Health Condition

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Lang G. 08(3). 67 - 73. (Journal Article)

Abstract

The Department of Defense has placed considerable emphasis on the identification of post-traumatic stress disorder (PTSD) in military personnel returning from Iraq and Afghanistan, and several mandatory screening tools are currently used by primary care clinicians to assist in this effort. PTSD has been shown to impair emotional and social functioning, and to affect physical health and quality of life. Previous research has identified that combat veterans meeting diagnostic criteria for PTSD are more likely to experience some form of sexual dysfunction. This article presents four clinical cases of Special Operations Forces (SOF) patients who experienced sexual problems in association with symptoms of PTSD. Mandatory screening forms may be able to identify a subset of patients with PTSD; however, the perceived stigma of PTSD may prevent SOF personnel from seeking appropriate care. On the other hand, the barriers to care for sexual dysfunction have been reduced in recent years. Young, healthy male combat veterans who seek treatment for sexual dysfunction should be questioned about symptoms of PTSD.

Keywords:

DOI:

A Shift From Resilience to Human Performance Optimization in Special Operations Training: Advancements in Theory and Practice

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Park GH, Messina LA, Deuster PA. 17(3). 109 - 113. (Journal Article)

Abstract

Within the Department of Defense over the past decade, a focus on enhancing Warfighter resilience and readiness has increased. For Special Operation Forces (SOF), who bear unique burdens for training and deployment, programs like the Preservation of the Force and Family have been created to help support SOF and their family members in sustaining capabilities and enhancing resilience in the face of prolonged warfare. In this review, we describe the shift in focus from resilience to human performance optimization (HPO) and the benefits of human performance initiatives that include holistic fitness. We then describe strategies for advancing the application of HPO for future initiatives through tailoring and cultural adaptation, as well as advancing methods for measurement. By striving toward specificity and precision performance, SOF human performance programs can impact individual and team capabilities to a greater extent than in the past, as well as maintaining the well-being of SOF and their families across their careers and beyond.

Keywords: human performance optimization; Special Operations Forces

PMID: 28910478

DOI: 23RQ-8OSZ

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A Skeletal Traction Technique for Proximal Femur Fracture Management in an Austere Environment

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Lidwell D, Meghoo CA. 16(3). 1 - 4. (Case Reports)

Abstract

Skeletal traction is a useful technique for managing proximal femur fractures in austere environments where fracture stabilization for this injury is difficult. We present a technique and a construct appropriate for field use that facilitates patient evacuation, and we provide guidelines for the use of this technique by an advanced medical provider managing these injuries. The objectives of this article are to enable to reader to (1) recognize the role of skeletal traction in managing proximal femur fractures in an austere environment, (2) identify the key steps in placing transfemoral skeletal traction pins, and (3) identify options and requirements for building a traction construct in resource-limited environments.

Keywords: traction skeletal; fracture proximal femur

PMID: 27734434

DOI: 1FZH-J8DY

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A Soldier With an Exertional Heat Injury, Ischemic-Appearing Electrocardiogram, and Elevated Troponins: A Clinical Case Report

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Schauer SG, Pfaff JA. 17(1). 14 - 16. (Case Reports)

Abstract

Heat injuries are a common occurrence in the military training setting due to both the physically demanding nature of the training and the environments in which we train. Testing is often done after the diagnosis of a heat injury to screen for abnormalities. We present the case of a 20-year-old male Soldier with an abnormal electrocardiogram (ECG) with a possible injury pattern and an elevated troponin level. He underwent a diagnostic cardiac angiogram, which demonstrated no abnormal findings. He was returned to duty upon recovery from the catheterization. Ischemic-appearing ECG and troponin findings may be noted after heat injury. In this case, it was not associated with any cardiac lesions.

Keywords: injury, heat; heat-associated injuries; electrocardiogram; cardiac

PMID: 28285475

DOI: KA54-5LBT

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A SORT Plus a GHOST Equals: Experience of Two Forward Medical Teams Supporting Special Operations in Afghanistan 2019

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Nam JJ, Milia DJ, Diamond SR, Gourlay DM. 19(3). 117 - 121. (Journal Article)

Abstract

Theater Special Operations Force (SOF) medical planners have been using Army forward surgical teams (FSTs) to maintain a golden hour for US SOF during Operation Freedom's Sentinel in the form of Golden Hour Offset Surgical Treatment Teams (GHOST-Ts) in Afghanistan. Recently, the Special Operations Resuscitation Team (SORT) was designed to decompress and augment a GHOST-T to help extend a golden hour ring in key strategic locations. This article describes both teams working together in Operation Freedom's Sentinel while deployed in support of SOF in central Afghanistan during the summer fighting season.

Keywords: prolonged field care; austere medicine; military medicine; damage control resuscitation; damage control surgery

PMID: 31539446

DOI: 4KB6-VDU3

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A Spanish Intentional Mass-Casualty Incidents Medical Response Model: Delphi Consensus

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Roca G, Martin L, Borraz D, Serrano L, Lynam B. 20(4). 95 - 99. (Journal Article)

Abstract

The increase in global violence in recent years has changed the paradigm of emergency health care, requiring early medical response to victims in hostile settings where the usual work cannot be done safely. In Spain, this specific role is provided by the Tactical Environment Medical Support Teams (in Spanish, EMAETs). The Victoria I Consensus document defines and recognizes this role, whose main lines of work are the emergency medical response to the tactical team and to the victims in areas under indirect threat, provided that the tactical operators can guarantee their safety. To reinforce the suitability of this approach, we submitted the possible outcomes of this response model to a panel of national experts to assess this proposal in the different areas of Spain. The chosen research design is a conventional Delphi method, based on the content of the Victoria I Consensus response model. The panel of 52 expert reviewers from 11 different regions were surveyed anonymously; a high degree of accord was recognized when the congruence of the responses exceeded 75%. Consensus agreement was reached in all sections of the survey after two iterations. Specific contributions and recommendations were made to achieve unanimous consensus despite the population and resource differences in the country. Our results suggest that the EMAET approach is useful in areas with short response times. However, in more sparsely populated areas, this may not be feasible, and a more pragmatic response model may be suitable.

Keywords: Spanish international mass-casualty incidents medical response; global violence; response model; casualty incidents

PMID: 33320320

DOI: V88F-N5IX

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A Study of Prehospital Medical Documentation by Military Medical Providers During Precombat Training

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McGarry AB, Mott JC, Kotwal RS. 15(1). 79 - 84. (Journal Article)

Abstract

Documentation of medical care provided is paramount for improving performance and ultimately reducing morbidity and mortality. However, documentation of prehospital trauma care on the battlefield has historically been suboptimal. Modernization of prehospital documentation tools have aligned data and information to be gathered with up-to-date treatment being rendered through Tactical Combat Casualty Care (TCCC) protocols and practices. Our study was conducted to evaluate TCCC Card completion, and accuracy of card completion, by military medical providers conducting precombat training through the Tactical Combat Medical Care Course. Study results do not show a deficiency in TCCC documentation training as provided by this course which should translate to adequate ability to accurately document prehospital trauma care on the battlefield. Leadership emphasis and community acceptance is required to increase compliance with prehospital documentation.

Keywords: combat; documentation; prehospital; trauma

PMID: 25770802

DOI: YNKL-U3V8

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A Survey of Tranexamic Acid Use by US Tactical Emergency Medical Support Providers

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McGuire SS, Klassen AB, Mullan AF, Sztajnkrycer MD. 21(2). 72 - 76. (Journal Article)

Abstract

Background: Tactical Emergency Medical Support (TEMS) providers may encounter severe traumatic injuries, with associated hemorrhagic shock, coagulopathy, and hyperfibrinolysis. Tranexamic acid (TXA) administration represents a potential intervention in this operational environment. This study evaluated TXA availability and use among US tactical medical personnel supporting law enforcement tactical teams. Methods: An anonymous on-line survey of the American College of Emergency Physicians (ACEP) Tactical Emergency Medicine (TEM) section was administered. Results: Fifty respondents were included in the final study. Fifty-four percent reported TXA availability, with 14% reporting its use at least once in the past year. Additional available resuscitative products included crystalloids (88%) and packed red blood cells (6%). Twenty-five respondents reported managing ≥ 1 patient(s) with hemorrhagic shock in the past year. Resuscitative measures included crystalloids (96%), TXA (68%), and blood products (16%). Overall, 88% of respondents were supportive of TXA use. Full-time teams, those with = 3 monthly callouts, and teams that carried blood products were more likely to have TXA. Conclusions: Half of respondents reported managing a patient with hemorrhagic shock in the past year. Although 88% were supportive of TXA use, only 54% reported availability. Tactical teams with higher call volume and more resources were more likely to carry TXA. Further studies evaluating TEMS patient wounding patterns and barriers to TXA utilization are required.

Keywords: TXA; TEMS; tactical EMS; tranexamic acid; operational medicine; trauma-induced coagulopathy

PMID: 34105125

DOI: 8U6H-2X8Z

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A Threat-based, Statewide EMS Protocol To Address Lifesaving Interventions In Potentially Volatile Environments

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Levy MJ, Straight KM, Marino MJ, Alcorta RL. 16(1). 98 - 102. (Journal Article)

Keywords:

PMID: 27045505

DOI: OD5M-ZWGH

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A Triple-Option Analgesia Plan for Tactical Combat Casualty Care: TCCC Guidelines Change 13-04

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Butler FK, Kotwal RS, Buckenmaier CC, Edgar EP, O'Connor KC, Montgomery HR, Shackelford SA, Gandy JV, Wedmore I, Timby JW, Gross K, Bailey JA. 14(1). 13 - 25. (Journal Article)

Abstract

Although the majority of potentially preventable fatalities among U.S. combat forces serving in Afghanistan and Iraq have died from hemorrhagic shock, the majority of U.S. medics carry morphine autoinjectors for prehospital battlefield analgesia. Morphine given intramuscularly has a delayed onset of action and, like all opioids, may worsen hemorrhagic shock. Additionally, on a recent assessment of prehospital care in Afghanistan, combat medical personnel noted that Tactical Combat Casualty Care (TCCC) battlefield analgesia recommendations need to be simplified-there are too many options and not enough clear guidance on which medication to use in specific situations. They also reported that ketamine is presently being used as a battlefield analgesic by some medics in theater with good results. This report proposes that battlefield analgesia be achieved using one or more of three options: (1) the meloxicam and Tylenol in the TCCC Combat Pill Pack for casualties with relatively minor pain who are still able to function as effective combatants; (2) oral transmucosal fentanyl citrate (OTFC) for casualties who have moderate to severe pain, but who are not in hemorrhagic shock or respiratory distress and are not at significant risk for developing either condition; or (3) ketamine for casualties who have moderate to severe pain but who are in hemorrhagic shock or respiratory distress or are at significant risk for developing either condition. Ketamine may also be used to increase analgesic effect for casualties who have previously been given opioids (morphine or fentanyl.)

Keywords: battlefield analgesia; fentanyl; ketamine; morphine

PMID: 24604434

DOI: CBRW-A2G1

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A Woman of No Importance: The Untold Story of the American Spy Who Helped Win World War II

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Graverson SP. 22(1). 141 - 141. (Book Review)

Abstract

Purnell S. A Woman of No Importance: The Untold Story of the American Spy Who Helped Win World War II. Viking; Illustrated edition (April 9, 2019); 368 pp; ISBN 978-0-7352-2531-2

Keywords:

AAJT Design and Testing

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Croushorn J. 16(2). 68 - 68. (Letter)

Keywords:

DOI:

Abdominal Aortic and Junctional Tourniquet Controls Hemorrhage From a Gunshot Wound of the Left Groin

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Croushorn J. 14(2). 6 - 8. (Journal Article)

Abstract

"Junctional hemorrhage" is defined as bleeding from the areas at the junction of the trunk and its appendages. This is an important cause of potentially preventable deaths on the battlefield and a difficult condition to treat in the civilian prehospital setting. Having a solution to definitively treat the condition decreases the mortality and morbidity of these injuries. The Abdominal Aortic and Junctional Tourniquet™ is (1) a Food and Drug Administration-cleared device that is currently indicated for pelvic, inguinal, and axillary bleeding; (2) the only junctional tourniquet with an indication for pelvic bleeding; (3) the only junctional tourniquet reported with a successful axillary use; and (4) effective at lower tissue pressures than other junctional tourniquets available.

Keywords: Abdominal Aortic and Junctional Tourniquet; hemorrhage; gunshot wound

PMID: 24952033

DOI: 8IYL-YPCC

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Abdominal Aortic Tourniquet Controls Junctional Hemorrhage From a Gunshot Wound of the Axilla

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Croushorn J, McLester J, Thomas G, McCord SR. 13(3). 1 - 4. (Journal Article)

Abstract

Junctional hemorrhage, bleeding from the areas at the junction of the trunk and its appendages, is a difficult problem in trauma. These areas are not amenable to regular tourniquets as they cannot fit to give circumferential pressure around the extremity. Junctional arterial injuries can rapidly lead to death by exsanguination, and out-of-hospital control of junctional bleeding can be lifesaving. The present case report describes an offlabel use of the Abdominal Aortic Tourniquet™ in the axilla and demonstrates its safety and effectiveness of stopping hemorrhage from a challenging wound. To our knowledge, the present report is the first human use of a junctional tourniquet to control an upper extremity junctional hemorrhage.

Keywords: AAT; hemorrhage; amputations

PMID: 24048982

DOI: 61DQ-2EIQ

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Abdominal Aortic Tourniquet™ Use in Afghanistan

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Anonymous A. 13(2). 1 - 2. (Journal Article)

Abstract

The Abdominal Aortic Tourniquet™ was used recently used in Afghanistan to control severe hemorrhage in a casualty who had traumatic bilateral amputations of the lower extremities. Excerpts from the medical provider's account of the tactical evacuation phase of care are provided.

Keywords: Abdominal Aortic Tourniquet ™; AAT; hemorrhage; amputations

PMID: 24419826

DOI: HLJC-DMCK

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Abdominal Pain

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Banting J, Meriano T. 15(1). 118 - 122. (Journal Article)

Abstract

The series objective is to review various clinical conditions/ presentations, including the latest evidence on management, and to dispel common myths. In the process, core knowledge and management principles are enhanced. A clinical case will be presented. Cases will be drawn from real life but phrased in a context that is applicable to the Special Operations Forces (SOF) or tactical emergency medical support (TEMS) environment. Details will be presented in such a way that the reader can follow along and identify how they would manage the case clinically depending on their experience and environment situation. Commentary will be provided by currently serving military medical technicians. The medics and author will draw on their SOF experience to communicate relevant clinical concepts pertinent to different operational environments including SOF and TEMS. Commentary and input from active special operations medical technicians will be part of the feature.

Keywords: pain; abdominal pain; appendicitis; diagnosis; treatment

PMID: 25770809

DOI: UM7V-UG95

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Accuracy and Reliability of Triage at the Point of Injury During Operation Enduring Freedom

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Plackett TP, Nielsen JS, Hahn CD, Rames JM. 16(1). 51 - 56. (Journal Article)

Abstract

Background: Accurate point-of-injury reports and casualty evacuation requests allow for optimal resource utilization. However, the accuracy of these reports has not been previously studied. Methods: All trauma patients treated at one of three forward surgical elements (FSE) in Western Afghanistan during May-August 2012 were prospectively included. North American Treaty Organization (NATO) 9-line medical evacuation request and mechanism, injuries, signs, and treatments (MIST) reports were compared to the initial findings on arrival to the FSE. Results: There were 179 casualty evacuation reports and 298 patients. NATO 9-line and/or MIST reports were available for 70% of these. Triage was accurate for 77%, but there was 17% overtriage and 6% undertriage (k = .619). The number of patients was accurate in 95% of reports, the mechanism of injury was accurate for 98%, and the body region involved was accurate for 92% (k = .850, .943, and .870, respectively). There was no difference between the mean vital signs at the point of injury or on arrival at the FSE. When analyzed individually, however, there was no correlation between each casualty's pulse, mean arterial pressure, or respiratory rate between the two time points. Discussion: There was a high degree of correlation between the triage category of casualty evacuation reports and the patient's actual medical needs. There was also a highly significant association with the number of patients, mechanism of injury, and bodily injuries. However, there was discordance between the vital signs at an individual level, which may represent regression toward the resuscitation threshold.

Keywords: triage; trauma; war; Afghanistan; combat; accuracy

PMID: 27045494

DOI: 0OJ3-SPB8

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Achilles Tendinopathy: Pathophysiology, Epidemiology, Diagnosis, Treatment, Prevention, and Screening

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Knapik JJ, Pope R. 20(1). 125 - 140. (Journal Article)

Abstract

Achilles tendinopathy (AT) is a clinical term describing a nonrupture injury of the Achilles tendon where the patient presents with pain, swelling, and reduced performance and symptoms exacerbated by physical activity. About 52% of runners experience AT in their lifetime and in the United States military the rate of clinically diagnosed AT cases was 5/1000 person-yr in 2015. The pathophysiology can be viewed on a continuum proceeding from reactive tendinopathy where tenocytes proliferate, protein production increases, and the tendon thickens; to tendon disrepair in which tenocytes and protein production increase further and there is focal collagen fiber disruption; to degenerative tendinopathy involving cell death, large areas of collagen disorganization, and areas filled with vessels and nerves. Inflammation may be present, especially in the early phases. Some evidence suggests AT pain may be due to neovascularization and the ingrowth of new nerve fibers in association with this process. Prospective studies indicate that risk factors include female sex, black race, higher body mass index, prior tendinopathy or fracture, higher alcohol consumption, lower plantar flexion strength, greater weekly volume of running, more years of running, use of spiked or shock absorbing shoes, training in cold weather, use of oral contraceptives and/ or hormone replacement therapy, reduced or excessive ankle dorsiflexion range of motion, and consumption of antibiotics in the fluoroquinolone class. At least 10 simple clinical tests are available for the diagnosis of AT, but based on accuracy and reproducibility, patient self-reports of morning stiffness and/or pain in the tendon area, pain on palpation of the tendon, and detection of Achilles tendon thickening appear to be the most useful. Both ultrasound and magnetic resonance imaging (MRI) are useful in assisting in diagnosis with MRI providing slightly better sensitivity and specificity. Conservative treatments that have been researched include: (1) nonsteroidal anti-inflammatory medication, (2) eccentric exercise, (3) stretching, (4) orthotics, (5) bracing, (6) glyceryl trinitrate patches, (7) injection therapies (corticosteroids, hyaluronic acid, platelet-rich plasma injections), (8) shock wave therapy, and (9) low-level laser therapy. Nonsteroidal anti-inflammatory medication and corticosteroid injections may provide short-term relief but do not appear effective in the longer term. Eccentric exercise and shock wave therapies are treatments with the highest evidence- based effectiveness. Prevention strategies have not been well researched, but in specific populations balance training (soccer players) and shock-absorbing insoles (military recruits) may be effective. Ultrasound scans might be useful in predicting future AT occurrences.

Keywords: tendinitis; tendinosis; paratenonitis; ultrasound; morning stiffness; palpation pain; nonsteroidal anti-inflammatory drugs; eccentric exercise; orthotics; bracing; shock wave therapy; injection therapy

PMID: 32203618

DOI: QXTX-A72P

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Active Warfighter Mental Health Lower in Mid-Career

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Barczak-Scarboro NE, Cole WR, DeFreese JD, Fredrickson BL, Kiefer AW, Bailar-Heath M, Burke RJ, DeLellis SM, Kane SF, Lynch JH, Means GE, Depenbrock PJ, Mihalik JP. 22(3). 129 - 135. (Journal Article)

Abstract

Purpose: The present study investigated Special Operations Forces (SOF) combat Servicemember mental health at different SOF career stages in association with resilience. Methods: Fifty-eight SOF combat Service Members either entering SOF (career start; n=38) or multiple years with their SOF organization (mid-career; n=20) self-reported mild traumatic brain injury (TBI) history, resilience, subjective well-being, depression, anxiety, and posttraumatic stress. Poisson regression analyses were employed to test SOF career stage differences in each mental health symptom using resilience, while accounting for other pertinent military factors. Results: There were significant interaction effects of SOF career stage and resilience on mental health symptoms. SOF career start combat Servicemembers endorsed lower depression and posttraumatic stress and higher subjective well-being with higher resilience, but these associations between resilience and mental health symptoms were not seen in SOF mid-career Servicemembers. Conclusions: Although preliminary, the adaptive association between resilience and mental health seemed to be blunted in combat Servicemembers having served multiple years in SOF. This information informs research to provide evaluation tools to support prophylactic performance and long-term health preservation in military populations.

Keywords: depression; anxiety; posttraumatic stress; subjective well-being; military; concussion

DOI: I6M8-EZPL

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Active Warfighter Resilience: A Descriptive Analysis

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Barczak-Scarboro NE, Cole WR, DeFreese JD, Fredrickson BL, Kiefer AW, Bailar-Heath M, Burke RJ, DeLellis SM, Kane SF, Lynch JH, Means GE, Depenbrock PJ, Mihalik JP. 22(3). 22 - 28. (Journal Article)

Abstract

Purpose: Our aim in this study was to psychometrically test resilience assessments (Ego Resiliency Scale [ER89], Connor-Davidson Resilience Scale [CD-RISC 25], Responses to Stressful Experiences Scale [RSES short-form]) and describe resilience levels in a Special Operations Forces (SOF) combat sample. Methods: Fifty-eight SOF combat Servicemembers either entering SOF (career start; n = 38) or having served multiple years with their SOF organization (mid-career; n = 20) self-reported resilience, mild traumatic brain injury (mTBI) history, and total military service. Results: All resilience metrics demonstrated acceptable internal consistency, but ceiling effects were found for CD-RISC and RSES scores. ER89 scores were moderate on average. ER89 scores were higher in SOF career start than mid-career Servicemembers (ηρ2 = 0.07) when accounting for the interaction between SOF career stage and total military service (ηρ2 = 0.07). Discussion: SOF mid-career Servicemembers had similar ER89 resilience scores with more total military service. The SOF career start combat Servicemembers had higher ER89 measured resilience with less total military service only, potentially showing a protective effect of greater service before entering SOF. Conclusion: The ER89 may be a more optimal military resilience metric than the other metrics studied; longitudinal research on SOF combat Servicemember resilience is warranted.

Keywords: ego resiliency; US Army; US Air Force; psychometrics; readiness

PMID: 35862847

DOI: BHIF-QZUE

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Acute Mountain Sickness Prophylaxis In The SOF Operator

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Pennardt A, Talbot T. 08(3). 65 - 66. (Editorial)

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Acute Traumatic Wound Management in the Prolonged Field Care Setting

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Rapp J, Plackett TP, Crane J, Lu J, Hall A, Hardin RD, Loos PE, Kelly R, Murray CK, Keenan S, Shackelford S. 17(2). 132 - 149. (Journal Article)

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PMID: 28599047

DOI: Y9E0-4TLB

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Adaptations To A New Physical Training Program In The Combat Controller Training Pipeline

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Walker TB, Lennemann LM, Anderson V, Lyons W, Zupan MF. 11(3). 37 - 44. (Journal Article)

Abstract

Objectives: The United States Air Force combat controller (CCT) training pipeline is extremely arduous and historically has a high attrition rate of 70 to 80%. The primary objective of this study was to evaluate the impact of incorporating a 711 Human Performance Wing (HPW) / Biobehavior, Bioassessment, and Biosurveillance Branch (RHPF)-developed physical fitness-training program into the combat controller (CCT) 5-level training physical fitness program. Methods: One-hundred-nine CCT trainees were tested and trained during their initial eight weeks at the 720th Special Tactics Training Squadron (STTS) at Hurlburt Field. Modifications to their physical training program were principally aimed at reducing overtraining and overuse injury, educating trainees and cadre on how to train smarter, and transitioning from traditional to "functional" PT. A battery of physiological measurements and a psychological test were administered prior to and immediately after trainees undertook an 8-week modified physical fitness training program designed to reduce overtraining and injury and improve performance. We performed multiple physical tests for cardiovascular endurance (VO2max and running economy), "anaerobic" capacity (Wingate power and loaded running tests), body composition (skinfolds), power (Wingate and vertical jump), and reaction time (Makoto eye-hand test). We used the Mental Toughness Questionnaire 48 (MTQ-48) for the psychological test. Results: We observed several significant improvements in physical and physiological performance over the eight weeks of training. Body composition improved by 16.2% (p<0.05). VO2max, time-to-exhaustion, and ventilatory threshold were all significantly higher after implementation of the new program than before it. We observed strong trends towards improvement in work accomplished during loaded running (ρ = 0.07) and in average power per body mass during lower body Wingate (ρ = 0.08). Other measures of lower body power did not change significantly over the training period, but did show mild trends towards improvement. Upper body average and peak power per kilogram of body mass both improved significantly by 5.8% and 8.1%, respectively. Reaction time was significantly better posttraining as demonstrated by a 7% improvement during the reactive test. Reactive accuracy also improved significantly with the post test accuracy percentage jumping from 61% to 76%. Furthermore, overuse injuries, a major source of attrition fell by a dramatic 67%. Conclusions: The modifications resulted in significant improvement in trainees' graduation rate. In the eight classes prior to implementation of these changes, average CCT graduating class size was nine trainees. For the eight classes following the changes, average CCT graduating class rose to 16.5 trainees, an increase of 83%. Due to its success, STTS leadership expanded the modifications from the eight weeks prior to CDS to include the entire second year of the pipeline.

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PMID: 21706460

DOI: XYKE-P4N6

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Adapting to Death: Clarifying the Roles of Special Operations Combat Medics in Prolonged Field Care

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Jeschke EA. 18(4). 153 - 156. (Journal Article)

Abstract

I suggest that Special Operations Forces (SOF) medicine should explicitly acknowledge the Special Operations combat medic's role in attending death. This acknowledgment will allow researchers to evaluate and delimit the medic's needs in relationship to an expanded set of roles that move beyond life-saving care. This article comprises four sections. First, I provide background to my argument by exploring some assumptions of modern medicine and objections to exploring battlefield death care. Second, I describe how I see the medic's role expanding with the introduction of prolonged field care. Third, I address the implications of the medic's expanded role in relationship to role and function stress and strain. Fourth, I address the moral complexity related to withdrawing or withholding care. I conclude by briefly highlighting some of the implications for future research. In explicitly engaging death as a medical reality for which the medic ought to be prepared, SOF medicine could set the foundational development for seeing death as a valuable gift to be explored, not a failure to be avoided or burden to be overcome.

Keywords: death; ethics; combat casualty care; prolonged field care; Special Operations medic; death care; unconventional medicine

PMID: 30566744

DOI: QFSB-YB6F

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Adaptive Eyewear: Freeing The (visually) Oppressed

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DePold GD. 08(4). 25 - 26. (Journal Article)

Abstract

It is difficult for Special Operations Forces (SOF) to provide meaningful long-term medical solutions for the indigenous population in their area of operation (AO). Limited time, equipment, supplies, the inability to follow-up, and re-exposure to disease are common obstacles to effective local national patient care. Poor vision due to uncorrected refractive errors has a significant negative impact on quality of life in under-developed countries. New eyewear technology will give SOF Medics the ability to provide definitive care for this chronic, burdensome condition which will benefit both patient and mission.

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Addressing Maternal Healthcare Needs in the Counterinsurgency Environment

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Lang G, Lang C. 12(4). 39 - 44. (Journal Article)

Abstract

All pregnant women are at risk of obstetric complications, most of which occur during labor and delivery among women with no previously identified risk factors. More than 95 percent of these deaths occur in developing countries. In sub-Saharan Africa, a region of the world currently experiencing significant humanitarian crises, the lifetime risk of maternal death is one in 30 whereas the lifetime risk in developed countries is one in 2,800.1 The majority of maternal deaths from obstetric complications are due to hemorrhage, eclampsia, sepsis, or obstructed labor, each of which is treatable. Emergency obstetric care is critical to reducing maternal death and disability. SOF medical personnel supporting counterinsurgency (COIN) operations may find themselves in situations where no legitimate agencies are available to provide maternal healthcare. Similarly, SOF medical personnel should be prepared to assist in rebuilding infrastructure and basic services to include the provision for maternal health. This article provides an overview of maternal health in underdeveloped countries; the importance of addressing the unique healthcare needs of women during COIN operations; and how the employment of Female Treatment Teams (FTT) can assist in meeting these needs. A subsequent article will review the basics of prenatal care and life-saving emergency obstetric care, and discusses the essential information and skills that should be taught in a MEDSEM covering maternal healthcare.

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PMID: 23536456

DOI: BXJB-3SO3

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Admiral's Log: Surgeon General VADM Michael Cowan's Insights on Military Medicine

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Pennardt A. 17(1). 131 - 132. (Interview)

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PMID: 28285492

DOI: TJ31-0TGD

Advanced Airwaymanagement In Combat Casualties By Medics At The Point Of Injury: A Sub-Group Analysis Of The Reach Study

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Mabry RL, Cuniowski P, Frankfurt A, Adams BD. 11(3). 16 - 19. (Journal Article)

Abstract

Background: Optimal airway management protocols for the prehospital battlefield setting have not been defined. Airway management strategies in this environment must take into account the injury patterns, the environment and training requirements of military prehospital providers. Methods: This is a post-hoc, sub-group analysis of the Registry of Emergency Airways Arriving at Combat Hospitals or REACH database. This study examines only those patients who had advanced airways placed for trauma by an enlisted military medic at the point of injury. Results: Twenty (100%) of the patients had a traumatic injury, 19 (95%) were male, and 13 (65%) had a gun shot wounds (GSWs) as the mechanism of injury. The majority, 12 (60%) patients had an esophageal-tracheal airway device placed. Of the remaining patients, four (20%) underwent endotracheal intubation, three (15%) had a surgical cricothyroidotomy performed, and one (5%) had a Laryngeal Mask Airway (LMA) placed. Seventeen (85%) of the twenty patients were dead on arrival or died shortly after arrival at the Combat Support Hospital (CSH). All of the patients that died had a Glasgow Coma Scale (GCS) of three upon arrival. The Glasgow Coma Scale provides a score in the range 3-15; patients with scores of 3-8 are usually said to be in a coma. Three patients in this group survived to transfer from the CSH. Two of the transfers were lost to follow up, one with a GSW to the head and GCS of three, the other with a GCS of five from injuries sustained in an explosion. The third patient had a surgical cricothyroidotomy (SC) performed in the field for an expanding neck hematoma and recovered fully following surgery. Conclusions: Casualties that tolerate invasive airway management without sedation in the context of trauma prognosticates a very high mortality. Airway management algorithms for military providers should reflect the casualties encountered on the battlefield not patients in cardiac arrest which predominate in the civilian EMS airway management practice. Further data are needed to understand the injuries encountered on the battlefield and to develop airway management solutions that optimize outcomes of patients with battlefield trauma.

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PMID: 21706457

DOI: W35F-54HG

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Advanced Medical Technology Capacity Building and the Medical Mentoring Event: A Unique Application of SOF Counterinsurgency Medical Engagement Strategies

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Irizarry DJ, Tate C, Bingham MT, Wey P, Batjom E, Nicholas TA, Boedeker BH. 12(1). 24 - 30. (Journal Article)

Abstract

The Medical Civic Assistance Program (MEDCAP) is a military commander's tool developed during the Vietnam War to gain access to and positively influence an indigenous population through the provision of direct medical care provided by military medical personnel, particularly in Counter Insurgency Operations (COIN). An alternative to MEDCAPs is the medical seminar (MEDSEM). The MEDSEM uses a Commander's military medical assets to share culturally appropriate medical information with a defined indigenous population in order to create a sustainable training resource for the local population's health system. At the heart of the MEDSEM is the "train the trainer" concept whereby medical information is passed to indigenous trainers who then pass that information to an indigenous population. The MEDSEM achieves the Commander's objectives of increasing access and influence with the population through a medical training venue rather than direct patient care. Previous MEDSEMS conducted in Afghanistan by military forces focused on improvement of rural healthcare through creation of Village Health Care Workers. This model can also be used to engage host nation (HN) medical personnel and improve medical treatment capabilities in population centers. The authors describe a modification of the MEDSEM, a Medical Mentorship (MM), conducted in November 2010 in Kabul, Afghanistan, at the Afghan National Army (ANA) National Medical Hospital. This training was designed to improve intubation skills in Afghan National Army Hospitals by ANA medical providers, leave residual training capability, and build relationships within the institution that not only assist the institution, but can also be leveraged to foster Commanders' objectives, such as health and reconstruction initiatives and medical partnering for indigenous corps and medical forces described below.

Keywords: Counter-Insurgency; Medical Support; airway training; Afghan National Army

PMID: 22427046

DOI: YDEE-ZW9H

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Advanced Resuscitative Care in Tactical Combat Casualty Care: TCCC Guidelines Change 18-01:14 October 2018

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Butler FK, Holcomb JB, Shackelford SA, Barbabella S, Bailey JA, Baker JB, Cap AP, Conklin CC, Cunningham CW, Davis MS, DeLellis SM, Dorlac WC, DuBose JJ, Eastridge BJ, Fisher AD, Glasser JJ, Gurney JM, Jenkins DA, Johannigman J, King DR, Kotwal RS, Littlejohn LF, Mabry RL, Martin MJ, Miles EA, Montgomery HR, Northern DM, O'Connor KC, Rasmussen TE, Riesberg JC, Spinella PC, Stockinger Z, Strandenes G, Via DK, Weber MA. 18(4). 37 - 55. (Journal Article)

Abstract

TCCC has previously recommended interventions that can effectively prevent 4 of the top 5 causes of prehospital preventable death in combat casualties-extremity hemorrhage, junctional hemorrhage, airway obstruction, and tension pneumothorax- and deaths from these causes have been markedly reduced in US combat casualties. Noncompressible torso hemorrhage (NCTH) is the last remaining major cause of preventable death on the battlefield and often causes death within 30 minutes of wounding. Increased use of whole blood, including the capability for massive transfusion, if indicated, has the potential to increase survival in casualties with either thoracic and/or abdominopelvic hemorrhage. Additionally, Zone 1 Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) can provide temporary control of bleeding in the abdomen and pelvis and improve hemodynamics in casualties who may be approaching traumatic cardiac arrest as a result of hemorrhagic shock. Together, these two interventions are designated Advanced Resuscitative Care (ARC) and may enable casualties with severe NCTH to survive long enough to reach the care of a surgeon. Although Special Operations units are now using whole blood far-forward, this capability is not routinely present in other US combat units at this point in time. REBOA is not envisioned as care that could be accomplished by a unit medic working out of his or her aid bag. This intervention should be undertaken only by designated teams of advanced combat medical personnel with special training and equipment.

Keywords: Advanced Resuscitative Care; Committee on Emergency Casualty Care; guidelines

PMID: 30566723

DOI: YJB8-ZC0Y

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Advancing The Art And Science Of Medical Plans

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Reed B. 09(4). 96 - 98. (Journal Article)

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PMID: 20112653

DOI: V1OB-TOF2

Advancing the Practice of Contemporary Military Performance Psychology:A Full-Spectrum Approach to Psychological Health and Readiness

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Park GH, Knust SK, Haselhuhn S, Whalen SJ, Deuster PA, Greene CH, Dretsch MN, Bonvie JL, Lippy RD, Lunasco TK, Myatt CA. 22(1). 115 - 120. (Journal Article)

Abstract

The Department of Defense (DoD) continues to emphasize operational readiness, lethality, and optimal performance. Performance psychology is a critical aspect of and central dimension to human performance optimization in support of Preservation of the Force and Family (POTFF) and Total Force Fitness (TFF). The delivery of performance psychology services must continue to evolve to maximize its potential for enhancing combat performance and supporting psychological readiness in warfighters across all branches of service. The authors (1) provide a brief history of the evolution of military psychology; (2) explore how performance psychology complements and broadens approaches to support warfighter health and readiness; and (3) present a set of strategies to advance performance psychology services toward an aspirational model. Such strategies will more effectively promote best practices to better target operational performance, complement existing health and medical service delivery, and encompass a systems approach to sustainable training. Moreover, these strategies aim to increase return on investment of psychological readiness efforts for warfighters across all branches of service.

Keywords: military; psychology; performance optimization; performance psychology; psychological health; readiness

PMID: 35278327

DOI: 18DB-ITVE

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Advise and Assist: A Basic Medical Skills Course for Partner Forces

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April MD, Lopes T, Schauer SG, Meneses M, Roszenweig H, Byram D, Timms-Williams Z, Shields TP, Cross AN, Hoffmann LJ. 17(4). 63 - 67. (Journal Article)

Abstract

Background: Training partner forces in battlefield first-responder medical skills is an important component of US military advise-and-assist operations. We designed and executed a training curriculum focused on high-yield-based medical skills to prevent death on the battlefield for non-English speaking members of the Turkish, Azerbaijani, and Albanian militaries deployed to Afghanistan. Methods: We designed a 2-hour training curriculum focusing on four basic medical skills: (1) assessment of scene safety; (2) limb tourniquet application; (3) wound bandaging; and (4) patient transportation via litter. Our combat medics delivered standardized training using both didactic and practicum components. Instructors made beforeand- after assessments of the proficiency of each participant for each skill in accordance with the Dreyfus model of skill acquisition. We also administered before-and-after, Likertscale- based surveys for training participants to report their self-assessed comfort level with each of the four skills. Results: We delivered training to 187 participants over five classes. All 28 participants in the final teaching class completed the study. Instructors categorized each participant's skill level as novice before training for all four skills. After the training curriculum, all participants achieved a skill level consistent with advanced beginner for all four skills. Participants reported significant improvements in self-reported comfort levels for all taught procedures (ρ < .001 by Wilcoxon signed-rank test for all four skills). The largest reported increase in median comfort level was for tourniquet application: median pretraining comfort level, 4 (interquartile range [IQR], 0-6.25) versus 9.5 (IQR, 9-10) posttraining. Conclusion: Our curriculum resulted in significant improvements in instructor-assessed proficiency and self-reported comfort level for all four basic medical skills. Although our outcome measures have important limitations, this curriculum may be useful framework for future medics and physicians designing battlefield first-responder training curricula for members of foreign militaries.

Keywords: education; wounds and injuries; emergency medical services; military personnel

PMID: 29256197

DOI: TESU-T5DQ

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Aid and Comfort to the Enemy: A Surgeon's View of the War in Iraq

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Hester RA. 12(3). 77 - 77. (Book Review)

Abstract

Timothy Floyd, MD
Artbook Press, 2010.

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Air Force Special Operations Command Special Operations Surgical Team (sost) Conops

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Ervin MD. 08(2). 68 - 75. (Journal Article)

Abstract

The call for small surgical teams to provide direct support to SOF units has gained intensity over the last seven years. In July of 2003, the need for SOF specific Level II (including forward surgical support) was one of the top SOCOM medical lessons learned from OEF. In October of the same year, SOCOM put forth a tasking to develop organic resuscitative surgical capability within SOF. To respond to this tasking, the components looked to the existing smallest surgical units present in the services' inventories such as the FST, FRSS, and MFST. Army Forward Surgical Teams (FST) and Navy Forward Resuscitative Surgical Squadrons (FRSS) are designed to provide trauma care during maneuver warfare to battalion- sized forces and have delivered exceptional results in OIF. But even though these units are small compared to traditional Level III surgical hospitals, their size is too large to support emerging and short duration SOF missions. While other components were hindered by the lack of very small surgical units within their services' conventional inventories, AFSOC was able to rapidly acquire a few Air Force Mobile Field Surgical Teams (MFST) and begin developing the training, tactics, techniques, and procedures to meet the SOF community's needs. In doing so, it became clear that "SOF specific" surgical units serve a unique customer, must work within unique constraints, and must be agile enough to provide unique solutions. This paper presents the experiences and lessons learned in the ongoing development of the AFSOC Special Operations Surgical Team (SOST).

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Airway Management for Army Reserve Combat Medics: An Interdisciplinary Workshop

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Miller BM, Kinder C, Smith-Steinert R. 19(3). 64 - 70. (Journal Article)

Abstract

Background: An Army Reserve Combat Medic's training is focused on knowledge attainment, skill development, and building experience and training to prepare them to perform in austere conditions with limited resources like on the battlefield. Unfortunately, the exposure to skills they may be responsible for performing is limited. Research shows that greater than 90% of battlefield deaths occur in the prehospital setting, 24% of which are potentially survivable. Literature demonstrates that 91% of these deaths are related to hemorrhage; the remaining are related to other causes, including airway compromise. The skill and decision-making of this population are prime targets to optimize outcomes in the battlefield setting. Methods: Army Reserve combat medics were selected to voluntarily participate in an educational intervention provided by anesthesia providers focusing on airway management. Participants completed a preintervention assessment to evaluate baseline knowledge levels as well as comfort with airway skills. Medics then participated in a simulated difficult airway scenario. Next, airway management was reviewed, and navigation of the difficult airway algorithm was discussed. The presentation was followed by simulations at four hands-on stations, which focused on fundamental airway concepts such as bag-mask ventilation and placement of oral airways, tracheal intubation, placement of supraglottic airways, and cricothyrotomy. Pre/post knowledge assessments and performance evaluation tools were used to measure the effectiveness of the intervention. Results: Statistically significant results were found in self-reported confidence levels with airway skills (z = -2.803, p = .005), algorithm progression (z = -2.807, p = .005), and predicting difficulty with airway interventions based on the patient's features (z = -2.809, p = .005). Establishment of ventilation was completed faster after the intervention. More coherent and effective airway management was noted, new knowledge was gained, and implications from psychological research applied. Conclusion: Supplementing the training of Army Reserve Combat Medics with the utilization of anesthesia providers is an effective platform. This exercise imparted confidence in this population of military providers. This is critical for decision-making capabilities, performance, and the prevention of potentially survivable mortality on the battlefield.

Keywords: airway; mortality; military; nurse anesthetist; education

PMID: 31539435

DOI: BYYM-39ZI

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Airway Management in Prolonged Field Care

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Dye C, Keenan S, Carius BM, Loos PE, Remley MA, Mendes B, Arnold JL, May I, Powell D, Tobin JM, Riesberg JC, Shackelford SA. 20(3). 141 - 156. (Journal Article)

Abstract

This Role 1, prolonged field care (PFC) clinical practice guideline (CPG) is intended to be used after Tactical Combat Casualty Care (TCCC) Guidelines, when evacuation to higher level of care is not immediately possible. A provider must first and foremost be an expert in TCCC, the Department of Defense standard of care for first responders. The intent of this PFC CPG is to provide evidence and experience-based solutions to those who manage airways in an austere environment. An emphasis is placed on utilizing the tools and adjuncts most familiar to a Role 1 provider. The PFC capability of airway is addressed to reflect the reality of managing an airway in a Role 1 resource-constrained environment. A separate Joint Trauma System CPG will address mechanical ventilation. This PFC CPG also introduces an acronym to assist providers and their teams in preparing for advanced procedures, to include airway management.

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PMID: 32969020

DOI: BAF7-3BM3

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Airway Management in the Prehospital, Combat Environment: Analysis of After-Action Reviews and Lessons Learned

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Schauer SG, Naylor JF, Beaumont DM, April MD, Tanaka K, Baldwin D, Maddry JK, Becker TE, De Lorenzo RA. 20(3). 62 - 66. (Journal Article)

Abstract

Introduction: Airway compromise is the second leading cause of potentially survivable death on the battlefield. Studies show that airway management is a challenge in prehospital combat care with high error and missed opportunity rates. Lacking is user information on the perceived reasons for the challenges. The US military uses several performance improvement and field feedback systems to solicit feedback regarding deployed experiences. We seek to review feedback and after-action reviews (AARs) from end-users with specific regard to airway challenges noted. Methods: We queried the Center for Army Lessons Learned (CALL), the Army Medical Department Lessons Learned (AMEDDLL), and the Joint Lessons Learned Information System (JLLIS).Our queries comprised a series of search terms with a focus on airway management. Three military emergency medicine expert reviewers performed the primary analysis for lessons learned specific to deployment and predeployment training lessons learned. Upon narrowing the scope of entries to those relevant to deployment and predeployment training, a panel of eight experts performed reviews. The varied nature of the sources lent itself to an unstructured qualitative approach with results tabulated into thematic categories. Results: Our initial search yielded 611 nonduplicate entries. The primary reviewers then analyzed these entries to determine relevance to the project-this resulted in 70 deployment- based lessons learned and four training-based lessons learned. The panel of eight experts then reviewed the 74 lessons learned. We categorized 37 AARs as equipment challenges/malfunctions, 28 as training/education challenges, and 9 as other. Several lessons learned specifically stated that units failed to prioritize medic training; multiple comments suggested that units should consider sending their medics to civilian training centers. Other comments highlighted equipment shortages and equipment malfunctions specific to certain mission types (e.g., pediatric casualties, extreme weather). Conclusions: In this review of military lessons learned systems, most of the feedback referenced equipment malfunctions and gaps in initial and maintenance training.This review of AARs provides guidance for targeted research efforts based the needs of the end-users.

Keywords: prehospital; combat; airway; review; lessons

PMID: 32969005

DOI: 71P3-Y5H9

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Airway Management With Noninvasive Positive Pressure Ventilation

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Papalski W, Siedler J, Callaway DW. 22(2). 93 - 96. (Journal Article)

Abstract

Noninvasive positive-pressure ventilation (NPPV) is a form of ventilatory support that does not require the placement of an advanced airway. The authors discuss the use of NPPV on patients who will likely benefit. The use of NPPV has reduced the need for patients to require intubation and/or mechanical ventilation in some cases, as well as benefits.

Keywords: noninvasive positive-pressure ventilation (NPPV); continuous positive airway pressure (CPAP); bilevel positive airway pressure (BiPAP); noninvasive ventilation (NIV); acute respiratory failure (ARF)

PMID: 35639901

DOI: URGL-D2X1

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Albumin for Prehospital Fluid Resuscitation of Hemorrhagic Shock in Tactical Combat Casualty Care

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Studer NM, April MD, Bowling F, Danielson PD, Cap AP. 17(2). 82 - 88. (Journal Article)

Abstract

Optimal fluid resuscitation on the battlefield in the absence of blood products remains unclear. Contemporary Combat medics are generally limited to hydroxyethyl starch or crystalloid solutions, both of which present significant drawbacks. Obtaining US Food and Drug Administration (FDA)-approved freeze-dried plasma (FDP) is a top casualty care research priority for the US Military. Interest in this agent reflects a desire to simultaneously expand intravascular volume and address coagulopathy. The history of FDP dates to the Second World War, when American expeditionary forces used this agent frequently. Also fielded was 25% albumin, an agent that lacks coagulation factors but offers impressive volume expansion with minimal weight to carry and requires no reconstitution in the field. The current potential value of 25% albumin is largely overlooked. Although FDP presents an attractive future option for battlefield prehospital fluid resuscitation once FDA approved, this article argues that in the interim, 25% albumin, augmented with fibrinogen concentrate and tranexamic acid to mitigate hemodilution effects on coagulation capacity, offers an effective volume resuscitation alternative that could save lives on the battlefield immediately.

Keywords: albumin; fluid resuscitation; Hextend®; colloid; Tactical Combat Casualty Care; prolonged field care

PMID: 28599038

DOI: VANK-3YRP

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Aligning and Assessing Core Attributes of Spiritual Fitness for Optimizing Human Performance

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Alexander DW, Deuster PA. 21(1). 109 - 112. (Journal Article)

Abstract

The United States Special Operations Command (SOCOM)'s Preservation of the Force and Family Program (POTFF) identifies spiritual performance (SP) as a key pillar for holistically caring for and optimizing the performance of all Special Operations Forces (SOF) and their families. Enhancing SP is key to sustaining core spiritual beliefs, values, awareness, relationships and experiences. The SOCOM Spiritual Fitness Scale (SSFS) enables religious support teams in SOF communities and beyond to reliably measure SP according to POTFF's definition of SP and the Chairman of the Joint Chiefs of Staff Instruction (CJCSI) on Spiritual Fitness (SF). The three subscales of the SSFS relate to core attributes of SP/SF, which were identified through factor analysis during iterations of the tool's development. Directly aligning SP/SF programs with the core attributes of SSFS will allow chaplains to support both theists and nontheists and to retain certain traditional chaplain activities which no longer have universal connection to religious ministry in the public discourse. Chaplains are also empowered to immediately begin conducting relevant and spiritual assessments. We will illustrate how a chaplain can align SP initiatives with the three core attributes of SP/SF and leverage the SSFS to assess baseline unit needs, conceive and develop evidence-based initiatives, conduct rolling program assessments, and articulate program efficacy to key leaders and collaborators.

Keywords: spiritual metric; spiritual fitness; human performance optimization; total force fitness; program evaluation

PMID: 33721317

DOI: AM8C-FKH8

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All That Swells Is Not A Bruise The Morel-Lavallée Lesion

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Callahan CL, Eisenman J. 16(1). 109 - 111. (Journal Article)

Abstract

Frequently overlooked, Morel-Lavallée lesions are associated with a closed degloving or shearing mechanism causing a dehiscence of underlying soft tissue with formation of a potential space. This space fills with blood, lymph, and cellular debris, giving the lesion a fluctuant appearance on examination. The potential space associated with larger lesions can be a source for hemorrhage in the appropriate clinical context. However, these lesions are often diagnosed late in their clinical course or are misdiagnosed, leading to long-term complications. Management of this injury typically depends upon the size of the lesion. This article discusses a Morel-Lavallée lesion in an active-duty Servicemember requiring treatment by a plastic surgeon and includes the pathophysiology of Morel-Lavallée lesions, diagnostic strategies, and management pearls.

Keywords: Morel-Lavallée; injury, degloving; injury, shearing; pain, back

PMID: 27045507

DOI: ZP0D-HO71

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Altered Mental Status In A U.s. Army Special Forces Soldier

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Brandon JW, Hill GJ. 11(2). 27 - 29. (Journal Article)

Abstract

Special Operations medical provider must be familiar with the differential diagnosis for a patient with altered mental status since it includes multiple life-threatening illnesses. Potential diagnoses include meningitis, encephalitis, malaria and many others. While preparing to evacuate to definitive care from an austere location, they must also be prepared to initiate empiric therapy that is specific to the patient and the area of operations. We present a case of a U.S. Army Special Forces Soldier that developed limbic encephalitis of presumed Herpes Simplex Virus (HSV) origin. We will review the key differential diagnoses for this presentation with a focus on infectious etiologies. We will also summarize current diagnostic and therapeutic strategies. Our recommendation is to initiate oral acyclovir when IV acyclovir is not available and this diagnosis cannot be excluded.

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PMID: 21455907

DOI: A0GI-NNIE

An Analysis and Comparison of Prehospital Trauma Care Provided by Medical Officers and Medics on the Battlefield

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Fisher AD, Naylor JF, April MD, Thompson D, Kotwal RS, Schauer SG. 20(4). 53 - 59. (Journal Article)

Abstract

Background: Role 1 care represents all aspects of prehospital care on the battlefield. Recent conflicts and military operations conducted on behalf of the Global War on Terrorism have resulted in medical officers (MOs) being used nondoctrinally on combat missions. We are seeking to describe Role 1 trauma care provided by MOs and compare this care to that provided by medics. Methods: This is a secondary analysis of previously described data from the Prehospital Trauma Registry and the Department of Defense Trauma Registry from April 2003 through May 2019. Encounters were categorized by type of care provider (MO or medic). If both were documented, they were categorized as MO; those without either were excluded. Descriptive statistics were used. Results: A total of 826 casualty encounters met inclusion criteria. There were 418 encounters categorized as MO (57 with MO, 361 with MO and medic), and 408 encounters categorized as medic only. The composite injury severity score (median, interquartile range) was higher for casualties treated by the medic cohort (9, 3.5-17) than for the MO cohort (5, 2-9.5; P = .006). There was no difference in survival to discharge between the MO and medic groups (98.6% vs. 95.6%; P = .226). More life-saving interventions were performed by MOs compared to medics. MOs demonstrated a higher rate of vital sign documentation than medics. Conclusion: More than half of casualty encounters in this study listed an MO in the chain of care. The difference in proportion of interventions highlights differences in provider skills, training and equipment, or that interventions were dictated by differences in mechanisms of injury.

Keywords: prehospital; medic; healthcare provider; military medicine; war-related injuries

PMID: 33320313

DOI: L8S6-CU4F

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An Analysis of Battlefield Cricothyrotomy in Iraq and Afghanistan

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Mabry RL, Frankfurt A. 12(1). 17 - 23. (Journal Article)

Abstract

Objective: Historical review of modern military conflicts suggests that airway compromise accounts for 1-2% of total combat fatalities. This study examines the specific intervention of pre-hospital cricothyrotomy (PC) in the military setting using the largest studies of civilian medics performing PC as historical controls. The goal of this paper is to help define optimal airway management strategies, tools and techniques for use in the military pre-hospital setting. Methods: This retrospective chart review examined all patients presenting to combat support hospitals following prehospital cricothyrotomy during combat operations in Iraq and Afghanistan during a 22-month period. A PC was determined "successful" if it was documented as functional on arrival to the hospital. All PC complications that were documented in the patients' record were also noted in the review. Results: Two thirds of the patients died. The most common injuries were caused by explosions, followed by gunshot wounds (GSW) and blunt trauma. Eighty-two percent of the casualties had injures to face, neck or head. Those injured by gunshot wounds to the head or thorax all died. The largest group of survivors had gunshot wounds to the face and/or neck (38%) followed by explosion related injury to the face, neck and head (33%). Pre-hospital cricothyrotomy was documented as successful in 68% of the cases while 26% of the PC's failed to cannulate the trachea. In 6% of cases the patient was pronounced dead on arrival without documentation of PC function. The majority of PC's (62%) were performed by combat medics at the point of injury. Physicians and physician assistants (PA) were more successful performing PC than medics with a 15% versus a 33% failure rate. Complications were not significantly different than those found in civilian PC studies, including incorrect anatomic placement, excessive bleeding, air leak and right main stem placement. Conclusions: The majority of patients who underwent PC died (66%). The largest group of survivors had gunshot wounds to the face and/or neck (38%) followed by explosion related injury to the face, neck and head (33%). Military medics have a 33% failure rate when performing this procedure compared to 15% for physicians and physician assistants. Minor complications occurred in 21% of cases. The survival rate and complication rates are similar to previous civilian studies of medics performing PC. However the failure rate for military medics is three to five times higher than comparable civilian studies. Further study is required to define the optimal equipment, technique, and training required for combat medics to master this infrequently performed but lifesaving procedure.

Keywords:

PMID: 22427045

DOI: FYQG-8E49

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An Analysis of Prehospital Trauma Registry After-Action Reviews in Afghanistan

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Carius BM, Dodge PM, Fisher AD, Loos PE, Thompson D, Schauer SG. 21(2). 49 - 53. (Journal Article)

Abstract

Background: After-action reviews (AARs) in the Prehospital Trauma Registry (PHTR) enable performance improvements and provide commanders feedback on care delivered at Role 1. No published data exist exploring overall trends of end-user performance-improvement feedback. Methods: We performed an expert panel review of AARs within the PHTR in Afghanistan from January 2013 to September 2014. When possible, we categorized our findings and selected relevant medical provider comments. Results: Of 737 registered patient encounters found, 592 (80%) had AAR documentation. Most AAR patients were male (98%, n = 578), injured by explosion (48%, n = 283), and categorized for urgent evacuation (64%, n = 377). Nearly two thirds of AARs stated areas needing improvement (64%, n = 376), while the remainder left the improvement section blank (23%, n = 139) or specified no improvements (13%, n = 76). The most frequently cited areas for improvement were medical knowledge (23%, n = 136), evacuation coordination (19%, n = 115), and first responder training (16%, n = 95). Conclusions: Our expert panel reviewed AARs within the PHTR and found substantial numbers of AARs without improvements recommended, which limits quality improvement capabilities. Our analysis supports previous calls for better documentation of medical care in the prehospital combat setting.

Keywords: trauma; prehospital; military; after action review; performance

PMID: 34105121

DOI: 1EOJ-0HRV

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An Assessment of Decontamination Strategies for Materials Commonly Used in Canine Equipment

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Perry EB, Powell EB, Discepolo DR, Francis JM, Liang SY. 20(2). 127 - 131. (Journal Article)

Abstract

Working canines are frequently exposed to hazardous environments with a high potential for contamination. Environmental contamination may occur in many ways. Contamination may be chemical, biological, radiological, or nuclear. Examples may include a pipeline rupture following an earthquake, microbiological contamination of floodwaters, or exposure to toxic industrial chemical such as hydrogen chloride, ammonia, or toluene. Evidence to support effective methods for decontamination of equipment commonly used by working canines is lacking. Recent work has identified decontamination protocols for working canines, but little data are available to guide the decontamination of equipment used during tactical operations. The objective of our work was to investigate the effects of cleanser, cleaning method, and material type on contaminant reduction for tactical canine equipment materials using an oil-based contaminant as a surrogate for toxic industrial chemical exposure. A contaminant was applied, and effectiveness was represented as either success (= 50% contaminant reduction) or failure (< 50% contaminant reduction). A two-phase study was used to investigate cleanser, method of cleaning, and material types for effective contaminant reduction. In phase 1, Simple Green® cleanser had a higher frequency (P = .0075) of failure, but method and material did not affect contamination reduction (P > .05). In phase 2, Dawn® (P = .0004) and Johnson's® (P = .0414) successfully reduced contamination. High-pressure cleaning (HPC) resulted in successful decontamination (P < .0001). These novel data demonstrate potential techniques for reduction of contaminants on tactical canine equipment.

Keywords: working caninie; decontamination; equipment

PMID: 32573749

DOI: PQXV-5V3G

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An Evaluation of Common Cleaning Methods for the Removal of a Clinical Isolate of Escherichia coli in Personal Hydration System Water Reservoirs

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Helmus S, Blythe J, Guevara P, Washington MA. 16(2). 101 - 104. (Journal Article)

Abstract

Waterborne infection is an important cause of morbidity and mortality throughout the world. Personal hydration packs have been used by military personnel since the Gulf War and are now a common issue item. Since military personnel tend to operate under austere conditions and may use a variety of water sources, preventing the acquisition of waterborne infections is extremely important. Further, since hydration pack water reservoir replacements may not be available during combat operations, the development of a reliable cleaning protocol for use in the field is essential. Several methods for cleaning have been described. In the current study, three common cleaning methodologies-bleach treatment, baking soda treatment, and proprietary CAMELBAK Cleaning Tabs™-were evaluated for the ability to remove Escherichia coli contamination from hydration pack water reservoirs. The study results suggest that the use of bleach and proprietary CAMELBAK tablets should be encouraged since they both operate by releasing bactericidal chlorine compounds into solution, which is more effective at reducing post-treatment bacterial burden. It should be noted that no method was 100% effective at completely eliminating bacteria from the reservoirs and that mechanical cleaning was not attempted.

Keywords: CAMELBAK Cleaning Tab&tm;; infection, waterborne; hydration packs, personal; cleaning methodologies; Escherichia coli contamination

PMID: 27450612

DOI: 5DV1-JBPH

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An Evaluation Of Tactical Combat Casualty Care Interventinos In A Combat Environment

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Tien HC, Jung V, Rizoli SB, Acharya SV, MacDonald JC. 09(1). 65 - 68. (Previously Published)

Previously published in the Journal of the American College of Surgeons, Vol. 207, No. 2, August 2008. Republished in JSOM with permission of Elsevier.

Abstract

Background: Tactical combat casualty care (TCCC) is a system of prehospital trauma care designed for the combat environment. Although widely adopted, very few studies have reported on how TCCC interventions are actually delivered on the battlefield, from a quality of care perspective. Study Design: This was a prospective study of all trauma patients treated at the Role 3 multinational medical unit (MMU) at Kandahar Airfield Base from February 7, 2006 to May 30, 2006. Primary outcomes were whether or not two TCCC interventions were underused, overused, or misused. Interventions studied were needle decompression of tension pneumothoraces and tourniquet application for exsanguinating extremity injuries. Results: One hundred thirty-four trauma patients were treated at the Role 3 MMU during the study period. Six patients had eight tourniquets applied. Five tourniquets were applied to four patients appropriately and saved their lives. There was one case of misuse where a venous tourniquet was applied. There was one case of overuse where one patient had two tourniquets placed for 4 hours on extremities with no vascular injury. There were seven cases where needle decompression was underused: Seven patients presented with vital signs absent with no needle decompression. There was one case of overuse of needle decompression. There were seven cases of misuse where the patients were decompressed too medially. Conclusions: Tourniquets save lives. Needle decompression can save lives, but is usually performed in patients with multiple critical injuries. TCCC instructors must reinforce proper techniques and indications for each procedure to ensure that the quality of care provided to injured soldiers on the battlefield remains high.

Keywords:

PMID: 19813350

DOI: S0XK-210M

An Integrated Approach for Special Operations

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Deuster PA, Grunberg NE, O'Connor FG. 14(2). 86 - 80. (Journal Article)

Abstract

The Department of Defense (DoD) faces unprecedented challenges as the Nation confronts balancing a strong military to confront threats with the realities of diminishing financial resources. That each warfighter is a critical resource was underscored the Special Operations principal tenet "humans are more important than hardware." These challenges have popularized the term "human performance optimization" (HPO), which became ingrained in DoD around 2005. This article is the first in a new series relating to HPO, and we define the term and concept of HPO, describe other phrases used (e.g., performance enhancement; performance sustainment, performance restoration; and human performance modification). Last, we introduce an integrated model for HPO.

Keywords: human performance optimization; demands; resource; OODA loop

PMID: 24952047

DOI: HETG-W3E1

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An Interview With SOMA President Steven Viola, SOCM, ATP, NREMT-P

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Pennardt A. 17(2). 151 - 152. (Interview)

Abstract

Interviewed by COL (Ret) Andre Pennardt, MD

Keywords: interviews; Viola, Steven

PMID: 28599049

DOI: 3M25-8SM1

An Introduction to Survival, Evasion, Resistance, and Escape (SERE) Medicine

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Smith MB. 13(2). 25 - 32. (Journal Article)

Abstract

When an individual finds himself/herself in a survival, evasion, resistance, or escape (SERE) scenario, the ability to treat injuries/illnesses can be the difference between life and death. SERE schools are responsible for preparing military members for these situations, but the concept of SERE medicine is not particularly well defined. To provide a comprehensive working description of SERE medicine, operational and training components were examined. Evidence suggests that SERE medicine is diverse, injury/illness patterns are situationally dependent, and treatment options often differ from conventional clinical medicine. Ideally, medical lessons taught in SERE training are based on actual documented events. Unfortunately, the existing body of literature is dated and does not appear to be expanding. In this article, four distinct facets of SERE medicine are presented to establish a basis for future discussion and research. Recommendations to improve SERE medical curricula and data-gathering processes are also provided.

Keywords: SERE; survival, evasion, resistance, escape; captivity; isolation; wilderness

PMID: 23817875

DOI: O21F-DJH2

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An Introduction to the Processionary Caterpillar, An Underrecognized Threat to US Military Personnel in Australia

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Washington MA, Farrell J, Meany J, Chow W. 21(4). 22 - 24. (Journal Article)

Abstract

Processionary caterpillars are well-described threats to human and animal health. They are found throughout Central Asia, Northern Africa, and Southern Europe. However, US military personnel may not be familiar with the threat that these organisms pose in Australia. The larval form of the bag-shelter moth (Ochrogaster lunifer) is a processionary caterpillar that has been found throughout inland and coastal Australia. These organisms are habitually associated with Acacia and Eucalyptus trees and they tend to form long chains known as "processions" as they travel between nesting and pupating sites. They are covered with numerous hairs that can detach, become airborne, and cause potentially life-threatening inflammatory reactions and ocular trauma in susceptible personnel. They can also cause severe inflammatory reactions in military working animals. It is important that military and preventive medical personnel become aware of the presence of processionary caterpillars in Australia, and that they can identify aerial or ground-based nests so that these dangerous organisms can be avoided by both humans and animals. Early identification is important so that prompt medical treatment can be rendered in the event of an accidental exposure.

Keywords: entomology; military animals; bag-shelter moth; Ochrogaster lunifer; processionary caterpillar

PMID: 34969122

DOI: VAWM-WD4J

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An Inventory of the Combat Medics' Aid Bag

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Schauer SG, Naylor JF, Uhaa N, April MD, De Lorenzo RA. 20(1). 61 - 64. (Journal Article)

Abstract

Introduction: Tactical Combat Casualty Care (TCCC) recommends life-saving interventions; however, these interventions can only be implemented if military prehospital providers carry the necessary equipment to the injured casualty. Combat medics primarily use aid bags to transport medical materiels forward on the battlefield. We seek to assess combat medic materiel preparedness to employ TCCC-recommended interventions by inventorying active duty, combat medic aid bags. Methods: We sought combat medics organic to combat arms units stationed at Joint Base Lewis McChord. Medics volunteered to complete a demographic worksheet and have the contents of their aid bag photographed and inventoried. We spoke with medic unit leadership prior to their participation and asked that the medics bring their aid bags in the way they would pack for a combat mission. We categorized medic aid bag contents in the following manner: (1) hemorrhage control; (2) airway management; (3) pneumothorax treatment, or (4) volume resuscitation. We compared the items found in the aid bags against the contemporary TCCC guidelines. Results: In January 2019, we prospectively inventoried 44 combat medic aid bags. Most of the medics were male (86%), in the grade of E4 (64%), and had no deployment experience (64%). More medics carried a commercial aid bag (55%) than used the standard issue M9 medical bag (45%). Overall, the most frequently carried medical device was an NPA (93%). Overall, 91% of medics carried at least one limb tourniquet, 2% carried a junctional tourniquet, 31% carried a supraglottic airway (SGA), 64% carried a cricothyrotomy setup/kit, 75% carried a chest seal, and 75% carried intravenous (IV) fluid. The most commonly stocked limb tourniquet was the C-A-T (88%), the airway kit was the H&H cricothyrotomy kit (38%), the chest injury set were prepackaged needle decompression kits (81%), and normal saline was the most frequently carried fluid (47%). Most medics carried a heating blanket (54%). Conclusions: Most medics carried materiels that address the common causes of preventable death on the battlefield. However, most materiels stowed in aid bags were not TCCC-preferred items. Moreover, there was a small subset of medics who were not prepared to handle the major causes of death on the battlefield based on the current state of their aid bag.

Keywords: combat; medic; aid bag; military

PMID: 32203608

DOI: FUHO-CU87

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An Observational Study Assessing Completion Time and Accuracy of Completing the Tactical Combat Casualty Care Card by Combat Medic Trainees

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Therien SP, Andrews JE, Nesbitt ME, Mabry RL. 14(2). 38 - 45. (Journal Article)

Abstract

Introduction: Prehospital care documentation is crucial to improving battlefield care outcomes. Developed by United States Army Ranger Special Operations Combat Medics (SOCMs), the Tactical Combat Casualty Care (TCCC) is currently fielded to deployed units to record prehospital injury data. This study documents length of time and accuracy of U.S. Army Combat Medic trainees in completing the minimum preestablished required fields on the TCCC card, establishing a baseline for point-of-injury cards. Design and Methods: This was a prospective observational study in which U.S. Army combat medic trainees were timed while recording data on the TCCC card in both the classroom and simulated combat environment. We hypothesized that trainees could complete the TCCC card in less than 1 minute with 90% or greater accuracy. Results: We enrolled 728 U.S. Army Combat Medic trainees in the study during May-June 2011 at Fort Sam Houston, TX. We observed an average TCCC card completion time of less than 1 minute with greater than 90% accuracy in the unstressed classroom environment but an increase to nearly 2 minutes on average and a decrease to 85% accuracy in the simulated combat environment. Conclusion: Results imply that the TCCC card is well designed to quickly and accurately record prehospital combat injury information. Further investigation and future studies may compare other prehospital data collection methods with the TCCC card in terms of timely and accurate data collection.

Keywords: Tactical Combat Casualty Care; Operation Iraqi Freedom; Operation Enduring Freedom; prehospital combat documentation; Global War on Terrorism

PMID: 24952039

DOI: FHAO-5YST

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An Ongoing Series on Dermatological Issues of Importance to the Deployed Special Forces

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Sola CA, Toren KL. 13(1). 68 - 71. (Journal Article)

Keywords:

PMID: 23526327

DOI: M1TR-0H3T

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An Outbreak Investigation Report and Lessons Learned by Multinational Coalition Forces: October 2016, Baghdad, Iraq

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Gorzelnik SA, Kephart LN, Miklos WE. 17(3). 123 - 129. (Journal Article)

Abstract

Background: Public health personnel from the 28th Combat Support Hospital in Baghdad, Iraq, conducted an outbreak investigation in response to many local cases of gastrointestinal (GI) illness presenting to U.S. medical facilities. The investigation was conducted to identify the source of the illness, assess the extent of cases, and make recommendations to prevent similar outbreaks. Methods and Materials: For this retrospective cohort study, medical records and patient outbreak questionnaires were reviewed. A patient case, relative to the outbreak, was defined as any person who had developed a GI illness and presented for medical evaluation to either sick call or an emergency service at a diplomatic or military medical facility in Baghdad from 30 September to 12 October 2016. Results: A total of 123 people met the case definition. The most common presenting symptom was diarrhea (91% to 96% of cases). Other symptoms included abdominal cramps, fatigue, and headache. Most cases were military personnel (n =100). Salad was significantly associated with GI illness (70% of respondents). Five salad ingredients had significantly elevated levels of Escherichia coli. Conclusion: Mitigation strategies to reduce the probability of similar outbreaks include purchasing food solely from approved vendors or thoroughly cooking all foods, including fruits and vegetables.

Keywords: gastrointestinal illness; Escherichia coli; public health

PMID: 28910482

DOI: P4S0-BEQ7

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An Unconscious Diver With Pulmonary Abnormalities: Problems Associated With Closed Circuit Underwater Breathing Apparatus

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Adkins DE, Mahon RT, Bennett S. 07(4). 28 - 32. (Journal Article)

Abstract

Closed circuit underwater breathing apparatus (UBA) have gained popularity in recreational diving. Closed circuit UBAs carry a unique set of risks to the diver. We present the case of a diver who lost consciousness while diving and had pulmonary abnormalities. The case is illustrative of the diving related problems associated with closed circuit UBA that a physician may be faced with.

Keywords:

DOI:

An Unusual Wound Infection Due to Acinetobacter junii on the Island of Oahu: A Case Report

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Griffin J, Barnhill JC, Washington MA. 19(1). 14 - 15. (Case Reports)

Abstract

The genus Acinetobacter has long been associated with war wounds. Indeed, A baumannii was responsible for so many infected wounds during Operation Iraqi Freedom that it was given the nickname "Iraqibacter." Therefore, it is important to monitor the occurrence and spread of Acinetobacter species in military populations and to identify new or unusual sources of infection. A junii is an infrequently reported human pathogen. Here, we report a case of a slow-healing wound infection with A junii in a woman on the island of Oahu. This case highlights the pathogenic potential of this organism and the need for proper wound care when dealing with slow-healing wounds of unknown etiology. It also underscores the need for identifying species of Acinetobacter that are not A baumannii to better understand the epidemiology of slow-healing wound infections.

Keywords: Acinetobacter junii; emerging infection; Hawaii; Oahu; wound

PMID: 30859518

DOI: DGPW-LSEN

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Analgesia and Sedation for Tactical Combat Casualty Care: TCCC Proposed Change 21-02

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Fisher AD, DesRosiers TT, Papalski W, Remley MA, Schauer SG, April MD, Blackman V, Brown J, Butler FK, Cunningham CW, Gurney J, Holcomb JB, Montgomery HR, Morgan MM, Motov SM, Shackelford SA, Springer T, Drew B. 22(2). 154 - 165. (Classical Conference)

Abstract

Analgesia in the military prehospital setting is one of the most essential elements of caring for casualties wounded in combat. The goals of casualty care is to expedite the delivery of life-saving interventions, preserve tactical conditions, and prevent morbidity and mortality. The Tactical Combat Casualty Care (TCCC) Triple Option Analgesia guideline provided a simplified approach to analgesia in the prehospital combat setting using the options of combat medication pack, oral transmucosal fentanyl, or ketamine. This review will address the following issues related to analgesia on the battlefield: 1. The development of additional pain management strategies. 2. Recommended changes to dosing strategies of medications such as ketamine. 3. Recognition of the tiers within TCCC and guidelines for higher-level providers to use a wider range of analgesia and sedation techniques. 4. An option for sedation in casualties that require procedures. This review also acknowledges the next step of care: Prolonged Casualty Care (PCC). Specific questions addressed in this update include: 1) What additional analgesic options are appropriate for combat casualties? 2) What is the optimal dose of ketamine? 3) What sedation regimen is appropriate for combat casualties?

Keywords: analgesia; prehospital; casualties; Tactical Combat Casualty Care (TCCC) Triple Option Analgesia guideline; fentanyl; ketamine

PMID: 35639907

DOI: 8CBI-GAOD

Analgesia and Sedation in the Prehospital Setting: A Critical Care Viewpoint

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DesRosiers TT, Anderson JL, Adams B, Carver RA. 22(2). 48 - 54. (Journal Article)

Abstract

Pain is one of the most common complaints of battlefield casualties, and unique considerations apply in the tactical environment when managing the pain of wounded service members. The resource constraints commonly experienced in an operational setting, plus the likelihood of prolonged casualty care by medics or corpsmen on future battlefields, necessitates a review of analgesia and sedation in the prehospital setting. Four clinical scenarios highlight the spectrum of analgesia and sedation that may be necessary in this prehospital and/or austere environment.

Keywords: traumatic brain injury; pathophysiology; prehospital management; critical care

PMID: 35639894

DOI: 8MNO-PTJH

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Analgesia and Sedation Management During Prolonged Field Care

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Pamplin JC, Fisher AD, Penny A, Olufs R, Rapp J, Hampton K, Riesberg JC, Powell D, Keenan S, Shackelford S. 17(1). 106 - 120. (Journal Article)

Keywords: sedation; analgesia; prolonged field care; guidelines

PMID: 28285489

DOI: KNC7-FF9M

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Androgens and Androgen Derivatives: Science, Myths, and Theories. Explored From a Special Operations Perspective

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Givens ML, Deuster PA. 15(3). 98 - 104. (Journal Article)

Abstract

Androgen use outside of legitimate medical therapy is a perceived concern that is drawing attention across military and specifically Special Operations Forces (SOF) communities. For leadership and the medical community to properly address the issue and relate to those individuals who are using or considering use, it will be crucial to understand the scope of the problem. Limited data suggest that the prevalence of androgen use may be increasing, and inferences made from the scientific literature suggest that SOF may be a population of concern. While risks of androgen use are well known, there are little data specific to military performance that can be applied to a rigorous risk:benefit analysis, allowing myths and poorly supported theories to perpetuate within the community. Further efforts to define the potential benefits balanced against the short- and longterm risks should be undertaken. Providers within the SOF community should arm themselves with information to engage androgen users and leadership in meaningful discussion regarding androgen use.

Keywords: androgen steroids; protein building

PMID: 26360363

DOI: 8M1J-GJFL

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Another Civilian Life Saved by Law Enforcement-Applied Tourniquets

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Robertson JN, McCahill P, Riddle A, Callaway DW. 14(3). 7 - 11. (Journal Article)

Abstract

Increasing data and anecdotal operational reports are supporting the early, aggressive, prehospital application of tourniquets in potentially life-threatening extremity trauma. Especially in the civilian urban setting where transport times are short, the benefit in terms of lives saved far outweighs the potential risk to the extremity. The popular press has reported frequently on law enforcement- applied tourniquets, but to date, no group has published a scientific review of any of these cases. This case report suggests that law enforcement personnel can be trained to safely identify indications for tourniquet application, properly apply them with limited training, and function as effective first care providers.

Keywords: tourniquet; law enforcement; tactical medicine

PMID: 25344705

DOI: DSRU-3YMB

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Application of Medical Intelligence Prep of the Environment: A Review of Operational Vignettes

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Caci JB. 15(4). 117 - 124. (Journal Article)

Abstract

Medical intelligence is an underused or sometimes misapplied tool in the protection of our Soldiers and the execution of nonkinetic operations. The somewhat improved infrastructure of the operational environment in Iraq and Afghanistan led to an inevitable sense of complacency in regard to the threat of disease nonbattle injury (DNBI). The picture changed somewhat in 2010 with the advent of the village stability program and the establishment of SOF camps in austere locations with degraded living situations rife with exposure risks. In addition, the increasing deployments to unstable locations around the globe, reminiscent of typical Special Operations Forces (SOF) missions before the Global War on Terrorism, indicate a need for better preparation for deployment from the standpoint of disease risk and force health protection. A knowledge gap has developed because we simply did not need to apply as stringent an evaluation of DNBI risk in environments where improved life support mitigated the risk for us. The tools necessary to decrease or even eliminate the impact of DNBI exist but they must be shared and implemented. This article will present four vignettes from current and former SOF Force Health Protection personnel starting with a simple method of executing Medical Intelligence Prep of the Environment (MIPOE) and highlighting situations in which it either was or could have been implemented to mitigate risk and decrease the impact on mission accomplishment and individual operators. A follow-on article will present vignettes of the successful application of MIPOE to nonkinetic operations.

Keywords: Medical Intelligence Prep of the Environment; nonkinetic operations; disease nonbattle injury

PMID: 26630107

DOI: FGRZ-KFXD

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Applications of Fish Oil Supplementation for Special Operators

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Heileson JL, Funderburk LK, Cardaci TD. 21(1). 78 - 85. (Journal Article)

Abstract

Fish oil supplementation (FOS) is beneficial for human health and various disease states. FOS has recently received attention related to its anabolic and anti-catabolic effects on skeletal muscle and cognitive performance. Since Special Operations Forces (SOF) personnel endure rigorous combat and training environments that are mentally and physically demanding, FOS may have important applications for the SOF Warfighter. The purpose of this narrative review is to explore the evidence for FOS and its application to multiple physiological and psychological contexts experienced by SOF personnel. For physical performance, FOS may promote lean body mass (LBM) accretion; however, there seems to be minimal impact on strength, power, or endurance. During physiological stress, FOS may preserve strength, power, LBM (during muscle disuse, not weight loss) and enhance recovery. For cognition, FOS likely improves reaction time, mental fatigue, and may reduce the incidence and severity of mild traumatic brain injury; however, FOS has minimal impact on attentional control and mood states. No safety concerns were evident. In conclusion, there are multiple applications of FOS for SOF personnel. Due to the minimal safety concerns and potential anabolic, anti-catabolic and cognitive benefits, FOS is a viable method to promote and sustain SOF Warfighter physical and cognitive performance. Although promising, the FOS trials to date have not been conducted in the context of the multi-stressor environments experienced by SOF personnel, thus, future studies should be conducted in a SOF population.

Keywords: omega-3 fatty acids; eicosapentaenoic acid; docosahexaenoic acid; skeletal muscle; cognition; performance

PMID: 33721311

DOI: YZI5-1NMV

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Applications of the SOCOM Spiritual Fitness Scale: Program Development and Tailored Coaching for Optimized Performance

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Alexander DW. 20(3). 109 - 112. (Journal Article)

Abstract

The SOCOM Spiritual Fitness Scale (SSFS) enables religious support teams and other spiritual fitness/performance (SF/SP) stakeholders in the Special Operations Forces community to reliably measure both "horizontal" and "vertical" dimensions of spirituality, as defined by the chairman of the Joint Chiefs of Staff Instruction on SF. The SSFS's three subscales relate to core attributes of SF/SP, which were identified through factor analysis during the iterations of the tool's development. The SSFS is capable of generating baseline assessments for research related to SF/SP. It is also capable of generating unique SF/SP profiles for individuals and groups, which can shape programs and inform tailored coaching for optimized performance.

Keywords: spirituality; spiritual metric; spiritual fitness; human performance optimization; total force fitness

PMID: 32969013

DOI: K9G4-Z2CC

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Applying Swiss Armed Forces Training Didactics and Methodology for Tactical Combat Casualty Care Training

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Anonymous A. 19(4). 114 - 117. (Journal Article)

Abstract

Some of the current methods of instruction used within international armed forces courses are not always goal oriented and satisfactory for both the teaching staff and the student. The Swiss Armed Forces approach presented here has been historically effective in preparing and sustaining national conscription with large numbers of recruits and new cadres every year.

Keywords: comprehension; goals; learning; training; NATO Special Operations Combat Medic; NSOCM; Swiss Armed Forces

PMID: 31910485

DOI: U2B3-1T1D

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Arctic Tactical Combat Casualty Care

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Samblanet K, Booy M. 22(2). 127 - 128. (Letter)

Keywords: Arctic; Tactical Combat Casualty Care; multidomain operations

PMID: 35649407

DOI: 03K0-TOAK

Are the King LTS Laryngeal Tube and the Ambu AuraOnce Laryngeal Mask Useful Airway Adjuncts for Military Medics?

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Regner D, Frykholm P. 18(2). 90 - 96. (Journal Article)

Abstract

Background: Airway management is a critical skill that may be essential in the battlefield. The aim of this study was to determine if combat life savers and medics with no or limited clinical experience could provide airway control using the disposable laryngeal suction tube (LTS-D) and the Ambu® AuraOnce ™ disposable laryngeal mask (LMA). Methods: Eight military medics with limited clinical experience and no airway management experience secured the airway on 19 intrahospital anesthetized patients using the LTS-D and the LMA. Each patient was treated with both airway adjuncts in a randomized order. Each medic was studied on at least two and not more than three patients. Success of insertion, number of attempts, and time to correct placement with verified ventilation were recorded. Results: When using the LTS-D, the first-attempt success rate for the medics with the first patient was 50% (four of eight) and 75% (six of eight) on the second attempt. With the second patient, the first-attempt success rate was 87.5% (seven of eight), and on the third patient, it was 100% (three of three). For all patients, the accumulated first-attempt success rate was 73.7% (14 of 19) and 84.2% (16 or 19) for second attempts with the LTS-D. The success rate on first attempt with the LMA was 100% (19 of 19) on the first patient. On the second intervention with the LMA, there was a significant decrease in mean time to verified ventilation, from 56.4 seconds to 27.7 seconds (ρ = .043), and time to verified ventilation with no leakage, from 61.3 seconds to 32.3 seconds (ρ = .029). Insertion attempts for three LTS-Ds and one LMA failed. Conclusion: This study suggests that for the safe use of the laryngeal tube suction by inexperienced airway providers, a clinical training program is required. The LMA proved superior to the LTS-D with a 100% success rate at the first attempt, which suggests that minimal training is needed before clinical use. We therefore recommend the LMA as the primary airway adjunct for military medics, despite a hypothetically inferior protection from aspiration.

Keywords: airway; airway management; combat; education; laryngeal tube; laryngeal tube suction; laryngeal mask; military medicine; supraglottic airway

PMID: 29889963

DOI: JKD5-7YCU

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Arthropod Borne and Zoonotic Infections Among Military Personnel in Georgia

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Chitadze N, Gureshidze N, Rostiaschvili N, Danelia N, Dalakishvili K, Durglishvili L, Kuchukhidze R, Imnadze P, Chlikadze R, Betashvili M, Kuchuloria T, Akhvlediani N, Rivard R, Nikolich M, Bautista CT, Washington MA, Akhvlediani T. 18(2). 136 - 140. (Journal Article)

Abstract

Military personnel are at an increased risk for exposure to arthropod- borne and zoonotic pathogens. The prevalence of these pathogens has not been adequately described in the country of Georgia. As the Georgian military moves toward an increased level of capability and the adoption of European Union and North Atlantic Treaty Organization standards, international field exercises will become more frequent and will likely involve an increasing number of international partners. This study was undertaken with the goal of defining the arthropod-borne and zoonotic pathogen threat in Georgia so force health protection planning can proceed in a rational and data-driven manner. To estimate disease burden, blood was taken from 1,000 Georgian military recruits between October 2014 and February 2016 and screened for previous exposure to a set of bacterial and viral pathogens using a antibody-based, serologic procedure. The highest rate of exposure was to Salmonella enterica serovar Typhi, and the lowest rate of exposure was to Coxiella burnettii (the causative agent of Q fever). These data provide insight into the prevalence of arthropod-borne infections in Georgia, fill a critical knowledge gap, will help guide future surveillance efforts, and will inform force health protection planning.

Keywords:

PMID: 29889971

DOI: MF2R-RMLC

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Articulating Tractical Traction Splint Use on Pulseless Forearm Fracture

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Schwartz DS. 14(1). 6 - 8. (Journal Article)

Abstract

An articulating tactical traction splint (REEL™ Tactical Traction Splint), commonly issued to U.S. military per-sonnel, was used to maintain traction in a pulseless fore-arm fracture during a confined space rescue, with good peripheral perfusion maintained through transport. This enabled a single rescuer to focus attention and provide care for other critical aspects of a multisystem trauma patient.

Keywords: articulating tactical traction splint; pulseless forearm fracture; fracture

PMID: 24604432

DOI: XHVQ-3444

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Ascaris

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Burnett MW. 18(2). 115 - 116. (Journal Article)

Keywords:

PMID: 29889967

DOI: FFEM-COO8

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Asclepius Snakebite Foundation Update

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Benjamin JM. 21(4). 116 - 117. (Journal Article)

Keywords:

PMID: 34969141

DOI: P7H4-74AW

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Assessment of Trainer Skill to Control Groin-Wound Bleeding: Use of Junctional Tourniquet Models on a Manikin

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Kragh JF, Aden JK, Shackelford S, Moore VK, Dubick MA. 17(2). 39 - 48. (Journal Article)

Abstract

Background: The purpose of this study was to assess the skills of trainers using different junctional tourniquet models to control groin bleeding in a manikin. Materials and Methods: In 204 assessments, 17 trainers used four junctional tourniquet models three times each to control simulated hemorrhage. The models included the Combat Ready Clamp (CRoC), Junctional Emergency Treatment Tool (JETT), Abdominal Aortic and Junctional Tourniquet (AAJT), and SAM Junctional Tourniquet (SJT). The criteria of assessment included effectiveness (i.e., control [yes-no]), time to stop bleeding, total blood loss, and bleeding rate. Results: All uses were effective. By model, the results of mean blood loss and time to stop bleeding were different with varying levels of statistical significance: control was worst with the JETT and AAJT, moderate with the AAJT and SJT, and best with the SJT and CRoC. The means sharing a level were not significantly different, but a mean in more than one level was not different from itself. The composite outcome results were 90% good for CRoC and 67% good for JETT, whereas results for the SJT and AAJT were in between, and only the result of the CROC and JETT comparison was significant. The ease of use varied significantly; JETT was more difficult to use and all others were easier. The analysis attributed to the users 19% of the variance of results for time, 44% for blood loss volume, and 67% for bleeding rate. Most users preferred the SJT (53% before and 70% after assessment). Conclusion: Effectiveness was attained by all users with each of the four models of junctional tourniquet. The analysis demonstrated that up to 67% of the variance of performance results could be attributed to the users.

Keywords: tourniquet; hemorrhage prevention and control; shock; damage control; resuscitation; emergency medical services; education; standards; methods; military medicine; medical device; first aid; inguinal

PMID: 28599033

DOI: PCSM-ZC4B

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Assessment of User, Glove, and Device Effects on Performance of Tourniquet Use in Simulated First Aid

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Kragh JF, Aden JK, Lambert CD, Moore VK, Dubick MA. 17(4). 29 - 36. (Journal Article)

Abstract

Background: The effects of users, glove types, and tourniquet devices on the performance of limb tourniquet use in simulated first aid were measured. Materials and Methods: Four users conducted 180 tests of tourniquet performance in eight glove groups compared with bare hands as a control. Results: Among tests, 99% (n = 179) had favorable results for each of the following: effectiveness (i.e., bleeding control), distal pulse stoppage, and tourniquet placement at the correct site. However, only 90% of tests ended with a satisfactory result, which is a composite outcome of aggregated metrics if all (patient status is stable, tourniquet placement is good, and pressure is good) are satisfactory. Of 18 unsatisfactory results, 17 (94%) were due to pressure problems. Most of the variance of the majority of continuous metrics (time to determination of bleeding control, trial time, overall time, pressure, and blood loss) could be attributed to the users (62%, 55%, 61%, 8%, and 68%, respectively). Glove effects impaired and slowed performance; three groups (cold gloves layered under mittens, mittens, and cold gloves) consistently had significant effects and five groups (examination gloves, flight gloves, leather gloves, glove liners, and glove liners layered under leather gloves) did not. For time to bleeding control and blood loss, performance using these same three glove groups had worse results compared with bare hands by 26, 18, and 17 seconds and by 188, 116, and 124mL, respectively. Device effects occurred only with continuous metrics and were often dominated by user effects. Conclusion: In simulated first aid with tourniquets used to control bleeding, users had major effects on most performance metrics. Glove effects were significant for three of eight glove types. Tourniquet device effects occurred only with continuous metrics and were often dominated by user effects.

Keywords: glove; mitten; manual skill; psychomotor performance; tourniquet; first aid; hemorrhage, prevention and control

PMID: 29256191

DOI: J38L-DAJD

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Associations Among Back and Extremity Pain With Alcohol, Tobacco, and Caffeine Use Among US Air Force Pararescuemen

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Bryan CJ, Wolfe AL, Morrow CE, Stephenson JA, Haskell J, Bryan AO. 15(3). 66 - 71. (Journal Article)

Abstract

Background: Caffeine, tobacco, and alcohol are the most widely used substances globally, but the majority of research on the associations among legal substance use and physical health has focused on the general population, not elite military personnel. The purpose of the current study was to describe patterns of tobacco, alcohol, and caffeine use and to examine the relationship of legal substance use with self-reported physical health complaints among US Air Force Pararescuemen (PJs) and Combat Rescue Officers (CROs). Methods: Participants were 196 US PJs and CROs. Participants completed self-report measures of legal drug use and somatic symptoms. Generalized linear modeling with robust maximum likelihood estimation was used for multivariate regression analyses. Chi-square analyses were conducted for univariate comparisons of categorical variables. Results: Reported rates of tobacco use (28.2%), alcohol consumption (83.2%), and regular caffeine consumption (88.8%) were similar to the general population. Daily caffeine intake was significantly higher among participants reporting they were bothered a lot by back pain [Wald χ²(2) = 11.39; ρ = .003] and extremity pain [Wald χ²(2) = 11.39; ρ = .003], even when controlling for age and deployment history. Participants with severe extremity pain also reported drinking approximately twice as many alcoholic beverages per week (mean, 5.46; standard error [SE], 0.91) than participants who were bothered a little (mean, 2.88; SE, 0.54) or not bothered at all (mean, 2.88; SE, 0.52) by extremity pain. Conclusion: Back and extremity pain is associated with greater caffeine and alcohol consumption among PJs.

Keywords: military; caffeine; alcohol; tobacco; pain; Pararescuemen

PMID: 26360356

DOI: AZL6-ZQY7

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Asymmetrical Loading Patterns in Military Personnel With a History of Self-Reported Low Back Pain

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Johnson AK, Royer SD, Ross JA, Poploski KM, Sheppard RL, Heebner NR, Abt JP, Winters JD. 21(4). 30 - 35. (Journal Article)

Abstract

Background: Servicemembers are required to operate at high levels despite experiencing common injuries such as chronic low back pain. Continuing high levels of activity while compensating for pain may increase the risk of musculoskeletal injuries. As such, the purpose of this project was to determine if servicemembers with chronic low back pain have reduced lower extremity performance, and if they use alternate strategies to complete a functional performance task as compared to healthy servicemembers. Methods: Of a total of 46 male United States Marine Corps Forces Special Operations Command (MARSOC) personnel, 23 individuals who suffered from chronic low back pain (age = 28.6 ± 4.4 years, weight = 84.2 ± 6.8 kg) and 23 healthy controls (age = 27.9 ± 3.8 years, weight = 83.8 ± 7.7 kg) completed a stop jump task. In this task, three-dimensional biomechanics were measured, and lower extremity and trunk strength were assessed. Results: The low back pain group exhibited higher vertical ground reaction force impulse on the dominant limb (0.26% body weight [BW]/s), compared to the nondominant limb (0.25% BW/s, p = .036). The control group demonstrated relationships between jump height and strength in both limbs (dominant: r = 0.436, p = .043; nondominant: r = 0.571, p = .006), whereas the low back pain group demonstrated relationships between jump height and dominant limb knee work (r = 0.470, p = .027) and ankle work (r = 0.447, p = .037). Conclusions: This study demonstrates that active-duty MARSOC personnel with a history of low back pain reach similar levels of jump height during a counter movement jump, as compared to those without a history of low back pain. However, the asymmetries displayed by the low back pain group suggest an alternate strategy to reaching similar jump heights as compared to healthy individuals.

Keywords: biomechanics; low back pain; asymmetries; jump height

PMID: 34969124

DOI: C1J6-3DMZ

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Atlas of Conducted Electrical Weapon Wounds and Forensic Analysis

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Bollard GA. 13(1). 73 - 73. (Book Review)

Abstract

Jeffrey D. Ho, MD; Donald M. Dawes, MD; Mark W. Kroll, PhD
Springer, 2012, 204 pages.

Keywords:

DOI:

Atrial Fibrillation with Rapid Ventricular Response following use of Dietary Supplement Containing 1,3 Dimethylamylamine and Caffeine

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Armstrong M. 12(4). 1 - 4. (Journal Article)

Abstract

Our nation's servicemembers commonly use dietary supplements to enhance their performance. Despite this prolific use, many of these products have detrimental side-effects that compromise servicemembers' health and could, by proxy, compromise a mission. This paper presents the case of a 32-year old Navy Special Operations Forces (SOF) Sailor who, prior to physical training, used a supplement containing 1,3 Dimethylamylamine (DMAA), and then developed atrial fibrillation with rapid ventricular response. He required intravenous calcium channel blocker administration, followed by beta blockers, for rate control. As military providers, we routinely ask our patients about their use of supplements and while the regulation of these products is beyond the scope of practice for most of us, it is our duty to become better educated about the risks and benefits of these supplements. We must educate our patients and our commands on the potential harm that these supplements may pose.

Keywords: atrial fibriliation; supplement; DMAA; Special Operations; 1,3 Dimethylamylamine

PMID: 23536449

DOI: 1MSW-PLTV

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Atropine Eye Drops: A Proposed Field Expedient Substitute in the Absence of Atropine Autoinjectors

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Calvano CJ, Enzenauer RW, Eisnor DL, Mazzoli RA. 17(3). 81 - 83. (Journal Article)

Abstract

Nerve agents are a threat to military and civilian health. The antidote, atropine sulfate, is delivered by autoinjector, which is a limited resource. We propose the use of 1% atropine ophthalmic solution (supplied commercially in 5mL or 15 mL bottles) via oral, ocular, and intranasal administration as an expedient substitute in austere environments.

Keywords: nerve agent; chemical warfare; atropine; antidote; alternative treatment

PMID: 28910474

DOI: DQ96-STYU

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Atypical Chronic Insomnia in a Special Forces Soldier: A Case Review

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Gay DG, Paul J. 12(3). 50 - 51. (Journal Article)

Keywords:

PMID: 23032320

DOI: EDD4-Y83Y

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Austere Fasciotomy: Alternative Equipment for Performance in the Field

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DeSoucy ES, Hewitt CW, Bolleter S. 22(1). 81 - 86. (Journal Article)

Abstract

Background: Acute compartment syndrome (ACS) following extremity trauma requires rapid fasciotomy to avoid significant morbidity and limb loss. Four-compartment fasciotomy of the leg is a surgical procedure typically performed in the operating room; however, casualties who cannot be rapidly transported may need fasciotomies in the prehospital setting. In the absence of traditional operating instruments (e.g., scalpel, long Metzenbaum scissors, electrocautery), alternative means of fasciotomy may be needed. We undertook a proof-of-concept study using cadaver models to determine whether leg fasciotomies could be performed with alternative devices compared with the surgical standard. Methods: Two-incision, four-compartment fasciotomies were performed on fresh, never-frozen, non-embalmed cadaver legs using a scalpel for the initial skin incision, followed by release of the fascia using one of the following instruments: 5.5-in curved Mayo scissors; Benchmade rescue hook (model BM-5BLKW); rescue hook on the Leatherman Raptor multitool (model 831741-FFP); Leatherman Z-Rex multitool rescue hook (model LM93408); or No. 10 PenBlade (model PB-M-10- CAS). The procedures were performed by a surgeon. Skin and fascia incisional lengths were recorded along with a subjective impression of the performance for each device. Post-procedural dissection was performed to identify associated injuries to the muscle, superficial peroneal nerve, and the greater saphenous vein (GSV). Results: All devices were able to adequately release the fascia in all four compartments. All rescue hooks (Benchmade, Raptor, and Z-Rex) required a "pull technique" and a skin incision of equal length to the fascia incision. The PenBlade was used in a "push technique," similar to the standard scissor fasciotomy through a smaller skin incision. There was one superficial peroneal nerve transection with the rescue hooks, but there were no GSV injuries or significant muscle damage with any instrument. Conclusion: Four-compartment fasciotomy can be performed with readily available alternative equipment such as rescue hooks and the PenBlade. Hook-type devices require longer skin incisions compared with scissors and the PenBlade. In contested environments, patients with ACS may require fasciotomy prior to evacuation to surgical teams; training combat medics in the use of these alternative instruments in the field may preserve life and limb.

Keywords: fasciotomy; austere medicine; compartment syndrome; combat casualty care

PMID: 35278319

DOI: R9YI-9E26

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Austere Surgical Team Management of an Unusual Tropical Disease: A Case Study in East Africa

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Cullen ML, Stephens M, Thronson E, Brillhart DB, Rizzo J. 20(4). 112 - 114. (Journal Article)

Keywords: buruli ulcer; Mycobacterium ulcerans; infectious skin disease

PMID: 33320323

DOI: QR63-LCBO

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Autopsy-Determined Atherosclerosis in Elite US Military Special Operations Forces

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Kotwal RS, Mazuchowski EL, Howard JT, Hanak JC, Harcke HT, Gurney JM, Shackelford SA. 21(2). 19 - 24. (Journal Article)

Abstract

Background: Autopsy studies of trauma fatalities have provided evidence for the pervasiveness of atherosclerosis in young and middle-aged adults. The objective of this study was to determine the prevalence of atherosclerosis in elite US military forces. Methods: We conducted a retrospective study of all US Special Operations Command (USSOCOM) fatalities from 2001 to 2020 who died from battle injuries. Autopsies were evaluated from Afghanistan- and Iraq-centric combat operations for evidence of coronary and/or aortic atherosclerosis and categorized as minimal (fatty streaking only), moderate (10-49% narrowing of ≥1 vessel), and severe (≥50% narrowing of ≥1 vessel). Prevalence of atherosclerosis was determined for the total population and by subgroup characteristics of age, sex, race/ethnicity, combat operation, service command, occupation, rank, cause of death, manner of death, and body mass index (BMI). Results: From the total of 388 USSOCOM battle injury fatalities, 356 were included in the analysis. The mean age was 31 years (range, 19-57 years), and 98.6% were male. The overall prevalence of coronary and/or aortic atherosclerosis was 17.4%. The prevalence of coronary atherosclerosis alone was 13.8%. Coronary atherosclerosis was categorized as minimal in 1.1%, moderate in 7.6%, and severe in 5.1%. Of those with atherosclerosis, 24.2% were <30 years old, 88.7% were from enlisted ranks, and 95.2% had combatant occupations. When BMI could be calculated, 73.5% of fatalities with atherosclerosis had a BMI =25. Conclusions: Autopsy-determined atherosclerosis is prevalent in elite US military Special Operations Forces despite young age and positive lifestyle benefits of service in an elite military unit.

Keywords: atherosclerosis; elite US military forces; coronary atherosclerosis; aortic atherosclerosis

PMID: 34105116

DOI: RLN9-UQ2X

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Avoiding Program-Induced Cumulative Overload (PICO)

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Orr R, Knapik JJ, Pope R. 16(2). 91 - 95. (Journal Article)

Abstract

This article defines the concept of program-induced cumulative overload (PICO), provides examples, and advises ways to mitigate the adverse effects. PICO is the excessive cumulative physical workload that can be imparted to military personnel by a military training program with an embedded physical training component. PICO can be acute (accumulating within a single day) or chronic (accumulating across the entirety of the program) and results in adverse outcomes for affected personnel, including detrimental fatigue, performance degradation, injuries, or illness. Strategies to mitigate PICO include focusing administration and logistic practices during the development and ongoing management of a trainee program and implementing known musculoskeletal injury prevention strategies. More training is not always better, and trainers need to consider the total amount of physical activity that military personnel experience across both operational training and physical training if PICO is to be mitigated.

Keywords: injuries, overload; training; prevention; programming

PMID: 27450610

DOI: MDE1-UEU0

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Baseline Dissociation And Prospective Success In Special Forces Assessment And Selection

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Morgan CA, Hazlett G, Dial-Ward M, Southwick SM. 09(2). 87 - 92. (Previously Published)

Previously Published in Psychiatry (Edgemont) 2008;5(7):52-57. Permission granted by Psychiatry 2008 to reproduce in the JSOM.

Abstract

Introduction: Although dissociation at the time of trauma (peritraumatic dissociation) has been shown to predict the development of posttraumatic stress disorder (PTSD), it is not yet known whether the tendency to dissociate under nonstressful circumstances (i.e., at baseline) can also serve as a predictor of vulnerability to stress in healthy individuals. Method: Baseline symptoms of dissociation (CADSS) were assessed in 774 active duty male Soldiers enrolled in Special Forces Assessment and Selection (SFAS). Results: Soldiers who endorsed experiencing any symptoms of dissociation at baseline were significantly less likely to be successful in SFAS. The greater the number of symptoms of dissociation endorsed at baseline, the greater the likelihood of failure. Discussion: These data explain our earlier findings of fewer symptoms of dissociation in elite troops and may have relevance for the selection and hiring of personnel for nonmilitary, at-risk professions. Better screening may lead to improved primary intervention strategies, better job placement, and lowered risk of PTSD.

Keywords:

PMID: 19813521

DOI: WOPM-1238

Basic Biostatistics and Clinical Medicine

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Banting J, Meriano T. 17(1). 76 - 76. (Journal Article)

Keywords: biostatics, statistics; tests; specificity; sensitivity

PMID: 28285484

DOI: 386W-D689

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Battlefield Analgesia: Adherence to Tactical Combat Casualty Care Guidelines

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Schauer SG, Fisher AD, April MD, Carter R, Cunningham CW, Aden JK, Fernandez JD, DeLorenzo RA. 19(1). 70 - 74. (Journal Article)

Abstract

Background: Low rates of prehospital analgesia, as recommended by Tactical Combat Casualty Care (TCCC) guidelines, have been demonstrated in the Joint Theaters combat setting. The reasons for this remain unclear. This study expands on previous reports by evaluating a larger prehospital dataset for determinants of analgesia administration. Methods: This was part of an approved quality assurance project evaluating adherence to TCCC guidelines across multiple modalities. Data were from the Prehospital Trauma Registry, which existed from January 2013 through September 2014, and comprises data from TCCC cards, Department of Defense 1380 forms, and after-action reports to provide real-time feedback to units on prehospital medical care. Results: Of 705 total patient encounters, there were 501 documented administrations of analgesic medications given to 397 patients. Of these events, 242 (34.3%) were within TCCC guidelines. Special Operations Command had the highest rate of overall adherence, but rates were still low (68.5%). Medical officers had the highest rates of overall administration. The low rates of administration and adherence persisted across all subgroups. Conclusion: Rates of analgesia administration remained low overall and in subgroup analyses. Medical officers appeared to have higher rates of compliance with TCCC guidelines for analgesia administration, but overall adherence to TCCC guidelines was low. Future research will be aimed at finding methods to improve administration and adherence rates.

Keywords: analgesia; combat; compliance; military; pain; prehospital; Tactical Combat Casualty Care

PMID: 30859531

DOI: KDHW-QBQZ

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Battlefield Analgesia: TCCC Guidelines Are Not Being Followed

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Schauer SG, Robinson JB, Mabry RL, Howard JT. 15(1). 85 - 89. (Journal Article)

Abstract

Background: Servicemembers injured in combat often experience moderate to severe acute pain. Early and effective pain control in the prehospital setting has been shown to reduce the sequelae of untreated pain. Current data suggest that lack of point-of-injury (POI) analgesia has significant, downstream effects on healthcare quality and associated costs. Methods: This was a process improvement project to determine the current rate of adherence to existing prehospital pain management guidelines. The records of patients who had sustained a major injury and met current Tactical Combat Casualty Care (TCCC) criteria for POI analgesia from July 2013 through March 2014 were reviewed to determine if pain medication was given in accordance with existing guidelines, including medication administration and routes. On 31 October 2013, the new TCCC guidelines were released. The "before" period was from July 2013 through October 2013. The "after" period was from November 2013 through March 2014. Results: During the project period, there were 185 records available for review, with 135 meeting TCCC criteria for POI analgesia (68 pre-, 66 postintervention). Prior to 31 October 2013, 17% of study patients received analgesia within guidelines at the POI compared with 35% in the after period. The most common medication administered preand post-release was oral transmucosal fentanyl citrate. Special Operations Forces had higher adherence rates to TCCC analgesia guidelines than conventional forces, but these still were low. Conclusion: Less than half of all eligible combat casualties receive any analgesia at the POI. Further research is needed to determine the etiology of such poor adherence to current TCCC guidelines.

Keywords: analgesia; point of injury; combat; fentanyl; ketamine; morphine; military

PMID: 25770803

DOI: 9P6A-1W1Q

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Battlefield Extracorporeal Cardiopulmonary Resuscitation for Out-of-Hospital Cardiac Arrest: A Feasibility Study During Military Exercises

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Reva VA, Pochtarnik AA, Shelukhin DA, Skvortzov AE, Semenov EA, Emelyanov AA, Nosov AM, Demchenko KN, Reznik ON, Samokhvalov IM, DuBose JJ. 20(4). 77 - 83. (Journal Article)

Abstract

Purpose: To evaluate the feasibility of prehospital extracorporeal cardiopulmonary resuscitation (E-CPR) in the military exercise setting. Methods: Three 40kg Sus scrofa (wild swine) underwent controlled 35% blood loss and administration of potassium chloride to achieve cardiac arrest (CA). During CPR, initiated 1 minute after CA, the animals were transported to Role 1. Femoral vessels were cannulated, followed by E-CPR using a portable perfusion device. Crystalloid and blood transfusions were initiated, followed by tactical evacuation to Role 2 and 4-hour observation. Results: All animals developed sustained asystole. Chest compressions supported effective but gradually deteriorating blood circulation. Two animals underwent successful E-CPR, with restoration of perfusion pressure to 80mmHg (70-90mmHg) 25 and 23 minutes after the induction of CA. After transportation to Role 2, one animal developed abdominal compartment syndrome as a result of extensive (9L) fluid replacement. The other animal received a lower volume of crystalloids (4L), and no complications occurred. In the third animal, multiple attempts to cannulate arteries were unsuccessful because of spasm and hypotension. Open aortic cannulation enabled the circuit to commence. No return of spontaneous circulation was ultimately achieved in either of the remaining animals. Conclusion: Our study demonstrates both the potential feasibility of battlefield E-CPR and the evolving capability in the care of severey injured combat casualties.

Keywords: conbat trauma; extracorporeal membrane oxygenation; endovascular; battlefield; cardiac arrest; cardiopulmonary resuscitation

PMID: 33320317

DOI: H2KX-EKHQ

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Battlefield Management of Facial Fractures Using Minnie Ties: An Innovative Technique for Maxillomandibular Fixation

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Ivory JW, Jenzer AC. 22(1). 87 - 91. (Journal Article)

Abstract

Application of maxillomandibular fixation (MMF) for the treatment of jaw fractures has a long history stretching back thousands of years. Modern methods of MMF require extensive training for correct application and are often not practical to perform in a forward operating environment. Most MMF methods carry inherent risks of sharps injuries and exposure to bloodborne pathogens. The authors present a method of MMF with Minnie Ties, which are simple, effective, and much safer than traditional methods of MMF.

Keywords: facial bones; facial injuries; mandible fractures; maxilla fractures; jaw fractures; military dentistry; oral surgery

PMID: 35278320

DOI: ABX3-D3G2

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Battlefield Use Of Human Plasma By Special Operations Forces

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Murphy C. 08(4). 27 - 29. (Journal Article)

Abstract

Recently a select group of Special Operations medical providers have carried fresh thawed human plasma as a resuscitative fluid on the battlefield at the evacuation phase of Tactical Combat Casualty Care (TCCC) and in rare occasions at the tactical field care phase of TCCC. Plasma in certain circumstances should be considered as an adjunct to treatment of coagulapathic battlefield casualties. Plasma does however have limitations due to logistical constraints. The long term solution is to develop a field stable variant of plasma which would make this life-saving fluid available to a broader range of care providers. Recent studies have shown that the development of lyophilized plasma is feasible.

Keywords:

DOI:

Be in the Know: Dietary Supplements for Cognitive Performance

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Crawford C, Deuster PA. 20(2). 132 - 135. (Journal Article)

Abstract

Dietary supplements promoted for brain health and enhanced cognitive performance are becoming increasingly popular. Special Operations Forces (SOF) is likely a prime target for this market as they strive to continually optimize and then sustain their high level of performance at all times. When a dietary supplement hits the market, it is considered safe until it is proven otherwise; yet the majority have not been analyzed for quality or tested for safety. The authors describe issues related to products marketed for brain health and cognitive enhancement and focus on products brought to our attention by the operational communities. The overwhelming majority of product labels were found to be misbranded and some were found to contain prohibited ingredients and drugs. The problematic ingredients in these products are introduced. The Operation Supplement Safety scorecard algorithm is demonstrated as a tool to quickly screen a product for potential safety; it can be used in real-time when considering the use of any dietary supplement product. These resources are available to help SOF medical assets evaluate whether a product's claims may be deceiving and potentially harmful to the health or career of Operators.

Keywords: consumer product safety; decision aid; dietary supplements; education; mental processes

PMID: 32573750

DOI: 9ANO-BXRD

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Behind the Lines: A Critical Survey of Special Operations in World War II

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Hester RA. 14(1). 104 - 105. (Book Review)

Abstract

Michael F. Dilley. Casemate; 2013. Hardcover: 280 pages.
ISBN: 978-1-612001-83-8. eIBN: 978-1-612001-84-5.

Keywords:

PMID: 24604449

DOI: LAL2-SJ6E

Benefit of Critical Care Flight Paramedic-Trained Search and Rescue Corpsmen in Treatment of Severely Injured Aviators

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Snow RW, Papalski W, Siedler J, Drew B, Walrath B. 18(1). 19 - 22. (Case Reports)

Abstract

During routine aircraft start-up procedures at a US Naval Air Station, an aviation mishap occurred, resulting in the pilot suffering a traumatic brain injury and the copilot acquiring bilateral hemopneumothoraces, a ruptured diaphragm, and hepatic and splenic contusions. The care of both patients, including at point of injury and en route to the closest trauma center, is presented. This case demonstrates a benefit from advanced life-saving interventions and critical care skills beyond the required scope of practice of search and rescue medical technicians as dictated by relevant instructions.

Keywords: en route care; MEDEVAC; military; traumatic brain injury; pneumothorax; critical care

PMID: 29533427

DOI: 8WN3-K4MR

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Best Tourniquet Holding and Strap Pulling Technique

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Wall PL, Buising CM, Donovan S, McCarthy C, Smith K, Renner CH. 19(2). 48 - 56. (Journal Article)

Abstract

Background: Appropriate strap pressure before tightening-system use is an important aspect of nonelastic, limb tourniquet application. Methods: Using different two-handed techniques, the strap of the Generation 7 Combat Application Tourniquet (C-A-T7), Tactical Ratcheting Medical Tourniquet (Tac RMT), Tactical Mechanical Tourniquet (TMT), Parabelt, and Generation 3 SOF® Tactical Tourniquet-Wide (SOFTTW) was secured mid-thigh by 20 appliers blinded to pressure data and around a thigh-sized ballistic gel cylinder by gravity and 23.06kg. Results: Pulling only outward (90° to strap entering buckle) achieved the lowest secured pressures on thighs and gel. For appliers, the best holding location was above the buckle, and the best strap-pulling direction was tangential to the thigh or gel (0° to strap entering buckle). Preceding tangential pulling with outward pulling resulted in higher secured pressures on the gel but did not aid appliers. Appliers generally did not reach secured pressures achievable for their strength. Of 80 thigh applications per tourniquet, 77 C-A-T7, 41 Tac RMT, 35 TMT, 16 Parabelt, and 10 SOFTTW applications had secured pressures greater than 100mmHg. Conclusions: The default for best tourniquet strap-application technique is to hold above the buckle and pull the strap tangential to the limb at the buckle. Additionally, neither strength nor experience guarantees desirable strap pressures in the absence of pressure knowledge.

Keywords: tourniquet; hemorrhage; first aid; emergency treatment

PMID: 31201751

DOI: H9GT-Q602

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Beyond Tears: The Potential Hazards Of The O-Chlorobenzylidene-Malononitrile (Cs) Gas Under Scrutiny

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Asuku ME, Milner SM, Gerold KB. 11(1). 28 - 30. (Journal Article)

Keywords:

PMID: 22113724

DOI: 6CXK-K4GY

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Bilateral Pneumothoraces in a Tandem Parachuting Passenger Without Traumatic Impact: A Case Report

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Fedor PJ, Riley B, Fowl DA, Donahue A. 22(3). 94 - 97. (Case Reports)

Abstract

In parachuting, orthopedic and head injuries are well-documented risks associated with the parachute deployment and landing phases. Thoracic injuries have only been seen on rare occasion in conjunction with direct impact trauma. In this report, we detail a case of a young, healthy, tandem skydiving passenger who suffered bilateral pneumothoraces with delayed symptom onset, with no identifiable injury during the jump or landing. Exploring the forces of the parachute "opening shock," we suggest a plausible compressive mechanism for this novel presentation, as well as briefly discuss the options for diagnosis and conservative management of pneumothorax in the operational context. While this is an exceedingly rare event, pneumothorax should be considered in patients complaining of thoracic symptoms following a skydive.

Keywords: pneumothorax; prolonged field care; military medicine; prehospital ultrasound; parachute injuries; parachuting

PMID: 35862843

DOI: LMFZ-KK8K

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Biofeedback Self-Regulation Training to Treat Post-Concussion Headache in a Special Operations Support Soldier

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Jenkins CM. 12(4). 24 - 27. (Journal Article)

Abstract

Biofeedback assisted self-regulation training can be an effective treatment for post-concussion headaches. The following is an example of using biofeedback assisted self-regulation training as an intervention to treat posttrauma headaches in a Special Operations Forces (SOF) support soldier. This Soldier was a 23-year-old male who had suffered a concussion while off duty four months earlier and continued to experience headache. Threemodality biofeedback (temperature, surface electromyogram and skin conduction) was used to help the patient learn to self-regulate and control his headaches. This was accomplished over four visits over two weeks. This was a compressed timeline to allow him to deploy with his unit. This form of treatment can be a viable nonmedication based option for addressing post concussion headaches for deploying Soldiers.

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PMID: 23536453

DOI: N6H3-HR2D

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Biometrics in Support of Special Forces Medical Operations

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Kershner MR. 12(4). 29 - 32. (Journal Article)

Abstract

Recommendations on ways in which the ODA can leverage biometrics in medical operations to improve their security, improve relations with indigenous personnel, and contribute to the larger theater biometrics program.

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PMID: 23536454

DOI: 3T4Z-68EP

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Blast Traumatic Brain Injury - What Do We Know?

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Rolan T. 13(3). 45 - 50. (Journal Article)

Abstract

Traumatic brain injury (TBI) is a significant problem in both the civilian and military worlds. Although much is understood about the effects of TBI, relatively few diagnostic or therapeutic modalities are available. Currently, TBI treatment is in a primitive phase and other than acute lifesaving interventions, is largely relegated to rehabilitation efforts. This article discusses known aspects of neuronal injury related to blast TBI, as well as a review of the current state of diagnostic and therapeutic interventions.

Keywords: blast traumatic brain injury; neuronal dysfunction

PMID: 24048989

DOI: SVAV-PUAE

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Blood and Belonging: Journeys Into the New Nationalism

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Farr WD. 16(4). 126 - 126. (Book Review)

Abstract

Ignatieff, Michael. Blood and Belonging: Journeys Into the New Nationalism. New York, NY: Farrar, Straus, and Giroux; 1995. Paperback: 276 pages. ISBN-10: 0374524483 and ISBN-13:978-0374524487.

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Blood and Belonging: Journeys Into the New Nationalism

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Farr WD. 17(4). 138 - 138. (Book Review)

Abstract

Ignatieff, Michael. Blood and Belonging: Journeys Into the New Nationalism. New York, NY: Farrar, Straus, and Giroux; 1995. Paperback: 276 pages. ISBN-10: 0374524483 and ISBN-13:978-0374524487.

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Blood Flow Restriction Rehabilitation for Extremity Weakness: A Case Series

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Hylden C, Burns T, Stinner DJ, Owens J. 15(1). 50 - 56. (Journal Article)

Abstract

Background: Blood flow restricted (BFR) training, the brief and partial restriction of venous outflow of an extremity during low load resistance exercises, is a safe and effective method of improving strength in healthy, active individuals. A relatively unexplored potential of this adjunctive modality lies in treating patients with severe musculoskeletal trauma, persistent chronic quadriceps and hamstring weakness despite traditional therapy, and low improvement during early postoperative strengthening. Methods: This case series describes patients with chronic quadriceps and hamstring weakness who received an intervention of BFR at low loads, 20% of 1 repetition max (1RM), to restore strength. A case series was conducted of seven patients, all located at one hospital and all with traumatic lower extremity injuries. The seven patients were treated at the same medical center and with the same BFR protocol. All seven patients had isokinetic dynamometer testing that showed persistent thigh muscle weakness despite previous rehabilitation with traditional therapy and 35% to 75% peak torque deficit in either knee extension or flexion compared with the contralateral lower extremity. Patients underwent 2 weeks of BFR training therapy using a pneumatic tourniquet set at 110mmHg while performing leg extensions, leg presses, and reverse leg presses. All affected extremities were retested after 2 weeks (six treatment sessions). Dynamometer measurements were done with flexion and extension at two speeds: 90° and 300°/sec. The data recorded included peak torque normalized for body weight, average power, and total work. Results: All seven patients demonstrated improvements in peak torque, average power, and total work for both knee flexion and extension, with power being the most improved overall. Peak torque improved an average of 13% to 37%, depending on contraction direction and speed. Average power improved an average of 42% to 81%, and total work improved an average of 35% to 55%. Conclusion: BFR therapy at low loads can affect improvement in muscle strength in patients who are unable to perform high-resistance exercise or patients who have persistent extremity weakness despite traditional therapy.

Keywords: strengthening; muscle mass; tourniquet; physical therapy; blood flow restriction; vascular occlusion

PMID: 25770798

DOI: DQOF-LTY6

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Blood Lead Toxicity Analysis of Multipurpose Canines and Military Working Dogs

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Reid P, George C, Byrd CM, Miller L, Lee SJ, Motsinger-Reif A, Breen M, Hayduk DW. 18(1). 74 - 76. (Journal Article)

Abstract

Special Operations Forces and their accompanying tactical multipurpose canines (MPCs) who are involved in repeated live-fire exercises and military operations have the potential for increased blood lead levels and toxicity due to aerosolized and environmental lead debris. Clinical lead-toxicity symptoms can mimic other medical disorders, rendering accurate diagnosis more challenging. The objective of this study was to examine baseline lead levels of MPCs exposed to indoor firing ranges compared with those of nontactical military working dogs (MWDs) with limited or no exposure to the same environment. In the second part of the study, results of a commercially available, human-blood lead testing system were compared with those of a benchtop inductively coupled plasma-mass spectrometry (ICP-MS) analysis technique. Blood samples from 18 MPCs were tested during routine clinical blood draws, and six samples from a canine group with limited exposure to environmental lead (nontactical MWDs) were tested for comparison. There was a high correlation between results of the commercial blood-testing system compared with ICP-MS when blood lead levels were higher than 4.0µg/dL. Both testing methods recorded higher blood lead levels in the MPC blood samples than in those of the nontactical MWDs, although none of the MPC samples tested contained lead levels approaching those at which symptoms of lead toxicity have previously been reported in animals (i.e., 35µg/dL).

Keywords: heavy metal toxicity; aerosolization; lead, blook toxicity analysis; canines, multipurpose; dogs, military working

PMID: 29533437

DOI: 1XJJ-72QL

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Blood Product Administration During Transport Throughout the US Africa Command Theater of Operation

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Schauer SG, Naylor JF, Fisher AD, Hyams DG, Carius BM, Escandon MA, Linscomb CD, McDonald H, Cap AP, Bynum J. 21(3). 66 - 70. (Journal Article)

Abstract

Background: United States Africa Command (US AFRICOM) is one of six US Defense Department's geographic combatant commands and is responsible to the Secretary of Defense for military relations with African nations, the African Union, and African regional security organizations. A full-spectrum combatant command, US AFRICOM is responsible for all US Department of Defense operations, exercises, and security cooperation on the African continent, its island nations, and surrounding waters. We seek to characterize blood product administration within AFRICOM using the in-transit visibility tracking tool known as TRAC2ES (TRANSCOM Regulating and Command & Control Evacuation System). Methods: We performed a retrospective review of TRAC2ES medical evacuations from the AFRICOM theater of operations conducted between 1 January 2008 and 31 December 2018. Results: During this time, there were 963 cases recorded in TRAC2ES originating within AFRICOM, of which 10 (1%) cases received blood products. All patients were males. One was a Department of State employee, one was a military working dog, and the remainder were military personnel. Of the ten humans, seven were the result of trauma, most by way of gunshot wound, and three were due to medical causes. Among human subjects receiving blood products for traumatic injuries, a total of 5 units of type O negative whole blood, 29 units of packed red blood cells (pRBCs), and 9 units of fresh frozen plasma (FFP) were transfused. No subjects underwent massive transfusion of blood products, and only one subject received pRBCs and FFP in 1:1 fashion. All subjects survived until evacuation. Conclusions: Within the TRAC2ES database, blood product administration within AFRICOM was infrequent, with some cases highlighting lack of access to adequate blood products. Furthermore, the limitations within this database highlight the need for systems designed to capture medical care performance improvement, as this database is not designed to support such analyses. A mandate for performance improvement within AFRICOM that is similar to that of the US Central Command would be beneficial if major improvements are to occur.

Keywords: prehospital; blood; Africa; prolonged field care; AFRICOM

PMID: 34529808

DOI: 4SI5-9IRH

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Blood Transfusion as a Therapeutic Maneuver

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Anderson JL, Johannigman J. 21(3). 111 - 117. (Journal Article)

Keywords: Lest We Forget; combat casualty care; blood; transfusion; fluid resuscitation

PMID: 34529817

DOI: QKCJ-Z263

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Body Cavity Bombers: The New Martyrs. A Terrorism Research Center Book

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Farr WD. 19(2). 141 - 141. (Book Review)

Abstract

Bunker RJ, Flaherty CJ. Body Cavity Bombers: The New Martyrs: A Terrorism Research Center Book. Bloomington, IN: iUniverse LLC, 2013. Paperback: 350 pages. ISBN 978-1-4917-0310-3.

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Brain Natriuretic Peptide Level In Six Basic Underwater Demolitions/SEAL Recruits Presenting With Swimming Induced Pulmonary Edema (SIPE)

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Shearer D, Mahon RT. 09(3). 44 - 50. (Journal Article)

Abstract

Swimming induced pulmonary edema (SIPE) is associated with both SCUBA diving and strenuous surface swimming; however, the majority of reported cases and clinically observed cases tend to occur during or after aggressive surface swimming.1 Capillary stress failure appears to be central to the pathophysiology of this disorder. Regional pulmonary capillaries are exposed to relatively high pressures secondary to increased vascular volume, elevation of pulmonary vascular resistance, and regional differences in perfusion secondary to forces of gravity and high cardiac output. Acute pulmonary edema can be classified as either cardiogenic or noncardiogenic or both. Cardiogenic pulmonary edema occurs when the pulmonary capillary hydrostatic pressure exceeds plasma oncotic pressure. Noncardiogenic pulmonary edema occurs when pulmonary capillary permeability is increased. Given the pathophysiology noted above, SIPE can be described as a cardiogenic pulmonary edema, at least in part, since an increased transalveolar pressure gradient has been implicated in the pathogenesis of SIPE.2 Brain natriuretic peptide (BNP) is used in the clinical setting to differentiate cardiac from pulmonary sources of dyspnea, specifically to diagnose cardiogenic pulmonary edema.3,4 During clinical management, BNP levels were drawn on six BUD/S recruits simultaneously presenting with pulmonary complaints consistent with SIPE, after an extended surface bay swim. This paper analyzes that data after de-identification and reviews the pathophysiology and clinical management of SIPE. LEARNING OBJECTIVES 1. Describe the signs and symptoms of SIPE. 2. Describe the immediate care and treatment of SIPE. 3. Demonstrate understanding of the fundamental pathophysiology of SIPE.

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PMID: 19739476

DOI: MPGH-O4NQ

Bringing Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) Closer to the Point of Injury

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Pasley JD, Teeter WA, Gamble WB, Wasick P, Romagnoli AN, Pasley AM, Scalea TM, Brenner ML. 18(1). 33 - 36. (Case Reports)

Abstract

Background: The management of noncompressible torso hemorrhage remains a significant issue at the point of injury. Resuscitative endovascular balloon occlusion of the aorta (REBOA) has been used in the hospital to control bleeding and bridge patients to definitive surgery. Smaller delivery systems and wirefree devices may be used more easily at the point of injury by nonphysician providers. We investigated whether independent duty military medical technicians (IDMTs) could learn and perform REBOA correctly and rapidly as assessed by simulation. Methods: US Air Force IDMTs without prior endovascular experience were included. All participants received didactic instruction and evaluation of technical skills. Procedural times and pretest/posttest examinations were administered after completion of all trials. The Likert scale was used to subjectively assess confidence before and after instruction. Results: Eleven IDMTs were enrolled. There was a significant decrease in procedural times from trials 1 to 6. Overall procedural time (± standard deviation) decreased from 147.7 ± 27.4 seconds to 64 ± 8.9 seconds (ρ < .001). There was a mean improvement of 83.7 ± 24.6 seconds from the first to sixth trial (ρ < .001). All participants demonstrated correct placement of the sheath, measurement and placement of the catheter, and inflation of the balloon throughout all trials (100%). There was significant improvement in comprehension and knowledge between the pretest and posttest; average performance improved significantly from 36.4.6% ± 12.3% to 71.1% ± 8.5% (ρ < .001). Subjectively, all 11 participants noted significant improvement in confidence from 1.2 to 4.1 out of 5 on the Likert scale (ρ < .001). Conclusion: Technology for aortic occlusion has advanced to provide smaller, wirefree devices, making field deployment more feasible. IDMTs can learn the steps required for REBOA and perform the procedure accurately and rapidly, as assessed by simulation. Arterial access is a challenge in the ability to perform REBOA and should be a focus of further training to promote this procedure closer to the point of injury. Keywords: hemorrhage control; independent duty medical technician; resuscitative endovascular balloon occlusion of the aorta; REBOA

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PMID: 29533431

DOI: FNS3-0CIQ

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Broken Bodies/Shattered Minds: A Medical Odyssey from Vietnam to Afghanistan

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Hester RA. 11(4). 79 - 80. (Book Review)

Abstract

Ronald J. Glasser, MD
History Publishing Co LLC, August 2011. ISBN: 9781933909479. 280 pages.

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Brucellosis

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Crecelius EM, Burnett MW. 21(2). 98 - 99. (Journal Article)

Abstract

Human brucellosis can be caused by different Brucella spp. When conducting operations in a country with high rates of brucellosis, extra precautions should be taken. Appropriate personal protective measures should be used in situations when close contact with animal carcasses cannot be avoided. Clinical diagnosis, treatment, and prevention are discussed.

Keywords: brucellosis; infectious diseases; zoonotic infections; Brucella spp.

PMID: 34105131

DOI: QMQR-TI7J

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Caffeine and Performance

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Yarnell AM, Deuster PA. 16(4). 64 - 70. (Journal Article)

Abstract

The role of caffeine in enhancing performance has been studied for years, and there is no doubt that caffeine can be performance enhancing. Also, a wealth of information allows for an interesting distinction between physical and cognitive performance. Most adults in America consume moderate doses of caffeine in various forms on a daily basis as caffeine is typically found in coffee, tea, soft drinks, dietary supplements, energy drinks, energy shots, and chocolate, as well as over-the-counter pills and gums. Although caffeine is readily available and widely consumed, when using it to enhance performance, a few factors should be considered. The authors discuss caffeine use among Servicemembers, its properties and effects on physical and cognitive performance, how to use it to optimize performance, and, finally, some of safety and regulatory considerations. The bottom line is that all individuals do not respond the same way to caffeine and their response depends on how the body uses and breaks down caffeine. Thus, as a user, you should monitor your own responses and performance changes when using caffeine based on the general recommendations provided.

Keywords: caffeine; performance enhancement

PMID: 28088820

DOI: WKND-5J8W

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Caffeine Gum Does Not Improve Marksmanship, Bound Duration, Susceptibility to Enemy Fire, or Cognitive Performance During Tactical Combat Movement Simulation

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Stein JA, Hepler TC, DeBlauw JA, Beattie CM, Beshirs CD, Holte KM, Kurtz BK, Heinrich KM. 21(3). 86 - 92. (Journal Article)

Abstract

Background: Military personnel supplement caffeine as a countermeasure during unavoidable sustained wakefulness. However, its utility in combat-relevant tasks is unknown. This study examined the effects of caffeinated gum on performance in a tactical combat movement simulation. Materials and Methods: Healthy men (n = 30) and women (n = 9) (age = 25.3 ± 6.8 years; mass 75.1 ± 13.1 kg) completed a marksmanship with a cognitive workload (CWL) assessment and a fire-andmove simulation (16 6-m bounds) in experimental conditions (placebo versus caffeinated gum, 4mg/kg). Susceptibility to enemy fire was modeled on bound duration during the fireand- move simulation. Results: Across both conditions, bound duration and susceptibility to enemy fire increased by 9.3% and 7.8%, respectively (p = .001). Cognitive performance decreased after the fire-and-move simulation across both conditions (p < .05). However, bound duration, susceptibility to enemy fire, marksmanship, and cognitive performance did not differ between the caffeine and placebo conditions. Conclusion: These data do not support a benefit of using caffeinated gum to improve simulated tactical combat movements.

Keywords: caffeine gum; marksmanship; bound duration; enemy fire; cognitive performance; tactical combat movement simulation

PMID: 34529811

DOI: C9GO-XEUM

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Canine Tactical Combat Casualty Care (K9TCCC) Guidelines

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Edwards TH, Palmer LE, Baxter RL, Sager TC, Coisman JG, Brown JC, George C, McGraw AC. 20(1). 101 - 111. (Journal Article)

Abstract

First introduced in 1996, Tactical Combat Casualty Care (TCCC) redefined prehospital, point-of-injury (POI), battlefield trauma care for the human combat casualty. Today, many consider TCCC as one of the most influential interventions for reducing combat-related case fatality rates from preventable deaths in human combat casualties. Throughout history, Military Working Dogs (MWDs) have proved and continue to prove themselves as force multipliers in the success of many military operations. Since the start of the Global War on Terror in 2001, these elite canine operators have experienced an upsurge in combat-related deployments, placing them at a higher risk for combat-related injuries. Until recently, consensus- based Canine-TCCC (K9TCCC) guidelines for POI battlefield trauma care did not exist for the MWD, leaving a critical knowledge gap significantly jeopardizing MWD survival. In 2019, the Canine Combat Casualty Care Committee was formed as an affiliate of the Committee on Tactical Combat Casualty Care with the intent of developing evidence- based, best practice K9TCCC guidelines. Modeled after the same principles of the human TCCC, K9TCCC focuses on simple, evidence-based, field-proven medical interventions to eliminate preventable deaths and to improve MWD survival. Customized for the battlefield, K9TCCC uniquely adapts the techniques of TCCC to compensate for canine-specific anatomic and physiological differences.

Keywords: canine; military working dog; Tactical Combat Casualty Care; prehospital care; trauma

PMID: 32203614

DOI: YUMR-DBOP

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Canine Tactical Field Care Part One: The Physical Examination And Medical Assessment

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Taylor WM. 08(3). 54 - 60. (Journal Article)

Abstract

Military and law enforcement agencies have seen a dramatic increase in the utilization of working canine officers both at home and in foreign deployments. Due to the fact that professional veterinary care is often distant from internal disaster or foreign deployment sites, the military medic, police tactical medic, or other first-response medical care provider may be charged with providing emergency or even basic, non-emergency veterinary care to working canines. The medical principles involved in treating canines are essentially the same as those for treating humans, but the human healthcare provider needs basic information on canine anatomy and physiology and common emergency conditions in order to provide good basic veterinary care until a higher level of veterinary care can be obtained. This article represents the first in a series of articles designed to provide condensed, basic veterinary information on the medical care of working canines, including police canines, federal agency employed working canines, and search-and-rescue dogs, in addition to Military Working Dogs (MWD), to those who are normally charged with tactical or first responder medical care of human patients.

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Canine Tactical Field Care Part Three - Thoracic and Abdominal Trauma

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Taylor WM. 10(1). 50 - 58. (Journal Article)

Abstract

Military and law enforcement agencies have seen a dramatic increase in the utilization of working canines both at home and in foreign deployments. Due to the fact that professional veterinary care is sometimes distant from internal disaster or foreign deployment sites, the military medic, police tactical medic, or other first-response medical care provider may be charged with providing emergency or even basic, non-emergency veterinary care to working canines. (Editor's Note: Military veterinary detachments are collocated next to the major human treatment facilities in a deployment environment. In a deployed environment veterinary care is located in areas where they are most needed or where most of the animals are located.) The medical principles involved in treating canines are essentially the same as those for treating humans, but the human healthcare provider needs basic information on canine anatomy and physiology and common emergency conditions in order to provide good basic veterinary care until a higher level of veterinary care can be obtained. This article represents the third in a series of articles designed to provide condensed, basic veterinary information on the medical care of working canines, to include military working dogs (MWDs), police canines, federal agency employed working canines, and search and rescue dogs, to those who are normally charged with tactical or first responder medical care of human patients. This article provides and overview of the diagnosis and treatment of common traumatic injuries to the thorax and abdomen.

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PMID: 20306416

DOI: B70F-IKJR

Canine Tactical Field Care Part Two - Massive Hemorrhage Control And Physiologic Stabilization Of The Volume Depleted, Shock-affected, Or Heatstroke-affective Canine

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Taylor WM. 09(2). 13 - 21. (Journal Article)

Abstract

Military and law enforcement agencies have seen a dramatic increase in the utilization of military working dogs (MWDs) and working canine officers, respectively both at home and in foreign deployments. Due to the fact that professional veterinary care is often distant from internal disaster or foreign deployment sites, the military medic, police tactical medic, or other first-response medical care providers may be charged with providing emergency or even basic, non-emergency veterinary care to working canines. The medical principles involved in treating canines are essentially the same as those for treating humans; however, the human healthcare provider needs basic information on canine anatomy and physiology, and common emergency conditions, in order to provide good basic veterinary care until a higher level of veterinary care can be obtained. This article represents the second in a series designed to provide condensed, basic veterinary information on the medical care of working canines, including police canines, federal agency employed working canines, and search-and-rescue dogs, in addition to the MWD, to those who are normally charged with tactical or first responder medical care of human patients. This article focuses on diagnosing and treating some of the more common high-mortality conditions affecting canines in the field including massive hemorrhage, volume-depletion, shock, and heatstroke.

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PMID: 19813515

DOI: V7B3-973P

Care of the Burn Casualty in the Prolonged Field Care Environment

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Studer NM, Driscoll IR, Daly IM, Graybill JC. 15(3). 86 - 93. (Journal Article)

Abstract

Burns are frequently encountered on the modern battlefield, with 5% - 20% of combat casualties expected to sustain some burn injury. Addressing immediate lifethreatening conditions in accordance with the MARCH protocol (massive hemorrhage, airway, respirations, circulation, hypothermia/head injury) remains the top priority for burn casualties. Stopping the burning process, total burn surface area (TBSA) calculation, fluid resuscitation, covering the wounds, and hypothermia management are the next steps. If transport to definitive care is delayed and the prolonged field care stage is entered, the provider must be prepared to provide for the complex resuscitation and wound care needs of a critically ill burn casualty.

Keywords: burn injury; inhalation injury; Tactical Combat Casualty Care; prolonged field care; Silverlon; Water-Jel; Burntec

PMID: 26360361

DOI: QMS7-HZ8F

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Care Of The Military Working Dog By Medical Providers

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Vogelsang R. 07(2). 33 - 47. (Journal Article)

Abstract

Military Working Dogs (MWD) are important force multipliers. The U.S. Department of Defense MWD program has expanded significantly in both total numbers of dogs and scope of their missions. MWDs are utilized to enhance law enforcement and force protection capabilities usually associated with detection of explosives or illicit/illegal drugs. Currently, in support of the Global War on Terrorism, MWDs are particularly involved with explosives detection and perform duties such as vehicle and building checks, route and minefield clearing, cache sweeps, crowd control, and cordon searches. Though there currently are no MWDs organic to SOF, the concept of using MWDs within SOF is being considered. Depending on the size and maturity of a particular theater, conventional veterinary support may or may not be readily available to any MWDs which could potentially be used in support of SOF. In situations where veterinary support is difficult to obtain, or is non-existent, the only care available for MWDs will have to come from the handler or medical providers within the supported unit. MWDs are valuable and scarce assets which cannot be replaced easily or in a timely fashion. As such, it is important for medical providers to have at least a minimal knowledge set of emergent conditions common and/or unique to the MWD so that their intervention has the best chance of success to preserve life, limb, or eyesight of the canine patient. Though many conditions in the dog are treated in a similar fashion in the human patient, differences in anatomy, vital sign and laboratory parameters and, medications and dosages, may give the medical provider cause for hesitation to attend to canine patients. This article attempts to provide medical providers some basic knowledge of MWD patients, their conditions, and treatments.

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Carfentanil: A New and Often Unrecognized Threat

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Cowles CE, Mitchell J, Stepp JE, Bewley VZ. 17(3). 120 - 122. (Journal Article)

Abstract

Law enforcement officers, whether working the streets or on narcotic detail, and even those who operate in strike teams, face a new danger from an old drug: carfentanil. Drug dealers seeking to increase profits cut this cheap synthetic drug into expensive heroin, providing an extreme high. As a potent synthetic opioid narcotic, it is finding its way to the streets of the United States and can pose a threat to life for law enforcement, first responders, and medical examiners.

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PMID: 28910481

DOI: 8N90-FU1K

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Case of a 5-Year-Old Foreign National Who Sustained Penetrating Abdominal Trauma

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McLeroy RD, Ellis JL, Karnopp JM, Dellavolpe J, Gurney J, Keenan S, Powell D, Riesberg JC, Edwards M, Matos R, Pamplin JC. 16(4). 110 - 113. (Journal Article)

Abstract

Objective: Review application of telemedicine support for penetrating trauma. Clinical Context: Special Operations Resuscitation Team (SORT) deployed in Africa Area of Responsibility (AOR) Organic expertise: Internal Medicine physician, two Special Operations Combat medics (SOCMs), and one radiology technician Closest surgical support: Non-US surgical support 20km away; a nonsurgeon who will perform surgeries; neighboring country partner-force surgeon 2 hours by fixedwing flight. Earliest Evacuation: Evacuated 4 days after presentation to a neighboring country with surgical capability.

Keywords: critical care; telemedicine; military personnel; emergency treatment; patient transfer; combat casualty care

PMID: 28088829

DOI: DGS0-Q8OR

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Case Presentation: Creation and Utilization of a Novel Field Improvised Autologous Transfusion System in a Combat Casualty

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Scarborough T, Turconi M, Callaway DW. 19(2). 134 - 137. (Journal Article)

Abstract

This case report describes the technical aspects in first use of a novel field improvised autologous transfusion (FIAT) system. It highlights a potential solution for specific trauma patients during advanced resuscitative care (ARC) and prolonged field care (PFC) scenarios where other blood products are not available.

Keywords: blood transfusion; resuscitation; shock, hemorrhagic; fluid therapy; military medicine; warfare; unconventional medicine

PMID: 31201769

DOI: 9H4Q-OJW6

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Case Report And Review Of The Literature Of Anterior Thigh Heterotopic Ossification In A U.s. Air Force Special Operations Parachutist

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Delmonaco BL. 07(2). 48 - 50. (Journal Article)

Abstract

The development of heterotopic ossification (HO), also known as myositis ossificans, after blunt trauma to the quadriceps muscles is a well-described disease in athletes. It is a disease with an interesting and predictable course; it is the unusual case that leads to chronic morbidity or requires surgery. This report describes a case of HO in a U.S. Air Force Special Operations parachutist following a routine parachute landing fall (PLF) after performing a high-altitude-low-opening (HALO) jump. The literature was reviewed; however, no other reports of HO in the parachutist occupation were identified. The work-up to rule out other diseases, particularly sarcoma of the thigh is reviewed, as well as the recommended management and expected course of the disease.

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Case Report of an Anthrax Presentation Relevant to Special Operations Medicine

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Winkler S, Enzenauer RW, Karesh JW, Pasteur N, Eisnor DL, Painter RB, Calvano CJ. 16(2). 9 - 12. (Journal Article)

Abstract

Special Operations Forces (SOF) medical personnel function worldwide in environments where endemic anthrax (caused by Bacillus anthracis infection) may present in one of three forms: cutaneous, pulmonary, or gastrointestinal. This report presents a rare periocular anthrax case from Haiti to emphasize the need for heightened diagnostic suspicion of unusual lesions likely to be encountered in SOF theaters.

Keywords: periocular anthrax; Bacillus anthracis; ophthalmology; diagnostics

PMID: 27450596

DOI: SRPB-TJ0N

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Case Report of Infectious Myositis in the Austere Setting

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Sarkisian S, Sletten ZJ, Roberts P, Powell T. 21(2). 80 - 84. (Journal Article)

Abstract

Although skin and soft tissue infections are common in the deployed setting, infectious myositis is relatively uncommon. Bacterial infection of the muscle is the most common infectious etiology and can result in a spectrum of disease, to include abscess formation to necrotizing myositis, toxic shock syndrome, and death. Diagnosis can be elusive, particularly in the early stages. Recognition and proper management are crucial to prevent complications. The authors present a case report of infectious myositis diagnosed and managed in an austere deployed environment, as well as a discussion regarding current recommendations on diagnosis and treatment.

Keywords: infectious myositis; myositis; austere; antibiotics

PMID: 34105127

DOI: CER8-0MO5

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Case Report Stimulant-Induced Atrial Flutter in a Remote Setting

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Thomas A, Pagenhardt J, Balcik B. 20(1). 37 - 39. (Case Reports)

Abstract

Atrial flutter and atrial fibrillation are among the most commonly encountered cardiac arrhythmias; however, there is a dearth of clinical trials or case studies regarding its occurrence in the setting of stimulants such as caffeine and nicotine in otherwise healthy young patients. Described here is a case of a 29-year-old physically fit white man without significant past medical history who presented in stable condition complaining only of palpitations. He was found to have atrial flutter without rapid ventricular response on cardiac monitoring, most likely due to concomitant presence of high levels of nicotine and caffeine via chewing tobacco and energy drinks. He was treated conservatively with vagal maneuvers and intravenous fluids with complete resolution of symptoms and electrocardiographic abnormalities within 14 hours. This demonstrates an alternate conservative treatment strategy in appropriately risk stratified patients who present in an austere field setting with limited resources.

Keywords: atrial flutter; caffeine; nicotine; vagal maneuver; athlete

PMID: 32203603

DOI: XGYB-CIHY

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Case Report: Acute Intermittent Porphyria In A 21-year-old Active Dutymale

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Thompson WD. 11(3). 52 - 56. (Journal Article)

Abstract

Acute Intermittent Porphyria (AIP) is one of a group of rare metabolic disorders arising from reduced activity of any of the enzymes in the heme biosynthetic pathway. The porphyrias can be very difficult for the practitioner to understand. There are several types of porphyrias, which have been known by various different names and are classified from different perspectives1 based on where the defective synthesis site is, or what the clinical manifestations are. Since practitioners rarely encounter this disease process, it is commonly not considered in the differential diagnoses. AIP can be confused with other causes of acute abdominal disorders such as appendicitis with peritonitis or nephrolithiasis. Patients with AIP typically give a history of constipation, fatigue, irritability, and insomnia that precede their acute attack. Symptoms occur intermittently in some patients with acute attacks lasting for several days or longer and were usually followed by complete recovery. This case report deals with an initial presentation of AIP in an otherwise healthy 21-year-old active duty male Soldier. Clinical presentation, diagnosis and treatment are discussed as is a brief historical anecdote.

Keywords: porphyria; emergency department; medication, motion sickness; urine

PMID: 21706462

DOI: 2R5G-K0SU

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Case Report: Use Of The Immediate Post Concussion Assessment And Cognitive Testing (ImPACT) To Assist With Return To Duty Determination Of Special Operations Soldiers Who Sustained Mild Traumatic Brain Injury

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Hettich T, Whitfield E, Kratz K, Frament C. 10(4). 48 - 55. (Case Reports)

Keywords:

PMID: 21442593

DOI: 8M0J-6GHZ

Case Series of Pectoralis Major Muscle Tears in Joint Special Operations Task Force-Philippines Soldiers Diagnosed by Bedside Ultrasound

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Ball V, Maskell K, Pink J. 12(4). 5 - 9. (Journal Article)

Abstract

Pectoralis major muscle tears are an uncommon injury although reported most prevalently among young male athletes (e.g. SOF personnel). We describe two cases occurring in Joint Special Operations Task Force-Philippines (JSOTF-P) Soldiers, review the physical examination and sonographic findings suggestive of a high-grade injury, and discuss treatment options.

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PMID: 23536450

DOI: L390-LK4Y

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Case Series on 2g Tranexamic Acid Flush From the 75th Ranger Regiment Casualty Database

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Androski CP, Bianchi W, Robinson DL, Zarow GJ, Moore CH, Deaton TG, Drew B, Gonzalez S, Knight RM. 20(4). 85 - 91. (Journal Article)

Abstract

Early tranexamic acid (TXA) administration for resuscitation of critically injured warfighters provides a mortality benefit. The 2019 Tactical Combat Casualty Care (TCCC) recommendations of a 1g drip over 10 minutes, followed by 1g drip over 8 hours, is intended to limit potential TXA side effects, including hypotension, seizures, and anaphylaxis. However, this slow and cumbersome TXA infusion protocol is difficult to execute in the tactical care environment. Additionally, the side effect cautions derive from studies of elderly or cardiothoracic surgery patients, not young healthy warfighters. Therefore, the 75th Ranger Regiment developed and implemented a 2g intravenous or intraosseous (IV/IO) TXA flush protocol. We report on the first six cases of this protocol in the history of the Regiment. After-action reports (AARs) revealed no incidences of post-TXA hypotension, seizures, or anaphylaxis. Combined, the results of this case series are encouraging and provide a foundation for larger studies to fully determine the safety of the novel 2g IV/IO TXA flush protocol toward preserving the lives of traumatically injured warfighters.

Keywords: tranexamic acid; TXA; TXA flush; TXA intraosseous; TXA protocol; Tactical Combat Casualty Care; TCCC

PMID: 33320318

DOI: CG6S-N11M

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Casualty Evacuation (CASEVAC) Platform Review and Case Series of US Military Enroute Critical Care Team With Contract Personnel Recovery Services in an Austere Environment

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Boyer NL, Mazarella JA, Thronson EE, Brillhart DB. 21(4). 99 - 103. (Journal Article)

Abstract

In a rapidly changing operational environment, in which there has been an emphasis on prolonged field care and limited evacuation platforms, military providers must practice to the full scope of their training to maximize outcomes. In addition to pushing military providers further into combat zones, the Department of Defense has relied on contracted personnel to help treat and evacuate servicemembers. This article is a retrospective review on the interoperability of the expeditionary resuscitative surgical team (ERST) and a contracted personnel recovery (CPR) team in a far-forward austere environment and will discuss actual patient transport case reviews that used multiple evacuation platforms across thousands of miles of terrain. To effectively incorporate CPR personnel into a military transport team model, we recommend including cross-training on equipment and formularies, familiarization with CPR evacuation platforms, and mass casualty (MASCAL) exercises that incorporate the different platforms available.

Keywords: patient transport; air evacuation; prolonged field care; Special Operations; Expeditionary Resuscitative Surgical Team; contract personnel recovery; austere

PMID: 34969136

DOI: EVC3-UJQ2

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Casualty Wounding Patterns In Special Operations Forces In Operation Iraqi Freedom

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Royal J. 08(2). 55 - 60. (Journal Article)

Abstract

This report describes compiled data on wound patterns for casualties sustained by Special Operations Forces (SOF) of the Combined Joint Special Operations Task Force-Arabian Peninsula during Operation Iraqi Freedom. The intent of this report is to provide information to the SOF Medic on the types of combat-related wounds that are most common in the ongoing Iraq war. During the period evaluated, the extremities and the head were the most common wound sites. Extremity wounds were commonly associated with fractures. Most of the fatally-injured had head and/or neck wounds. The information in this report may be used by SOF Medics to focus training to better address the types of injuries that are commonly seen on the current battlefield and to plan operational and logistical aspects of combat trauma medicine. Objectives: 1. Describe common combat wound sites in SOF patients wounded in OIF. 2. Use wound pattern data to train and prepare for and execute emergency medical aspects of combat missions. 3. Provide guidelines for the compilation and analysis of SOF casualty data in future conflicts.

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Cat on a Hot Tin Roof: Mechanical Testing of Models of Tourniquet After Environmental Exposure

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O'Conor DK, Kragh JF, Aden JK, Dubick MA. 17(1). 27 - 35. (Journal Article)

Abstract

Background: The purpose of the present study was to mechanically assess models of emergency tourniquet after 18 months of environmental exposure to weather to better understand risk of component damage. Materials and Methods: An experiment was designed to test tourniquet performance on a manikin thigh. Three tourniquet models were assessed: Special Operations Forces Tactical Tourniquet Wide, Ratcheting Medical Tourniquet, and Combat Application Tourniquet. Unexposed tourniquets formed a control group stored in a laboratory; exposed tourniquets were placed outdoors on a metal roof for 18 months in San Antonio, Texas. Two users, a military cadet and a scientist, made 300 assessments in total. Assessment included major damage (yes-no), effectiveness (hemorrhage control, yes-no), casualty survival (alive-dead), time to stop bleeding, pressure, and blood loss. Time, pressure, and blood loss were reported in tests with effectiveness. Results: Exposed devices had worse results than unexposed devices for major damage (3% [4/150] versus 0% [0/150]; ρ = .018), effectiveness (89% versus 99%; ρ = .002), and survival of casualties (89% versus 100%; ρ < .001). In tests for effectiveness, exposed devices had worse results than unexposed devices for time to stop bleeding (29 seconds versus 26 seconds; ρ = .01) and pressure (200mmHg versus 204mmHg; ρ = .03, respectively), but blood loss volume did not differ significantly. Conclusion: Compared with unexposed control devices, environmentally exposed tourniquets had worse results in tests of component damage, effectiveness, and casualty survival.

Keywords: first aid; damage control; hemorrhage prevention and control; shock; tourniquet; resuscitation; emergency medical services

PMID: 28285478

DOI: V2L7-IR4Q

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CBRNE TC3: A Hybrid Approach to Casualty Care in the CBRNE Environment

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Strain JE. 13(2). 44 - 53. (Journal Article)

Abstract

The implementation of Tactical Combat Casualty Care (TCCC) guidelines for the Operation Enduring Freedom and Operation Iraqi Freedom contingency operations has dramatically reduced preventable combat deaths. A study of these principles and their application to medical treatment in the chemical, biological, radiological, nuclear, and high-yield explosives (CBRNE), weapons of mass destruction (WMD) environment is presented as a potential readiness and force multiplier for units engaged in this area of operations. Preparing medical operators for support of WMD sampling and mitigation missions requires extensive preventive medicine and post-exposure and downrange trauma threat preparedness. Training and equipping CBRN operators with treatment skills and appropriate interventional material requires pre-implementation planning specific to WMD threats (e.g., anthrax, radiation, organophosphates, and contaminated trauma). A scenario-based study reveals the tactics, techniques, and procedures for training, resourcing, and fielding the CBRN operator of the future.

Keywords: TCCC Guideline; tactical field care; care under fire; WMD threats

PMID: 23817878

DOI: X1TU-PJ61

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Centipede Bites

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Randich HB, Burnett MW. 21(4). 106 - 107. (Journal Article)

Abstract

The genus Scolopendra includes large centipedes that inhabit tropical regions of Southeast Asia and the Pacific Islands as well as South America and the Southwestern US. They are capable of inflicting a clinically significant venomous bite. These multilegged arthropods may enter tents or buildings at night in search of prey and tend to hide in bedding and clothing. Presentation and management are discussed.

Keywords: Scolopendra subspinipes; centipedes; stings

PMID: 34969138

DOI: S3H4-KZPZ

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Central Retinal Vein Occlusion In An Army Ranger With Glucose-6-Phosphate Dehydrogenase Deficiency

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Kotwal RS, Butler FK, Murray CK, Hill GJ, Rayfield JC, Miles EA. 09(3). 59 - 63. (Previously Published)

Previously published in Military Medicine, 174, 5:544, 2009. Permission granted to republish in the JSOM.

Abstract

Glucose-6-phosphate dehydrogenase (G6PD) deficiency is the most prevalent human enzyme deficiency, affecting an estimated 400 million people worldwide. G6PD deficiency increases erythrocyte vulnerability to oxidative stress and may precipitate episodes of hemolysis when individuals are exposed to triggering agents. Although central retinal vein occlusion (CRVO) does occur in G6PD-deficient individuals, G6PD-deficient individuals exposed to oxidative stressors have not been previously reported to have an increase in CRVO incidence. This is a case of an Army Ranger who deployed to Afghanistan with unrecognized G6PD deficiency and was placed on primaquine following his return to the United States and subsequently developed CRVO. Primaquine is a well-recognized cause of hemolysis in individuals with G6PD deficiency. Hemolytic anemia may contribute to thrombosis as a result of increased erythrocyte aggregation and erythrocyte-endothelium interaction. This case underscores the continued need for routine G6PD screening and avoidance of known triggers in G6PD-deficient individuals.

Keywords:

PMID: 19739477

DOI: O372-V7CY

Certified Tactical Paramedic: A Benchmark for Competency in Austere and Hostile Environments

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Clark JR. 13(3). 99 - 100. (Editorial)

Keywords:

PMID: 24048998

DOI: ZZ3F-0F1F

Cessation of Vital Signs Monitored During Lethal Hemorrhage: A Swine Study

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Bodo M, Pearce FJ, Tsai MD, Garcia A, vanAlbert S, Armonda R. 13(4). 63 - 75. (Journal Article)

Abstract

Introduction: Two challenges of trauma triage are to identify wounded who are in danger of imminent death and to enable medics to determine if resuscitation is possible when making "dead or alive" decisions on the battlefield. Hemorrhagic shock is the leading cause of death in combat injuries. The purpose of this study was to establish the sequence of vital sign cessation during lethal hemorrhage in swine. Our hypothesis was that brain electrical activity (electroencephalography [EEG]) and respiration are earlier indicators of imminent death than traditional modalities measured during triage, such as heart electrical activity (electrocardiography [ECG]) and blood pressure. Methods: Lethal hemorrhage was induced in anesthetized Yorkshire pigs. Vital sign modalities measured were respiration, heart electrical activity (ECG), heart sound, blood pressure (systemic arterial pressure), and brain electrical activity (EEG). Results: The sequence of vital sign cessation was (1) respiration, (2) brain electrical activity (EEG), (3) heart sound, (4) blood pressure, and (5) heart electrical activity (ECG). Cessation of respiration occurred at approximately the same time that brain electrical activity stopped ("flatlined") for 2 seconds and then resumed briefly before cessation; cessation of heart electrical activity occurred almost 8 minutes later. Conclusions: A 2-second EEG flatline and final respiration are useful event markers to indicate an opportunity to prevent irreversible brain damage from lethal hemorrhage. Since the 2-second EEG flatline and final respiration occur about 8 minutes before cessation of heart electrical activity (ECG), EEG and final respiration are earlier indicators of imminent death. The use of deployable noninvasive brain monitors implementing these findings can be live-saving on the battlefield as well is in civilian environments.

Keywords: lethal hemorrhage; vital sign monitoring; EEG; respiration; event marker; data processing; swine

PMID: 24227564

DOI: 20NR-BE1R

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Challenges of Transport and Resuscitation of a Patient With Severe Acidosis and Hypothermia in Afghanistan

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Brazeau MJ, Bolduc CA, Delmonaco BL, Syed AS. 18(1). 23 - 28. (Case Reports)

Abstract

We present the case of a patient with new-onset diabetes, severe acidosis, hypothermia, and shock who presented to a Role 1 Battalion Aid Station (BAS) in Afghanistan. The case is unique because the patient made a rapid and full recovery without needing hemodialysis. We review the literature to explain how such a rapid recovery is possible and propose that hypothermia in the setting of his severe acidosis was protective.

Keywords: new-onset diabetes; severe acidosis; hypothermia; hemodialysis

PMID: 29533428

DOI: CXKQ-GX0L

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Characterizing a System for Measuring Limb Tourniquet Pressures

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Hingtgen E, Wall PL, Buising CM. 20(1). 47 - 54. (Journal Article)

Abstract

Background: Pressure is an important variable in emergency use limb tourniquet science. This study characterizes one system for measuring tourniquet-applied pressure. Methods: A neonatal blood pressure cuff bladder was inflated to target pressures over atmospheric. Unconstrained or constrained within 1-inch tubular polyester webbing, the neonatal cuff was placed in a 500mL Erlenmeyer flask. A 3-hole stopper provided connections to flask interior (chamber) and bladder pressure sensors and a 60mL syringe for altering chamber pressure: atmospheric to >1500mmHg absolute to atmospheric. Results: Within a finite range of chamber pressures, the neonatal cuffbased system accurately indicates applied pressure (minimum and maximum 95% confidence interval linear regression slopes of 0.9871 to 0.9953 and y-intercepts of -0.1144 to 2.157). The visually defined linear response ranges for bladder inflation pressures were as follows for unconstrained/ constrained: 100 to 400mmHg unconstrained/450mmHg constrained for 10mmHg, 150 unconstrained/100 constrained to 450mmHg for 12mmHg, 150 to 500mmHg for 15mmHg, 150 to 500mmHg unconstrained/550mmHg constrained for 18mmHg, 150 to 550mmHg for 21mmHg. Below the linear response range, the inflated bladder system indicated higher pressures than chamber pressures. Above the linear response range, the system indicated progressively lower pressures than chamber pressures. Conclusions: Within the linear response range, the bladder pressure accurately indicates surface-applied pressure.

Keywords:

PMID: 32203606

DOI: KRT6-FUKJ

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Chemical Contamination Transfer in the Management of War Casualties

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Collectif MCV T. 18(3). 67 - 70. (Journal Article)

Abstract

The use of chemical weapons agents (CWAs) was suspected in recent conflicts, during international conflicts, terrorist attacks, or civil wars. Little is known about the prevention needed for caregivers exposed to the risk of contamination transfer. We present a case of chemical contamination of health servicemembers during the management of casualties.

Keywords: weapons, chemical; contamination; improvised explosive devices

PMID: 30222840

DOI: NDKZ-RBDR

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Chemical Warfare Agents in Terrorist Attacks: An Interregional Comparison, Tactical Response Implications, and the Emergence of Counterterrorism Medicine

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Tin D, Pepper M, Hart A, Hertelendy A, Ciottone G. 21(3). 51 - 54. (Journal Article)

Abstract

Background: Terrorist attacks are growing in frequency, increasing concerns about chemical warfare agents (CWAs). Asphyxiants (e.g., cyanide), opioids (e.g., carfentanyl), and nerve agents (e.g., ricin) represent some of the most lethal CWAs. Our aim was to define the epidemiology of CWA use in terrorism and detail specific agents used to allow for the development of training programs for responders. Methods: The open-source Global Terrorism Database (GTD) was searched for all chemical attacks from January 1, 1970, to December 31, 2018. Attacks were included when they fulfilled the terrorism-related criteria as set forth in the internal Codebook of the GTD. Events meeting only partial criteria were excluded. Results: A total of 347 terrorism-related chemical events occurred, with 921 fatalities and 13,361 nonfatal injuries (NFIs) recorded during the study period. South Asia accounted for nearly 30% (101 of 347) of CWA attacks, with 73 of 101 occurring in Afghanistan. The Taliban was implicated in 40 of 101 events utilizing a mixture of agents, including unknown chemical gases (likely representing trials of a number of different chemicals), contamination of water sources with pesticides, and the use of corrosive acid. The largest death toll from a single event (200 fatalities) was attributed to a cult-related mass murder in the Kasese District of Uganda in March 2000. East Asia sustained the highest NFI toll of 7,007 as a result of chemical attacks; 5,500 were attributed to the Tokyo subway sarin gas attack of 1995 by Aum Shinrikyo. Conclusion: The use of CWAs remains a concern given the rising rate of terrorist events. First responders and healthcare workers should be aware of potential chemical hazards that have been used regionally and globally and should train and prepare to respond appropriately.

Keywords: chemical warfare agents; terrorist attacks; counter-terrorism medicine

PMID: 34529805

DOI: UU8Q-EDYQ

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Chest Seal Placement for Penetrating Chest Wounds by Prehospital Ground Forces in Afghanistan

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Schauer SG, April MD, Naylor JF, Simon EM, Fisher AD, Cunningham CW, Morissette DM, Fernandez JD, Ryan KL. 17(3). 85 - 89. (Journal Article)

Abstract

Background: Thoracic trauma represents 5% of all battlefield injuries. Communicating pneumothoraces resulting in tension physiology remain an important etiology of prehospital mortality. In addressing penetrating chest trauma, current Tactical Combat Casualty Care (TCCC) guidelines advocate the immediate placement of a vented chest seal device. Although the Committee on TCCC (CoTCCC) has approved numerous chest seal devices for battlefield use, few data exist regarding their use in a combat zone setting. Objective: To evaluate adherence to TCCC guidelines for chest seal placement among personnel deployed to Afghanistan. Methods: We obtained data from the Prehospital Trauma Registry (PHTR). Joint Trauma System personnel linked patients to the Department of Defense Trauma Registry, when available, for outcome data upon reaching a fixed facility. Results: In the PHTR, we identified 62 patients with documented gunshot wound (GSW) or puncture wound trauma to the chest. The majority (74.2%; n = 46) of these were due to GSW, with the remainder either explosive-based puncture wounds (22.6%; n = 14) or a combination of GSW and explosive (3.2%; n = 2). Of the 62 casualties with documented GSW or puncture wounds, 46 (74.2%) underwent chest seal placement. Higher proportions of patients with medical officers in their chain of care underwent chest seal placement than those that did not (63.0% versus 37.0%). The majority of chest seals placed were not vented. Conclusion: Of patients with a GSW or puncture wound to the chest, 74.2% underwent chest seal placement. Most of the chest seals placed were not vented in accordance with guidelines, despite the guideline update midway through the study period. These data suggest the need to improve predeployment training on TCCC guidelines and matching of the Army logistical supply chain to the devices recommended by the CoTCCC.

Keywords: chest; wound; seal; prehospital; military; combat

PMID: 28910475

DOI: 8ILY-W3MX

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Chest Wall Thickness In Military Personnel: Implications For Needle Thoracentesis In Tension Pneumothorax

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Harcke HT, Pearse LA, Levy AD, Getz JM, Robinson SR. 08(2). 96 - 99. (Previously Published)

Previously Published in MILITARY MEDICINE. 172. 12:000.2007. Republished in JSOM with permission.

Abstract

Needle thoracentesis is an emergency procedure to relieve tension pneumothorax. Published recommendations suggest use of angiocatheters or needles in the 5cm range for emergency treatment. Multidetector computed tomography scans from 100 virtual autopsy cases were used to determine chest wall thickness in deployed male military personnel. Measurement was made in the second right intercostal space at the midclavicular line. The mean horizontal thickness was 5.36cm (SD = 1.19 cm) with angled (perpendicular) thickness slightly less with a mean of 4.86cm [SD 1.10cm). Thickness was generally greater than previously reported. An 8cm angiocatheter would have reached the pleural space in 99% of subjects in this series. Recommended procedures for needle thoracentesis to relieve tension pneumothorax should be adapted to reflect use of an angiocatheter or needle of sufficient length.

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Chikungunya

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Burnett MW. 14(4). 129 - 130. (Journal Article)

Abstract

Chikungunya is a rapidly emerging infectious disease caused by a virus of the genus Alphavirus, family Togaviridae. Most commonly, patients have an acute onset of fever with often debilitating symmetric joint discomfort that can relapse months after the initial infection. This infection is typically transmitted by the bite of an infected Aedes aegypti or Aedes albopictus mosquito, vectors that also transmit dengue and yellow fever. Special Operations Forces Medical Providers should be aware of this disease, which is currently being diagnosed worldwide.

Keywords: Chikungunya; infectious disease; virus; mosquito vector

PMID: 25399382

DOI: 8H36-WO5P

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Cinnarizine for Sea Sickness During a Remote Pacific Ocean Rescue Mission

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Lyon RF, Rush SC, Roland T, Jethanamest D, Schawn CP, Kharod C. 15(2). 1 - 6. (Case Reports)

Abstract

Motion sickness can be a limiting factor for sea and air missions. We report the experience of a Pararescue (PJ) team on a Pacific Ocean rescue mission in which motion sickness was prevalent. Cinnarizine, an antagonist of H1-histamine receptors, was used to treat affected PJs. We also report findings of a survey of PJs regarding motion sickness. A family of four on a disabled sailboat 900 miles off the coast of Mexico sent out a distress call because their 1-year-old daughter became severely ill with fever and diarrhea. Four PJs were deployed on a C-130, performed a free-fall parachute insertion into the ocean, and boarded the sailboat. All four PJs experienced onset of motion sickness at some point during the early part of the mission and symptoms persisted through the first 24 hours. Three PJs experienced ongoing nausea, vomiting, dizziness, and sensory imbalances. The captain of the sailboat offered the three sick PJs approximately 18mg of cinnarizine two or three times a day with relief of symptoms and improvement on operational effectiveness. A new, anonymous, voluntary survey of Air National Guard PJs and combat rescue officers revealed that 78.4% of Operators have experienced motion sickness at sea. We discuss the current theories on motion sickness, the effect of motion sickness on operational effectiveness, and research on treatment of motion sickness, including the medication cinnarizine.

Keywords: motion sickness; cinnarizine; military operations; military medicine; sea sickness; medication, motion sickness; pararescue

PMID: 26125158

DOI: 1WWL-1OHZ

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Clinical Diagnoses In A Special Forces Group: The Musculoskeletal Burden

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Lynch JH, Pallis MP. 08(2). 76 - 80. (Journal Article)

Abstract

The published literature contains little epidemiologic information concerning the spectrum of morbidity in Special Operations units. This study defines the burden of illness and injury seen in a Special Forces Group by quantifying the distribution of diagnoses. Excluding administrative categories, musculoskeletal conditions comprised 40% of all clinical diagnoses, raising the question of what more can be done to address the preventable causes of lost time due to injuries. We conclude there is need for increased training in the diagnosis and treatment of musculoskeletal injuries among all healthcare professionals assigned to Special Forces Groups as well as a need for increased education and resources to achieve better strength, conditioning, rehabilitation, and injury prevention for our units.

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Clinical Encounters in Tactical Medicine: A Mission-Specific Analysis of the Maryland State Police Experience

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Levy MJ, Smith R, Gerold KB, Alves D, Tang N. 14(2). 98 - 104. (Journal Article)

Abstract

Introduction: The Maryland State Police (MSP) Tactical Medical Unit (TMU) provides tactical emergency medical support (TEMS) through the deployment of specially trained state trooper tactical paramedics. The MSP TMU maintains an operational database of all mission related medical activity. This information constitutes a robust dataset derived from real world operational medicine experiences. Methods: A retrospective analysis of deidentified entries from the MSP TMU operational response database was performed for the 5-year period of 2007-2013. A summative analysis of missions, as well as a subgroup analysis of types of patients encountered, was performed to further characterize patient encounters based on the type of law enforcement tactical mission. Results: Analysis was performed on 1,042 tactical missions, of which there were 367 total patient encounters during the study period. The majority (67%; 246/367) of patients encountered were law enforcement tactical team personnel. The most frequently occurring mission, by type, was high-risk warrant service, accounting for 45% (470/1,042) of all missions in this series. Law enforcement training support missions comprised 25% (259/1,042), and 15% (157/1,042) of all missions in the database were medical standbys for law enforcement operations. The highest number of patient contacts were associated with training activities, resulting in 29% (108/367) of clinical encounters. The next most common mission associated with patient encounters was high-risk warrant service (24%; 88/367). Conclusion: The 5-year analysis conducted in this study represents the largest known retrospective assessment of a state police tactical medical program. Training activities resulted in the highest number of patient encounters by this program, with law enforcement/tactical team personnel comprising the majority of patient encounters. The majority of chief complaints encountered were non-life threatening and reinforce the need for expanded scope of practice training and enhanced treatment protocols for tactical medics.

Keywords: tactical emergency medical support; tactical medicine

PMID: 24952050

DOI: ERYZ-TOMA

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Clinical Guidelines for Stellate Ganglion Block to Treat Anxiety Associated With Posttraumatic Stress Disorder

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Mulvaney SW, Lynch JH, Kotwal RS. 15(2). 79 - 85. (Journal Article)

Abstract

Multiple case series published in the peer-reviewed medical literature have demonstrated the safety and efficacy of right-sided stellate ganglion block (SGB) for the treatment of anxiety symptoms associated with posttraumatic stress disorder (PTSD). As this is a new indication for a well-established procedure, there is relatively little information available to assist clinicians in determining the utility of SGB for their patients. Presented are clinical guidelines to assist the provider with patient selection, patient education, and follow-up. Also described is a technique to perform SGB under ultrasoundguidance. Although additional rigorous clinical research is needed to further investigate SGB for the treatment of anxiety symptoms associated with PTSD, these guidelines can also assist clinical investigators in their participant selection, design, and conduct of future research as it pertains to this important topic.

Keywords: posttraumatic stress disorder; stellate ganglion block; ultrasound, guided; anxiety; clinical guidelines

PMID: 26125169

DOI: EQ05-H5TO

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Clinical Image: Visual Estimation of Blood Loss

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Donham B, Frondozo R, Petro M, Reynolds A, Swisher J, Knight RM. 17(1). 68 - 71. (Journal Article)

Abstract

Military prehospital providers frequently have to make important clinical decisions with only limited objective information and vital signs. Because of this, accurate estimation of blood loss, at the point of injury, can augment any available objective information. Prior studies have shown that individuals significantly overestimate the amount of blood loss when the amount of hemorrhage is small, and they tend to underestimate the amount of blood loss with larger amounts of hemorrhage. Furthermore, the type of surface on which the blood is deposited can impact the visual estimation of the amount of hemorrhage. To aid providers with the ability to accurately estimate blood loss, we took several units of expired packed red blood cells and deposited them in different ways on varying surfaces to mimic the visual impression of combat casualties.

Keywords: hemorrhage diagnosis; war; military medicine; emergency medical services

PMID: 28285482

DOI: UUWG-H2J7

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Clinical Red Flags From The Ussocom Tmeps - Recognize, Act Fast, And Evacuate

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Gilpatrick S. 09(1). 20 - 26. (Journal Article)

Abstract

Military medical practitioners working in active duty clinics are known for seeing lots of people in a short amount of time. If you've ever seen what goes on every morning at a troop medical clinic on a training post or base you know what I mean. The goal of morning sick call is to find that one really sick person among the many not so sick standing in line for your services. What you learn from working in that setting is how to recognize the red flag - the sign or symptom that clues you in to a potentially dangerous condition. When at war, the ability to recognize the red flag is extremely important. In the austere or unsecure environment, the SOF Medic needs to be the one who knows what the red flags are and what to do about them once spotted.

Keywords:

PMID: 19813345

DOI: 2LB3-SCX8

Clinical Relevance of Optimizing Vitamin D Status in Soldiers to Enhance Physical and Cognitive Performance

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Wentz LM, Eldred JD, Henry MD, Berry-Caban CS. 14(1). 58 - 66. (Journal Article)

Abstract

Vitamin D deficiency initiates a loss of combat effectiveness by impairing physical and cognitive functioning of combat Operators. Synthesized in response to sunlight and consumed in the diet, vitamin D functions as a hormone and regulates gene expression for nearly 300 genes throughout the human body. These target genes are involved processes essential to combat operations, such as immune function, response to stress, inflammation, and regulation of calcium movement. Since widespread vitamin D deficiency is observed across the U.S. population, poor vitamin D status is expected in Servicemembers. Physical conditions linked to vitamin D deficiency include increased risk for muscle or bone injury, muscle weakness, and reduced neuromuscular function. Hormonally, vitamin D levels have been positively correlated with testosterone levels. Vitamin D deficiency is also associated with cognitive decline, depression, and may prolong recovery following mild traumatic brain injury (mTBI). Since vitamin D deficiency elevates systemic inflammation, poor vitamin D status at the time of brain injury may prolong the inflammatory response and exacerbate postconcussive symptoms. Furthermore, veterans with mTBI experience chronic endocrine dysfunction. While vitamin D status has not been assessed post-mTBI, it is plausible that vitamin D levels are altered along with testosterone and growth hormone, raising the question of whether vitamin D deficiency results from trauma-related hormonal abnormalities or whether vitamin D deficiency increases the risk for endocrine dysfunction. Through its association with testosterone production, vitamin D deficiency may increase the risk for posttraumatic stress disorder (PTSD) since testosterone levels are altered in veterans with PTSD. Therefore, vitamin D status has a significant impact on Operator health and performance. Supplementing vitamin D to deficient Operators provides a noninvasive and low-cost intervention to maintain combat force.

Keywords: vitamin D; 25-hydroxyvitamin D; inflammation; neuroprotection; musculoskeletal performance; combat readiness

PMID: 24604440

DOI: 52YL-XU05

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Clinical Update: Concepts of Prehospital Traumatic Hemorrhage Control in the Operational K9

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Palmer LE. 18(4). 123 - 130. (Journal Article)

Abstract

Major trauma often involves varying degrees of hemorrhage. Left unattended, any amount of trauma-induced hemorrhage may rapidly become life threatening. Similar to humans, Operational canines (OpK9s) can suffer penetrating trauma and blunt trauma that lead to compressible and noncompressible hemorrhage. Preserving organ function and saving the life of a massively bleeding OpK9 require the implementation of immediate and effective hemostatic measures. Effective hemorrhage control interventions for the exsanguinating OpK9 are similar to those for humans: direct pressure, wound packing, hemostatic agents and devices, pressure bandage, and, possibly, tourniquet application. Although tourniquet application is a life-saving intervention in humans experiencing extremity hemorrhage, it is not considered a necessary, immediate-action life-saving intervention for canines with extremity injuries. This article provides a brief description of the basic methods for identifying life-threatening hemorrhage and achieving immediate hemostasis in the bleeding OpK9 during the prehospital period.

Keywords: operational canine; hemorrhage control; trauma

PMID: 30566737

DOI: MYQ8-25A1

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Clinical Update: The Risk of Opioid Toxicity and Naloxone Use in Operational K9s

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Palmer LE, Gautier A. 17(4). 86 - 92. (Journal Article)

Abstract

The increasing use of opioids (e.g., fentanyl, carfentanil) for illicit drug manufacturing poses a potential life-threatening hazard to law enforcement officers and first responders (e.g., EMS, fire and rescue) who may unknowingly come into contact with these drugs during the course of their daily activities. Similarly, Operational canines (OpK9s) of all disciplines-detection (drug, explosive, accelerant), patrol, tracking, search and rescue, and others-are at risk for accidental illicit opioid exposure. The most serious adverse effect of opioid exposure is respiratory depression leading to slow, shallow breathing or complete cessation of voluntary breathing (respiratory arrest). Naloxone, an opioid antagonist, is the antidote for reversing the effects of an opioid overdose in both humans and OpK9s. This clinical update describes the potential risks associated with opioid exposure as well as the use of naloxone as it pertains to the OpK9.

Keywords: Operational K9s; opioid; naloxone; intranasal; overdose; canine medicine

PMID: 29256202

DOI: 6XRM-EW4X

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Closing The Gap: Improving Trauma Care On The Ukrainian Battlefield

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Stacey SK, Jones PH. 16(1). 122 - 124. (Journal Article)

Abstract

Since early 2014, Ukraine has been involved in a violent social and political revolution that has taken more than 7,000 lives. Many of these deaths were due to limited field medical care and prolonged evacuation times because the Ukrainian military has been slow to adopt standard combat medical processes. We deployed with the US Army's 173rd Airborne Brigade to train soldiers in the National Guard of Ukraine (NGU) on combat first aid. We discovered that a major deficiency limiting the quality of trauma care and evacuation is an endemic lack of prior coordination and planning. The responsibility for this coordination falls on military leaders; therefore, we delivered medical operations training to officers of the NGU unit and observed great improvement in medical care sustainment. We recommend systematic leader education in best medical practices be institutionalized at all levels of the Ukrainian Army to foster sustained improvement and refinement of trauma care.

Keywords: trauma; evacuation; training; Ukraine; education

PMID: 27045509

DOI: FMVO-YATR

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Clothing Effects on Limb Tourniquet Application

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Wall PL, Buising CM, Hingtgen E, Smith H, Renner CH. 20(2). 83 - 94. (Journal Article)

Abstract

Background: Sometimes tourniquets are applied over clothing. This study explored clothing effects on pressures and application process. Methods: Generation 7 Combat Application Tourniquets (C-A-T7), Generation 3 SOF® Tactical Tourniquets-Wide (SOFTTW), Tactical Ratcheting Medical Tourniquets (Tac RMT), and Stretch Wrap And Tuck Tourniquets (SWATT) were used with different clothing conditions (Bare, Scrubs, Uniform, Tights) mid-thigh and on models (ballistic gel and yoga mats). Results: Clothing affected pressure responses to controlled force applications (weight hangs, n=5 thighs and models, nonlinear curve fitting, p < .05). On models, clothing affected secured pressures by altering surface interactions (medians: Gel Bare C-A-T7 247mmHg, SOFTTW 99mmHg, Tac RMT 101mmHg versus Gel Clothing C-A-T7 331mmHg, SOFTTW 170mmHg, Tac RMT 148mmHg; Mats Bare C-A-T7 246mmHg, SOFTTW 121mmHg, Tac RMT 99mmHg versus Mats Clothing C-A-T7 278mmHg, SOFTTW 145mmHg, Tac RMT 138mmHg). On thighs, clothing did not significantly influence secured pressures (n=15 kneeling appliers, n=15 standing appliers) or occlusion and completion pressures (n=15). Eleven of 15 appliers reported securing on clothing as most difficult. Fourteen of 15 reported complete applications on clothing as most difficult. Conclusions: Clothing will not necessarily affect tourniquet pressures. Surface to tourniquet interactions affect the ease of strap sliding, so concern should still exist as to whether applications over clothing are dislodged in a distal direction more easily than applications on skin.

Keywords: tourniquet; hemorrhage; first aid; emergency treatment

PMID: 32573743

DOI: 2CXR-1UVJ

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Coagulopathy Associated With Trauma: A Rapid Review for Prehospital Providers

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Friedman J, Ditzel RM, Fisher AD. 22(2). 110 - 115. (Journal Article)

Abstract

The coagulopathy associated with trauma is a complex and convoluted process that is still poorly understood. However, there are recognized contributors to acute traumatic coagulopathy (ATC) and trauma induced coagulopathy (TIC) that are universal. They are hypothermia, acidosis, and coagulopathy, also known as the lethal triad. Recently, with new understanding of hypocalcemia's role in trauma mortality, the term lethal diamond has been coined to underscore calcium's importance. Prehospital providers often unknowingly exacerbate ATC and TIC with excessive crystalloid administration and poor hypothermia prevention. This article will serve as an overview of the physiologic and iatrogenic drivers of ATC and TIC, and will discuss how they can be prevented, assessed, and treated.

Keywords: lethal triad; critical care; prehospital; coagulopathy; trauma; resuscitation; lethal diamond

PMID: 35649406

DOI: UL89-SC0Z

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Cognitive Agility as a Factor in Human Performance Optimization

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Ross J, Miller L, Deuster PA. 18(3). 86 - 91. (Journal Article)

Abstract

Cognitive agility reflects the capacity of an individual to easily move back and forth between openness and focus. The concept is being translated into a tool to help train leaders to perform well in the "dynamic decision-making context." Cognitive agility training (CAT) has the potential to increase emotional intelligence by improving an individual's ability to toggle between highly focused states to levels of broad, outward awareness, which should enable dynamic decision-making and enhance personal communication skills. Special Operations Forces (SOF) Operators must work in rapidly evolving, complex environments embedded with multiple high-risk factors. Generally, success in these operational environments requires the ability to maintain highly focused states. However, SOF Operators must also be able to transition rapidly back to their roles within their families, where a more outwardly aware state is needed to allow flexibility in emotional responses. CAT addresses these seemingly conflicting requirements. Successful CAT must reflect the methodologies and culture already familiar within the SOF community (i.e., "live" scenario-based activities) to replicate challenges they may encounter when operationally deployed and when at home. This article provides an overview of cognitive agility, the potential benefits, applications that could be used for training SOF Operators to improve their cognitive agility to optimize performance, and sample training scenarios. The issue of what metrics to use is also discussed.

Keywords:

PMID: 30222844

DOI: QU7U-8ICE

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Collaboration of a Medical School With a Special Forces Group on Annual Training: A Blueprint

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Brisson PA, McGregor DW, Murphy Z. 22(2). 35 - 36. (Journal Article)

Abstract

Collaboration on annual training between a medical school and a National Guard Special Forces Group can be accomplished with great benefit to both parties. The authors describe the involvement by the Edward Via College of Osteopathic Medicine in providing training for the 20th Special Forces Group Medical Sergeants of the Alabama Army National Guard.

Keywords: training; collaboration; volunteers; military training; medical school

PMID: 35639890

DOI: 0HUT-F0MY

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Combat Casualty Care Training: Implementation of a Simulation-Based Program in a Cross-Cultural Setting: Experience of the French Military Health Service in West Africa

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Cotte J, Montcriol A, Benner P, Belliard V, Roumanet P, Puidupin A, Puidupin M. 21(1). 41 - 43. (Journal Article)

Abstract

Introduction: In the French army, combat casualty care (CCC) training involves the use of simulation. The application of this pedagogic method in a cross-cultural environment has not previously been described. In this report, we explore the challenges highlighted by multiple training sessions for foreign medical providers in West Africa. Methods: We collected the data from six 2-week courses held in Libreville, Gabon. Our main objective was to describe the course; our secondary objective was to assess our trainees' progress in their knowledge of CCC. Results: The first week involved lectures, technical workshops, and single-patient simulations. The second part emphasized multiple-victim simulations and interactions with combatants and was held in the Gabonese rainforest. Sixty- two trainees undertook the six sessions. Their knowledge improved during the course, from a median score of 4 (of a maximum of 40) before to 9.5 after (p < .05). Discussion: Our study is the first to describe medical-level CCC training in a cross-cultural environment. Challenges are numerous, notably differences in the expected roles of instructors and trainees. Mitigating those difficulties is possible through cultural awareness and self-awareness. Our results are limited by the absence of evaluation of improvement in the actual management of patients. Conclusion: CCC training using medical simulation is feasible in a cross-cultural environment.

Keywords: medical simulation; manikin; cross-cultural; combat casualty care

PMID: 33721305

DOI: 4A2S-2KM7

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Combat Ready Clamp Medic Technique

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Tovmassian RV, Kragh JF, Dubick MA, Billings S, Blackbourne LH. 12(4). 72 - 78. (Journal Article)

Abstract

Background: Junctional hemorrhage control device use on the battlefield might be lifesaving, but little experience is reported. The purpose of the present case report is to detail prehospital use of the Combat Ready Clamp (called the CRoC by its users, Combat Medical Systems, Fayetteville, NC; Instructions for Use, 2010) in casualty care in order to increase awareness of junctional hemorrhage control. Methods: The CRoC was used to control difficult inguinal bleeding on the battlefield for an Afghani man with a hindquarter traumatic amputation. Results: The device promptly controlled exsanguination from a critical injury when placed during rotary-wing casualty evacuation. The flight medic applied the device in 90 seconds. The device performed well without complications to control bleeding. Discussion: The CRoC, a new junctional hemorrhage control device, was used as indicated on the battlefield with mechanical and physiologic success and without device problems. By controlling difficult inguinal bleeding resulting from battlefield trauma, the device facilitated casualty stabilization and delivery to a surgical facility. The device facilitated the ability of a new flight medic to focus his expertise on a critically injured battlefield casualty with demonstrable success.

Keywords: tourniquet; bleeding; shock; prehospital care; emergency medical services

PMID: 23536460

DOI: KVBI-S6IL

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Combat Trousers as Effective Improvised Pelvic Binders A Comparative Cadaveric Study

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Loftus A, Morris R, Friedmann Y, Pallister I, Parker PJ. 17(3). 35 - 39. (Journal Article)

Abstract

Background: Improvised explosive devices and landmines can cause pelvic fractures, which, in turn, can produce catastrophic hemorrhage. This cadaveric study compared the intrapelvic pressure changes that occurred with the application of an improvised pelvic binder adapted from the combat trousers worn by British military personnel with the commercially available trauma pelvic orthotic device (TPOD). Methods: Six unembalmed cadavers (three male, three female) were used to simulate an unstable pelvic fracture with complete disruption of the posterior arch (AO/OTA 61-C1) by dividing the pelvic ring anteriorly and posteriorly. A 3-4cm manometric balloon filled with water was placed in the retropubic space and connected to a 50mL syringe and water manometer via a three-way tap. A baseline pressure of 8cm H2O (average central venous pressure) was set. The combat trouser binder (CTB) and TPOD were applied to each cadaver in a random sequence and the steady intrapelvic pressure changes were recorded. Statistical analysis was performed using the Wilcoxon rank-sum test and a paired t test depending on the normality of the data to determine impact on the intrapelvic pressure of each intervention compared with baseline. Results: The median steady intrapelvic pressure achieved after application of the CTB was 16cm H2O and after application of the TPOD binder was 18cm H2O, both of which were significantly greater than the baseline pressure (ρ < .01 and .036, respectively) but not significantly different from each other (ρ > .05). Conclusion: Pelvic injuries are increasingly common in modern theaters of war. The CTB is a novel, rapidly deployable, yet effective, method of pelvic binding adapted from the clothes the casualty is already wearing. This technique may be used in austere environments to tamponade and control intrapelvic hemorrhage.

Keywords: pelvic fracture; pelvic binder; trauma; hemorrhage; coagulopathy; military; combat; prehospital emergency care

PMID: 28910465

DOI: 1P7E-2OL4

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Commercial and Improvised Pelvic Compression Devices: Applied Force and Implications for Hemorrhage Control

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Bailey RA, Simon EM, Kreiner A, Powers D, Baker L, Giles C, Sweet R, Rush SC. 21(1). 44 - 48. (Journal Article)

Abstract

Uncontrolled hemorrhage secondary to unstable pelvic fractures is a preventable cause of prehospital death in the military and civilian sectors. Because the mortality rate associated with unstable pelvic ring injuries exceeds 50%, the use of external compression devices for associated hemorrhage control is paramount. During mass casualty incidents and in austere settings, the need for multiple external compression devices may arise. In assessing the efficacy of these devices, the magnitude of applied force has been offered as a surrogate measure of pubic symphysis diastasis reduction and subsequent hemostasis. This study offers a sensor-circuit assessment of applied force for a convenience sample of pelvic compression devices. The SAM® (structural aluminum malleable) Pelvic Sling II (SAM Medical) and improvised compression devices, including a SAM Splint tightened by a Combat Application Tourniquet® (C-A-T; North American Rescue) and a SAM® Splint tightened by a cravat, as well as two joined cravats and a standard-issue military belt, were assessed in male and female subjects. As hypothesized, compressive forces applied to the pelvis did not vary significantly based on device operator, subject sex, and subject body fat percentage. The use of the military belt as an improvised method to obtain pelvic stabilization is not advised.

Keywords: pelvic ring fractures; pelvic injuries; commercial pelvic compression devices; improvised pelvic compression devices; mass casualty incidents

PMID: 33721306

DOI: KRKS-8I7S

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Committee for Tactical Emergency Casualty Care (CoTECC) Update: Summer 2014

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Callaway DW, Smith R, Shapiro G, McKay SD. 14(2). 139 - 139. (Classical Conference)

Keywords:

PMID: 27689368

DOI: CC47-3BYI

Committee for Tactical Emergency Casualty Care (C-TECC) Update: Fall 2014

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Callaway DW, Smith R, Shapiro G, Bobko JP, McKay SD. 14(3). 135 - 139. (Classical Conference)

Abstract

The Johns Hopkins Center for Law Enforcement Medicine and Division of Special Operations in Baltimore generously hosted the June 2014 Committee for Tactical Emergency Casualty Care meeting (C-TECC). The C-TECC meeting focused on several critical issues including guideline updates, review of C-TECC member involvement in recent federal efforts regarding active violent incidents, examination of national best practices, and new partnership agreements.

Keywords:

PMID: 25344723

DOI: 4BZ1-0UFN

Committee on Surgical Combat Casualty Care Position: Statement on Single-Surgeon Teams

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Anonymous A, Anonymous A. 22(1). 144 - 145. (Classical Conference)

Keywords:

PMID: 35278331

DOI: SOZV-TQN9

Committee on Tactical Combat Casualty Care 7-8 September 2016: Meeting Highlights

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Butler FK, Giebner S. 16(4). 130 - 131. (Classical Conference)

Keywords:

PMID: 28088834

DOI: ZR48-DQHU

Committee on Tactical Combat Casualty Care Meeting Minutes. San Antonio, TX. 20-21 February 2019

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Butler FK, Giebner S. 19(3). 134 - 146. (Classical Conference)

Keywords:

PMID: 31539449

DOI: 1NQU-76DV

Committee on Tactical Combat Casualty Care Meeting Minutes: 10-11 September 2019 - San Antonio, Texas

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Butler FK, Greydanus DJ. 20(1). 148 - 161. (Classical Conference)

Keywords:

PMID: 32203621

DOI: MXKE-QHJ0

Committee on Tactical Combat Casualty Care Meeting. 2-3 February 2016, Atlanta, Georgia: Meeting Minutes

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Anonymous A. 16(2). 138 - 147. (Classical Conference)

Keywords:

PMID: 27689383

DOI: O7QI-BBFT

Committee on Tactical Combat Casualty Care Meeting: San Antonio, TX 5-6 September 2018 Meeting Minutes

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Butler FK, Giebner S. 19(1). 136 - 145. (Classical Conference)

Keywords:

PMID: 30859543

DOI: NLZX-UMOD

Committee on Tactical Combat Casualty Care: Meeting Minutes. 6-7 September, 2017; San Antonio, TX

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Butler FK, Giebner S. 18(1). 164 - 171. (Classical Conference)

Keywords:

PMID: 29533455

DOI: JZH4-UIAQ

Community Acquired Methicillin Resistant Staphylococcus Aureus

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Hammes JS. 07(3). 33 - 37. (Journal Article)

Abstract

Community acquired Methicillin Resistant Staphylococcus aureus (ca-MRSA) is an important cause of illness among active duty forces in general and among Special Operations personnel in particular. It is increasingly common and has the potential to continue to spread to affect a large proportion of the population. This pathogen may cause degradation in operational readiness, time lost from training, and potentially disabling damage to soft tissues and joints. This article has several purposes. It will describe background and significance of ca-MRSA related disease, describe the clinical manifestations of ca-MRSA disease, explain how the bacterium causes illness, and explain the measures needed to treat and prevent the spread of ca-MRSA infections.

Keywords:

DOI:

Comparison of Airway Control Methods and Ventilation Success With an Automatic Resuscitator

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Rodriquez D, Gomaa D, Blakeman T, Petroa M, Dorlac WC, Johannigman J, Branson R. 12(2). 65 - 70. (Journal Article)

Abstract

Mechanical ventilation in an austere environment is difficult owing to logistics, training, and environmental conditions. We evaluated the ability of professional caregivers to provide ventilatory support to a simulated patient using the Simplified Automated Ventilator (SAVe) with a mask hand attended ventilation, mask with single strap unattended ventilation, and supraglottic airway (King LT) ventilation. All three methods were performed using a SAVe with a set tidal volume of 600ml and respiratory rate of 10 breaths per minute. The simulator consisted of a head and upper torso with anatomically correct upper airway structures, trachea, esophagus, and lung which, also measured the delivered tidal volume, respiratory rate, inspiratory flow, and airway pressures. Volunteers used each airway control method to provide ventilation for 10 minutes in random order. Success of each technique was judged as a mean delivered tidal volume of > 500ml. The major finding of this study was that medical professionals using SAVe resuscitator and the manufacturer supplied face mask with single head strap failed to ventilate the airway model in every case.

Keywords: SAVe; ventilation; airway management; prehospital; mask ventilation

PMID: 22707027

DOI: TZUI-OXBV

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Comparison of Fibrinogen- and Collagen-Based Treatments for Penetrating Wounds with Comminuted Femur Fractures in a Swine Model

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Rothwell SW, Sawyer E, Lombardini E, Royal J, Tang H, Selwyn R, Bodo M, Settle TL. 13(1). 7 - 18. (Journal Article)

Abstract

Introduction: Military servicemembers in combat operations often sustain injuries to the extremities from highspeed projectiles, resulting in bleeding and comminuted open fractures. Severe injury with bone fragmentation can result in limb amputation. Surgical treatment options include materials that promote osteogenesis and bone proliferation, such as growth hormones, stem cells, or mineralized matrix adjuncts. However, none of these are amenable to use by the first responder, nor do they address the question of hemorrhage control, which is a common problem in traumatic injuries. Hypothesis: Our hypothesis was that treatment with a fibrinogen-based protein mixture at the time of the bone injury will provide both hemostasis and a supportive environment for preservation of injured bone. Methods: A comminuted femur fracture was produced in 28 female Yorkshire swine, and one of four treatments was instilled into the wound immediately after injury. Each animal was evaluated for the following parameters: inflammation, new bone growth, osteoclast proliferation, callus formation, and femur wound cavity fill, using post-mortem computed tomography and analysis of histological sections. Results: Overall, salmon fibrinogen-thrombin and porcine fibrinogen-thrombin showed a trend for improved healing based on bone filling and calcification. However, statistically significant differences could not be established between treatment groups. Conclusions: These findings indicate that a fibrinogen-thrombin matrix may be a useful as an immediate response product to enhance fracture healing. Salmon fibrinogen-thrombin has the advantages of cost and a pathogen profile compared to mammalian fibrinogens.

Keywords:

PMID: 23526316

DOI: 4SOQ-E5DJ

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Comparison of Muscle Paralysis After Intravenous and Intraosseous Administration of Succinylcholine in Swine

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Loughren MJ, Kilbourn J, Worth K, Burgert J, Gegel B, Johnson D. 14(2). 35 - 37. (Journal Article)

Abstract

Aim: To compare the onset and duration of intravenous (IV) and intraosseous (IO) administration of succinylcholine in swine. Methods: Electromyographic (EMG) amplitudes were used to characterize muscle paralysis following administration of succinylcholine via the IV or IO route in four Yorkshire-cross swine. Results: The onset of action of succinylcholine was statistically longer after IO administration (0.97 ± 0.40) compared with IV administration (0.55 ± 0.26) (ρ = .048). Duration of action was unaffected by route of administration: IO, 11.4 ± 4.2, and IV, 12.9 ± 3.8 (ρ = .65). Conclusions: Succinylcholine can be effectively administered via the IO route. However, an increased dose may be necessary when administering succinylcholine via the IO route to achieve the same rapid onset as standard IV dosing.

Keywords: intraosseous; succinylcholine; rapid sequence induction

PMID: 24952038

DOI: 4LYK-HTXM

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Comparison of Postexercise Cooling Methods in Working Dogs

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Davis MS, Marcellin-Little DJ, O'Connor E. 19(1). 56 - 60. (Journal Article)

Abstract

Background: Overheating is a common form of injury in working dogs. The purpose of this study was to evaluate the relative efficacy of three postexercise cooling methods in dogs with exercise-induced heat stress. Methods: Nine athletically conditioned dogs were exercised at 10kph for 15 minutes on a treadmill in a hot environmental chamber (30°C) three times on separate days. After exercise, the dogs were cooled using one of three Methods: natural cooling, cooling on a 4°C cooling mat, and partial immersion in a 30°C water bath for 5 minutes. Results: Time-weighted heat stress was lower for immersion cooling compared with the cooling mat and the control. The mean time required to lower gastrointestinal temperature to 39°C was 16 minutes for immersion cooling, 36 minutes for the cooling mat, and 48 minutes for control cooling. Conclusion: Water immersion decreased postexercise, time-weighted heat stress in dogs and provided the most rapid cooling of the three methods evaluated, even with the water being as warm as the ambient conditions. The cooling mat was superior to cooling using only fans, but not as effective as immersion. The placement of simple water troughs in working- dog training areas, along with specific protocols for their use, is recommended to reduce the occurrence of heat injury in dogs and improve the treatment of overheated dogs.

Keywords: canines; hyperthermia; heat injury

PMID: 30859528

DOI: 2ATZ-TMQ7

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Comparison of Scapular Manipulation With External Rotation Method of Reduction of Acute Anterior Shoulder Dislocation for Sedation Requirements and Success Rates

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Adhikari S, Koirala P, Kafle D. 18(3). 34 - 37. (Journal Article)

Abstract

Background: Anterior shoulder dislocation is a common sports-related musculoskeletal injury. Various methods have been described for reduction of the dislocation. A method that requires less sedation without compromising the success rate is likely to be highly useful in austere and prehospital settings. This study compares scapular manipulation with external rotation method for requirement of sedation and success rates. Methods: Forty-six patients with anterior shoulder dislocation were allocated alternatively to reduction using either scapular manipulation (SMM) or external rotation (ERM) techniques. The groups were compared for sedation requirements, pain scores, and success rates. Results: Reductions using SMM had fewer requirements for sedation (13% versus 39%; p < .05) and higher first-pass success rates (87% versus 61%; p < .05) as compared with ERM for anterior shoulder dislocation reduction. The numeric rating score of pain during reduction procedures was less in SMM (mean, 1.65 [standard deviation, 1.6]) than in ERM group (mean, 4.30 [standard deviation, 1.8]; p < .01). Conclusion: The SMM required less sedation and had higher first-pass success rates than ERM for reduction of anterior shoulder dislocation. The SMM is thus likely to be of advantage in resource-limited austere settings.

Keywords: shoulder reduction; scapular manipulation; external rotation

PMID: 30222834

DOI: W76R-Z4SN

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Compensatory Reserve for Early and Accurate Prediction of Hemodynamic Compromise: Case Studies for Clinical Utility in Acute Care and Physical Performance

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Stewart CL, Nawn CD, Mulligan J, Grudic G, Moulton SL, Convertino VA. 16(1). 6 - 13. (Journal Article)

Abstract

Background: Humans are able to compensate for significant loss of their circulating blood volume, allowing vital signs to remain relatively stable until compensatory mechanisms are overwhelmed. The authors present several clinical and performance case studies in an effort to demonstrate real-time measurements of an individual's reserve to compensate for acute changes in circulating blood volume. This measurement is referred to as the Compensatory Reserve Index (CRI). Methods: We identified seven clinical and two physical performance conditions relevant to military casualty and operational medicine as models of intravascular volume compromise. Retrospective analysis of photoplethysmogram (PPG) waveform features was used to calculate CRI, where 1 represents supine normovolemia and 0 represents hemodynamic decompensation. Results: All cases had CRI values suggestive of volume compromise (<0.6) not otherwise evident by heart rate and systolic blood pressure. CRI decreased with reduced central blood volume and increased with restored volume (e.g., fluid resuscitation). Conclusion: The results from these case studies demonstrate that machine-learning techniques can be used to (1) identify a clinical or physiologic status of individuals through real-time measures of changes in PPG waveform features that result from compromise to circulating blood volume and (2) signal progression toward hemodynamic instability, with opportunity for early and effective intervention, well in advance of changes in traditional vital signs.

Keywords:

PMID: 27045488

DOI: SFRB-RGN9

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Competing to Increase Capability: The Team From the Land Down Under's Experience at the National Tactical Medicine Competition 2018

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Makrides T, Davoren B. 18(2). 149 - 152. (Journal Article)

Keywords: National Tactical Medicine Competition 2018; competitions

PMID: 29889975

DOI: 2I3E-JCXO

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Comprehensive Performance Nutrition for Special Operations Forces

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Daigle KA, Logan CM, Kotwal RS. 15(4). 40 - 53. (Journal Article)

Abstract

Special Operations Forces (SOF) training, combat, and contingency operations are unique and demanding. Performance nutrition within the Department of Defense has emphasized that nutrition is relative to factors related to the desired outcome, which includes successful performance of mentally and physically demanding operations and missions of tactical and strategic importance, as well as nonoperational assignments. Discussed are operational, nonoperational, and patient categories that require different nutrition strategies to facilitate category-specific performance outcomes. Also presented are 10 major guidelines for a SOF comprehensive performance nutrition program, practical nutrition recommendations for Special Operators and medical providers, as well as resources for dietary supplement evaluation. Foundational health concepts, medical treatment, and task-specific performance factors should be considered when developing and systematically implementing a comprehensive SOF performance nutrition program. When tailored to organizational requirements, SOF unit- and culture-specific nutrition education and services can optimize individual Special Operator performance, overall unit readiness, and ultimately, mission success.

Keywords: nutrition; performance; military; Special Operations Forces; human performance optimization

PMID: 26630094

DOI: XCD3-0RWE

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Comprehensive Ultrasound Course for Special Operations Combat and Tactical Medics

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Fatima H, Kuppalli S, Baribeau V, Wong VT, Chaudhary O, Sharkey A, Bordlee JW, Leibowitz A, Murugappan K, Pannu A, Rubenstein LA, Walsh DP, Kunze LJ, Stiles JK, Weinstein J, Mahmood F, Matyal R, Lodico DN, Mitchell J. 21(4). 54 - 61. (Journal Article)

Abstract

Background: Advances in ultrasound technology with enhanced portability and high-quality imaging has led to a surge in its use on the battlefield by nonphysician providers. However, there is a consistent need for comprehensive and standardized ultrasound training to improve ultrasound knowledge, manual skills, and workflow understanding of nonphysician providers. Materials and Methods: Our team designed a multimodal ultrasound course to improve ultrasound knowledge, manual skills, and workflow understanding of nine Special Operations combat medics and Special Operations tactical medics. The course was based on a flipped classroom model with a total time of 43 hours, consisting of an online component followed by live lectures and hands-on workshops. The effectiveness of the course was determined using a knowledge exam, expert ratings of manual skills using a global rating scale, and an objective structured clinical skills examination (OSCE). Results: The average knowledge exam score of the medics increased from pre-course (56% ± 6.8%) to post-course (80% ± 5.0%, p < .001). Based on expert ratings, their manual skills improved from baseline to day 4 of the course for image finding (p = .007), image optimization (p = .008), image acquisition speed (p = .008), final image quality (p = .008), and global assessment (p = .008). Their average score at every OSCE station was > 91%. Conclusion: A comprehensive multimodal training program can be used to improve military medics' ultrasound knowledge, manual skills, and workflow understanding for various applications of ultrasound. Further research is required to develop a reliable, sustainable course.

Keywords: ultraound; medics; competency; curriculum

PMID: 34969127

DOI: R270-3KAL

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Concepts of Prehospital Advanced Airway Management in the Operational K9: A Focus on Cricothyrotomy

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Palmer LE. 19(1). 99 - 106. (Journal Article)

Abstract

Similar to people, airway obstruction is a potentially preventable cause of combat and line of duty death for civilian law enforcement Operational K9s (OpK9) and military working dogs (MWD). Basic (i.e., body positioning, manual maneuvers, bag-valve-mask ventilation) and advanced (i.e., endotracheal intubation, surgical airways) airway techniques are designed to establish a patent airway, oxygenate and ventilate, and protect from aspiration. A surgical airway (cricothyrotomy [CTT] or tracheostomy [TT]) is warranted for difficult airway scenarios in which less invasive means fail to open an airway (aka "Cannot intubate, cannot oxygenate"). In people, the surgical CTT is the preferred surgical airway procedure; most human prehospital providers are not even trained on the TT. Currently, only the TT is described in the veterinary literature as an emergent surgical airway for MWDs. This article describes the novel approach of instituting the surgical CTT for managing the canine difficult airway. The information provided is applicable to personnel operating within the US Special Operations Command as well as civilian tactical emergency medical services that may have the responsibility of providing medical care to an OpK9 or MWD.

Keywords: canine; cricothyrotomy; airway; trauma; tracheostomy; Operational K9s

PMID: 30859536

DOI: KV13-RV6C

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Conceptualized Use of Self-Expanding Foam to Rescue Special Operators From Abdominal Exsanguination: Percutaneous Damage Control for the Forward Deployed

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Rago AP, Sharma U, Sims K, King DR. 15(3). 39 - 45. (Journal Article)

Abstract

Background: Noncompressible hemorrhage is the leading cause of potentially survivable death on the battlefield. In Special Operations Forces (SOF), 50% of potentially survivable deaths have been related to noncompressible hemorrhage. Currently, there are no widely available presurgical interventions that can slow abdominal bleeding. Consequently, many of the preventable deaths occur en route to definitive care as a failure to rescue from exsanguination. A self-expanding polyurethane foam has been developed as a percutaneous damage control intervention to rescue casualties who would otherwise die of noncompressible hemorrhage, and allow them to survive long enough to reach surgical intervention. The purpose of this paper is to summarize the existing preclinical data, describe the role of SOF personnel in foam delivery-system development, and to integrate these together to conceptualize how foam could be incorporated into SOF medical care. Methods: All existing publications on self-expanding foam are reviewed. Additionally, eight SOF medical providers with combat experience provided end-user input to delivery-device design through an interactive human-factors testing process. Results: Ten preclinical publications described efficacy, safety, dose translation, and risk-benefit analysis of exsanguination rescue with percutaneous-foam damage control. SOF medical providers guided weight, cubic, operational requirements, and limits for the foam delivery device. Conclusion: Presurgical exsanguination rescue with percutaneous foam damage control is safe and effective with a favorable risk-benefit profile in preclinical studies. Battlefield, presurgical use by SOF medical providers is conceptually possible. Adoption of the technology on the battlefield should proceed with SOF medical provider input.

Keywords: hemorrhage; noncompressable; bleeding; foam; advanced medic; abdominal; austere; ResQFoam

PMID: 26360352

DOI: X2LL-7JPS

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Continuous One-Arm Kettlebell Swing Training on Physiological Parameters in US Air Force Personnel: A Pilot Study

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Wade M, O'Hara R, Caldwell L, Ordway J, Bryant D. 16(4). 41 - 47. (Journal Article)

Abstract

Background: The primary aim of this study was to investigate the effects of continuous one-arm kettlebell (KB) swing training on various US Air Force physical fitness testing components. Thirty trained male (n = 15) and female (n = 15) US Air Force (USAF) personnel volunteered and were sequentially assigned to one of three groups based on 1.5-mile run time: (1) KB one-arm swing training, (2) KB one-arm swing training plus highintensity running (KB + run), and (3) traditional USAF physical training (PT) according to Air Force Instruction 36-2905. Methods: The following measurements were made before and after 10 weeks of training: 1.5-mile run, 1-minute maximal push-ups, 1-minute maximal situps, maximal grip strength, pro agility, vertical jump, 40-yard dash, bodyweight, and percent body fat. Subjects attended three supervised exercise sessions per week for 10 weeks. During each exercise session, all groups performed a 10-minute dynamic warm-up followed by either (1) 10 minutes of continuous KB swings, (2) 10 minutes of continuous kettlebell swings plus 10 minutes of high-intensity running, or (3) 20 minutes of moderate intensity running plus push-ups and sit-ups. Average and peak heart rate were recorded for each subject after all sessions. Paired t tests were conducted to detect changes from pretesting to posttesting within each group and analysis of variance was used to compare between-group variability (ρ ≤ .05). Results: Twenty subjects completed the study. There were no statistically significant changes in 1.5-mile run time between or within groups. The 40- yard dash significantly improved within the KB swing (ρ ≤ .05) and KB + run group (ρ ≤ .05); however, there were no significant differences in the traditional PT group (ρ ≤ .05) or between groups. Maximal push-ups significantly improved in the KB + run group (ρ ≤ .05) and trends toward significant improvements in maximal push-ups were found in both the KB (ρ = .057) and traditional PT (ρ = .067) groups. Conclusions: This study suggests that continuous KB swing training may be used by airmen as a high-intensity, low-impact alternative to traditional USAF PT to maintain aerobic fitness and improve speed and maximal push-ups.

Keywords: kettelbell training; Air Force; 40-yard dash; physical fitness; military personnel

PMID: 28088816

DOI: F5AW-FA8Q

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Contrived Breathing Circuit Connection for Emergency Percutaneous Transtracheal Ventilation by Needle Cricothyrotomy in the Field

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Naftalovich R, Iskander AJ. 22(1). 102 - 103. (Journal Article)

Abstract

Surgical airway approaches are, at times, last resort options in difficult airway management. In Special Operations these interventions confront distorted anatomy from combat trauma, extreme conditions, and may be performed by non-medically trained personnel. Under these circumstances, needle cricothyroidotomy using a large bore intravenous catheter can be considered. A small syringe connected to the needle can confirm transtracheal placement through air aspiration before passing the angiocatheter over the needle. Button activated retracting needles should be avoided for this when possible. We recommend a 3-mL Luer-lock syringe because a small syringe is better suited for generating pressure and once the catheter is in the trachea, this same syringe can be connected to bag valve ventilation by replacing its plunger with a connector from a 6.5-, 7-, or 7.5-mm endotracheal tube. Adding these small and light high-yield items to the Tactical Combat Casualty Care medic inventory should be considered in future revisions.

Keywords: military medicine; airway management; combat disorders; intubation, intratracheal

PMID: 35278323

DOI: 1EPK-PZLZ

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Conversion of the Abdominal Aortic and Junctional Tourniquet (AAJT) to Infrarenal Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) Is Practical in a Swine Hemorrhage Model

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Stigall K, Blough PE, Rall JM, Kauvar DS. 21(1). 30 - 36. (Journal Article)

Abstract

Background: Two methods of controlling pelvic and inguinal hemorrhage are the Abdominal Aortic and Junctional Tourniquet (AAJT; Compression Works) and resuscitative endovascular balloon occlusion of the aorta (REBOA). The AAJT can be applied quickly, but prolonged use may damage the bowel, inhibit ventilation, and obstruct surgical access. REBOA requires technical proficiency but avoids many of the complications associated with the AAJT. Conversion of the AAJT to REBOA would allow for field hemorrhage control with mitigation of the morbidity associated with prolonged AAJT use. Methods: Yorkshire male swine (n = 17; 70-90kg) underwent controlled 40% hemorrhage. Subsequently, AAJT was placed on the abdomen, midline, 2cm superior to the ilium, and inflated. After 1 hour, the animals were allocated to an additional 30 minutes of AAJT inflation (continuous AAJT occlusion [CAO]), REBOA placement with the AAJT inflated (overlapping aortic occlusion [OAO]), or REBOA placement following AAJT removal (sequential aortic occlusion [SAO]). Following removal, animals were observed for 3.5 hours. Results: No statistically significant differences in survival, blood pressure, or laboratory values were found following intervention. Conversion to REBOA was successful in all animals but one in the OAO group. REBOA placement time was 4.3 ± 2.9 minutes for OAO and 4.1 ± 1.8 minutes for SAO (p = .909). No animal had observable intestinal injury. Conclusions: Conversion of the AAJT to infrarenal REBOA is practical and effective, but access may be difficult while the AAJT is applied.

Keywords: hemorrhage; Abdominal Aortic and Junctional Tourniquet; resuscitative endovascular balloon occlusion of the aorta; swine

PMID: 33721303

DOI: V5UD-1SVF

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Conversion: Simulated Method of Exchanging Tourniquet Use for Pressure Dressing Use

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Kragh JF, Aden JK, Dubick MA. 20(3). 44 - 51. (Journal Article)

Abstract

Background: Given little data to assess guidelines, we sought a way to exchange one type of intervention, field tourniquet use, for another, use of a pressure dressing. The study purpose was to test performance of controlling simulated bleeding with a stepwise procedure of tourniquet conversion. Methods: An experiment was designed to assess 15 tests of a caregiver making tourniquet-dressing conversions. Tests were divided into trials: tourniquet use and its conversion. In laboratory conditions, the tourniquet trial was care under gunfire; then, the conversion trial was emergency healthcare. A HapMed Leg Tourniquet Trainer simulated a limb amputation. An investigator provided healthcare. Results: Mean (± standard deviation [SD]) test time and blood loss were 9 ± 3.6 minutes and 334 ± 353.9mL, respectively. The first test took 17 minutes. By test number, times decreased; the last six took ≤7 minutes. All tourniquet trials controlled bleeding. Mean (±SD) tourniquet pressure and blood loss were 222 ± 18.0mmHg and 146 ± 40.9mL, respectively. Bleeding remained uncontrolled in one conversion. Initial attempts to wrap a dressing were effective in 73% of tries (n = 11 of 15). Four of 15 wrap attempts (27%) were repeated to troubleshoot bleeding recurrence, and the first three tests required a repetition. Mean (±SD) dressing pressures and blood losses were 141 ± 17.6mmHg and 188 ± 327.4mL, respectively. Unsatisfactory conversion trials had a dressing pressure <137mmHg. Dressings and wraps hid the wound to impair assessment of bleeding. Conclusions: In testing a method of converting a limb tourniquet to a pressure dressing, the caregiver performed faster with experience accrual. The tourniquet results were uniformly good, but conversion results were worse and more varied. Simulating conversion was disappointing on a manikin and indicated that its redesign might be needed to suit this method. The procedural method constituted a start for further development.

Keywords: bleeding control and prevention; bandage; dressing, emergency; skill; tourniquet

PMID: 32969003

DOI: 80PM-WTY9

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Corneal Foreign Body Management at a Role 1 Flight Line Aid Station

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Calvano CJ, Enzenauer RW, Wenkel JW, Henke JL, Rohrbough CK, Miller SL, Howerton PH, Schreffler JP. 14(2). 9 - 13. (Journal Article)

Abstract

Eye injuries are common in forward areas of operations. Definitive diagnosis and care may be limited not by provider skill but rather by available equipment. The ability to treat simple trauma such as corneal foreign bodies at the Role 1 level has advantages including rapid return to duty, decreased cost of treatment, and, most important, decreased risk of delayed care. We propose the device such as a hand-held portable slit lamp should be made available for appropriate Special Operations Medical Forces (SOFMED) or aviation providers.

Keywords: ocular; trauma; slit lamp; Role 1; aviation; Special Forces medicine

PMID: 24952034

DOI: GL72-A40G

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CoTCCC Hail and Farewell

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Anonymous A. 19(4). 130 - 131. (Classical Conference)

Keywords:

PMID: 31910489

DOI: CCGE-A09M

Could He Stay or Should He Go Now?

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Hampton K, Van Humbeeck L. 19(4). 118 - 118. (Journal Article)

Keywords: urinary bladder; pain; RUQ; scrotum

PMID: 31910486

DOI: 5C14-644T

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Counterinsurgency, Healthcare, And Human Nature: Tapping Into The Hierarchy Of Needs

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Caci JB. 11(2). 8 - 11. (Journal Article)

Keywords:

PMID: 21455903

DOI: 9L70-ECMC

COVID-19 Antibody Prevalence From July to September 2020: One Army Infantry Brigade's Experience

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Koo AY, Rodgers DK, Johnson KA, Gordon LL, Mease LE, Couperus KS. 21(3). 60 - 65. (Journal Article)

Abstract

Objectives: Lab companies developed serology tests for antibody detection of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) with United States Food and Drug Administration (FDA) emergency use authorization. Antibody detection uses purified proteins of SARS-CoV-2 to determine antibody binding via enzyme-linked immunosorbent assay, chemiluminescent immunoassay (CLIA), or colloidal gold-based immunochromatographic assay. With the advent of coronavirus disease 2019 (COVID-19), nucleic acid amplification technology (NAAT) SARS-CoV-2 testing for active infection was not widely available to healthy, active-duty Soldiers. The purpose of this surveillance survey was to determine the prevalence of prior SARS-CoV-2 infection and symptoms of COVID-19 within a mechanized infantry brigade. Materials and Methods: Active-duty military Servicemembers (= 18 years) from a mechanized infantry brigade provided serum samples for testing for the Elecsys® Anti-SARS-CoV-2 qualitative antibody test from June to September 2020 at Joint Base Lewis McChord (JBLM). In addition, participants filled out a questionnaire for symptoms and exposure to COVID-19 from January to September 2020. The surveillance team collected and analyzed antibody testing results and questionnaires from participants for antibody positivity rates and symptom prevalence. Results: A total of 264 participants were tested, with one (0.4%) participant testing positive for the SARS-CoV-2 antibody. On the questionnaire, 144 of 264 (54.5%) endorsed symptoms of COVID-19 from January to September 2020. The most common symptoms were headache (35%), rhinorrhea (34%), cough (35%), and sore throat (31%). A total of 31 respondents (12%) had been quarantined as a trace contact to a COVID-19 positive patient. Conclusions: While there are limitations inherent to SARS-CoV-2 antibody testing and the survey, prevalence of prior SARS-CoV-2 infection is low. In this sample, symptoms for COVID-19 were prevalent with significant days of duty lost. Prevalence of prior SARS-CoV-2 infection in this sample may be generalizable to the larger brigade. Prevalence of symptoms of possible COVID-19 are not generalizable to the larger brigade. There is utility to further studies of SARS-CoV-2 antibody prevalence in military populations for purposes of vaccination triaging and deployment readiness.

Keywords: COVID-19; SARS-CoV-2; antibody; Army Infantry Brigade; vaccines; vaccination; prevalence

PMID: 34529807

DOI: FES1-3YV5

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Crimean-Congo Hemorrhagic Fever

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Burnett MW. 15(4). 96 - 98. (Journal Article)

Abstract

In mid-September 2009, a 22-year-old critically ill Soldier was medically evacuated from a treatment facility in southern Afghanistan to Landstuhl Regional Medical Center in Germany. Despite the efforts of the team at Landstuhl, this patient died and became the US military's first known victim of Crimean-Congo hemorrhagic fever (CCHF). CCHF is caused by a virus, which bears the same name. Because a vaccine is lacking, as well as an effective antiviral treatment, prevention is key.

Keywords: Crimean-Congo hemorrhagic fever; infectious disease

PMID: 26630102

DOI: LEK6-UBAB

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Critical Competencies of Military Embedded Health and Performance Professionals: The "Culture General" Approach

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Chamberlin R, McCarthy R, Lunasco TK, Park GH, Deuster PA. 22(3). 118 - 123. (Journal Article)

Abstract

Human performance teams (HPT) delivering a wide range of services within military unit communities serve as a model for advancing business practices in support of the 2018 National Defense Strategy. Relatively new, the demand for these embedded professionals continues to grow in response to its favorable proximity, community-based design, operationalized delivery system, and adaptive business practices. However, many civilian professionals come from diverse disciplines of specialties and experiences. As they integrate into unit communities, it becomes known that many do not possess formal training or experience working with the US military or its Servicemembers, delivering community-based services, operating in the capacity of a force multiplier, or culturally adapting their professional skills. Given the steep learning curve in transitioning from a conventional delivery model to the military embedded model, even newly minted military health and performance professionals may be underprepared when they arrive at their assigned military unit communities. In this article, we examine the military's embedded health and performance service delivery model. We add specific focus on those critical "embedded" professional competencies and skills foundational to establishing and sustaining thriving service delivery. We then offer strategies and tools collected from embedded health and performance professionals currently serving in military unit communities across the Department of Defense (DoD). Finally, we provide a rationale for the need for embedded competency training to improve the preparedness of professionals who are currently serving, will be serving, or have a general interest in serving as an embedded professional within DoD military unit communities.

Keywords: professional embedded competencies; human performance teams; human performance optimization; culturally competent care; mission readiness

PMID: 35862851

DOI: Y5O4-7WUZ

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C-TECC Update

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Smith R. 14(1). 118 - 120. (Classical Conference)

Keywords:

PMID: 27689365

DOI: 8SGY-QVU0

Cultural Competency and Patient-Centered Communication: A Study of an Isolated Outbreak of Urinary Tract Infections in Afghanistan

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Culbertson NT, Scholl BJ. 13(3). 70 - 73. (Journal Article)

Abstract

Background: Personal hygiene is strongly associated with disease prevention and is especially important during prolonged patrol or combat operations. Understanding cultural variances associated with personal hygiene is critical for Special Operation Forces (SOF) medics to prevent, monitor, and treat acquired and transmitted infections while working with host nation personnel. Case Presentation: During a multiday, long-range patrol, approximately 40 male Afghan National Army troops between the ages of 22 and 49 presented for treatment of burning or pain while urinating. All patients were empirically diagnosed with urinary tract infections. Methods and Discussion: The high attack rate and isolated nature of the outbreak suggested that personal hygiene or sexual intercourse was the most likely cause of the isolated outbreak. However, the cultural sensitivity of both topics made social history gathering a difficult task. After participating in a detailed medical interview, one patient revealed that he and his comrades were blocking their urethras with clay plugs after voiding to prevent residual urine from dripping onto their clothes. Conclusions: This case study presents what might be an undocumented practice carried throughout many ethnic cultures endogenous to Afghanistan and discusses how cultural barriers can impact effective health care delivery.

Keywords: urinary tract infections; hygiene; primary prevention; patient-centered care; cultural competency

PMID: 24048993

DOI: R4L5-6O5T

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Cultural Self-Awareness as a Crucial Component of Military Cross-Cultural Competence

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Pappamihiel CJ. 13(3). 62 - 69. (Journal Article)

Abstract

The military forces in the United States represent a unique culture that includes many subcultures within their own military society. Acculturation into the military often deemphasizes the influence of personal narrative and thereby establishes the primacy of military culture over personal cultural influences. The authors make the argument that military personnel need to further develop an understanding and appreciation of personal cultural narrative as well as organizational culture. The increased integration of military personnel with interagency partners, along with cooperative efforts between relief organizations, and nongovernmental organizations in politically/economically unstable areas around the globe serves to make cross-cultural interaction unavoidable in the future. Military medical personnel are especially likely to interact with others who have culturally different values. These interactions can occur between organizations as easily as they can during patient care. They must be able to step outside of their military culture and develop cross-cultural competence that is grounded in cultural self-awareness. Without an appropriate level of cultural self-awareness, military and medical personnel run the risk of being unable to communicate across dissimilar cultures or worse, alienating key stakeholders in collaborative operations between military services, coalition partners, and nonmilitary organizations. It is the authors' contention that unless military personnel, especially those in the medical arena, are able to appropriately self-assess situations that are impacted by culture, both their own and the other personnel involved, the resulting cultural dissonance is more likely to derail any significant positive effect of such collaborations.

Keywords: military cultural sensitivity; cultural awareness in the Armed Forces; cultural self-awareness

PMID: 24048992

DOI: 06T8-A8SB

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Cutaneous Leishmaniasis

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Burnett MW. 15(1). 128 - 129. (Journal Article)

Abstract

Cutaneous leishmaniasis is the most common form of leishmaniasis, which also appears in mucosal and visceral forms. It is a disease found worldwide, caused by an intracellular protozoan parasite of which there are more than 20 different species. The disease is transmitted by the bite of an infected, female, phlebotomine sand fly, causing skin lesions that can appear weeks to years after a bite. A typical lesion will start out in a papular form, progressing to a nodular plaque and, eventually, to a persistent ulcerative lesion. Special Operations Forces medical providers should be aware of this disease, which must be in the differential diagnosis of a patient who has lived in endemic areas and who has a persistent skin lesion nonresponsive to typical therapies.

Keywords: leishmaniasis; parasitic disease

PMID: 25770811

DOI: SGU9-DDMT

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Cutaneous Leishmaniasis

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Crecelius EM, Burnett MW. 21(1). 113 - 114. (Journal Article)

Abstract

Leishmaniasis is a parasitic infection that can involve the skin, mucosal membranes, and internal organs. Soldiers are at highrisk of leishmaniasis when conducting operations in endemic regions. Medical providers should have a low threshold to consider Leishmaniasis as the cause of persisting skin lesions.

Keywords: leishmaniasis; parasites; infection

PMID: 33721318

DOI: IMV2-JGWD

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Cutaneous Leishmaniasis: The Efficacy of Nonantimony Treatment in the Austere Environment Using Cryotherapy, Thermotherapy, and Photodynamic Therapy as an Alternative Method of Treatment

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Kunzler B. 13(4). 40 - 45. (Journal Article)

Abstract

The author provides a retrospective review of clinical trials evaluating cryotherapy, photodynamic therapy (PDT), and thermotherapy in the treatment of cutaneous Leishmania infestations. Current cutaneous leishmaniasis (CL) treatment is based primarily on antimony compounds such as meglumine antimoniate, sodium stibogluconate, ketaconozole, amphotericin B, and other similar compounds. All have potentially severe sideeffects and relatively narrow therapeutic windows (i.e., the minimum doses that are therapeutic and do not cause harm). Investigational modalities using heat and cold therapies were shown to have similar results compared with current treatment regimens. Combination therapies have also been investigated and are the standard of treatment in the United States. Although the current therapies are effective in the treatment of the trypanosomatid protozoan Leishmania parasite, some effective alternative modalities have been shown to have fewer serious side-effects compared with current medications. Investigational studies that were reviewed showed that whether used individually or as an adjunct to traditional therapies, alternative treatment methods proved to be equally efficacious in treating CL. Some investigational therapies, such as cryotherapy as the sole modality, approached 92% cure rate. Any of the three investigated alternatives (i.e., heat, cold, or photodynamic) are techniques that could be readily used by Special Operations Forces (SOF) medics during their operations in remote and/or austere regions of the world.

Keywords: cutaneous leishmaniasis; cryotherapy; thermotherapy; diathemy; SOF medics; photodynamic therapy; Leishmania

PMID: 24227560

DOI: 6ZM0-WVIL

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Cypress Creek EMS Basic Tactical Operational Medical Support Course

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Godbee DC. 19(2). 34 - 39. (Journal Article)

Keywords: Cypress Creek EMS Basic Tactical Operational Medical Support; tactical EMS; course; class

PMID: 31201749

DOI: ON9K-JQ22

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Dadland

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Farr WD. 18(4). 157 - 157. (Book Review)

Abstract

Carew K. Dadland. New York, NY: Atlantic Monthly Press; 2016. 420 pages. ISBN: 978-0-8021-2514-9/978.0.8021-9038-3.

Keywords:

DOI:

Damage Control and Point of Injury Care: Extending the Care Continuum to Military Prehospital Providers

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Hetzler MR. 12(1). 1 - 10. (Journal Article)

Abstract

Damage control principles are well founded, well proven, and have been incorporated into many specialties of clinical care in both military and civilian practice. Theories regarding hemostatic and hypovolemic resuscitation and preventing the Lethal Triad have had profound effects on the survival of wounded during the present conflicts. As we continue to refine these practices, implementation of this theory should be extended to military prehospital providers. The impacts of damage control practices from those providing initial treatment could complete the continuity of care, prime patients for additional success, and affect overall morbidity and mortality. The basic tenets of damage control theory are easily transferred to the Role I provider in the field and may even address their unique requirements more appropriately. Understanding the working concept of damage control would improve decision-making skills in both therapeutics and evacuation while managing casualties in the uncontrolled environment of combat. Military prehospital damage control differs greatly from in-hospital use, in that the principles must incorporate both medical and tactical considerations for care of the wounded. Introducing damage control principles to established casualty care guidelines will recognize and unite an often underappreciated level of care into a successful practice.

Keywords:

PMID: 22427043

DOI: QE05-QAJL

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Damage Control Resuscitation For The Special Forces Medic - Simplifying And Improving Prolonged Trauma Care: Part Two

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Hetzler MR, Risk G. 09(4). 53 - 62. (Journal Article)

Abstract

Present and future Special Forces missions will require prolonged care of the trauma patient. The Special Forces Medic and Independent Duty Corpsman must be prepared to deal with these situations in the most challenging and austere environments. The implementation of damage control resuscitation for prolonged trauma care can maximize results with minimal support while preventing death, priming the patient for surgical success, and expediting recovery. Establishing this model of care and equipping medics with the essential equipment will have a lasting effect on the survival rate of our casualties, and negate the enemy's political victories when American and allied lives are lost.

Keywords:

PMID: 20112649

DOI: L00C-GU7X

Damage Control Resuscitation For The Special Forces Medic: Simplifying And Improving Prolonged Trauma Care: Part One

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Risk G, Hetzler MR. 09(3). 14 - 21. (Journal Article)

Abstract

Current operational theaters have developed to where medical evacuation and surgical assets are accessible in times comparable to the United States. While this has been an essential tool in achieving the best survivability on a battlefield in our history, the by-product of this experience is a recognized shortcoming in current protocols and capabilities of Special Forces medics for prolonged care. The purpose of this article is to provide a theory of care, identify training and support requirements, and to capitalize on current successful resuscitation theories in developing a more efficient and realistic capability under the worst conditions.

Keywords:

PMID: 19739472

DOI: LZUR-EIKS

Damage Control Resuscitation in Prolonged Field CareDamage Control Resuscitation in Prolonged Field Care

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Fisher AD, Washbum G, Powell D, Callaway DW, Miles EA, Brown J, Dituro P, Baker JB, Christensen JB, Cunningham CW, Gurney JM, Lopata J, Loos PE, Maitha J, Riesberg JC, Stockinger Z, Strandenes G, Spinella PC, Cap AP, Keenan S, Shackelford SA. 18(3). 109 - 119. (Journal Article)

Keywords:

PMID: 30222848

DOI: A9KJ-NAIG

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Dark Invasion - 1915: Germany's Secret War and the Hunt for the First Terrorist Cell in America

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Farr WD. 14(2). 105 - 105. (Book Review)

Abstract

Howard Blum. New York: HarperCollins; 2014. 491 pages. ISBN: 978-0-06-23075-5.

Keywords:

DOI:

Decompression Sickness Following Altitude-Chamber Training

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Studer NM, Hughes JR, Puskar J. 15(1). 11 - 15. (Case Reports)

Abstract

Decompression sickness (DCS) is one of several dysbarisms (medical conditions resulting from a change in atmospheric pressure) that can be encountered by the Special Operations Forces (SOF) medical provider. DCS can present with several different manifestations. The authors present the case of a 23-year-old Airman who presented with vague neurologic symptoms following altitude-chamber training. They discuss the care of casualties with DCS and its implications for SOF.

Keywords: decompression sickness; Type II DCS; dysbarism; gas embolism; hyperbaric oxygen; altitude chamber; demand value; Oxylator®; hypoxia; hypobaric

PMID: 25770794

DOI: HPG2-5IVS

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Deconstructing the Definition of Prolonged Field Care

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Keenan S. 15(4). 125 - 125. (Journal Article)

Keywords:

PMID: 26630109

DOI: BG09-1JE2

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Decontamination of Toxic Industrial Chemicals and Fentanyl by Application of the RSDL® Kit

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Verheij ER, Joosen MJ, Cochrane L, de Bruin-Hoegee M, de Koning MC. 20(1). 55 - 59. (Journal Article)

Abstract

Purpose: This study investigated the decontamination effectiveness of selected toxic industrial chemicals using RSDL® (Reactive Skin Decontamination Lotion Kit; Emergent BioSolutions Inc.; https://www.rsdl.com/). Materials and Methods: Quantitative analytical methods were developed for dermal toxic compounds of varying physicochemical properties: sulfuric acid, hydrofluoric acid, ammonia, methylamine, hydrazine, phenylhydrazine, 1,2-dibromoethane, capsaicin, and fentanyl. These methods were subsequently used to evaluate the decontamination effectiveness on painted metal substrates at an initial chemical contamination level of 10g/m2 (0.1g/m2 for fentanyl). Results: The decontamination effectiveness ranged from 97.79% to 99.99%. Discussion and Conclusion: This study indicates that the RSDL kit may be amenable for use as an effective decontaminant for material substrates beyond the classical chemical warfare agents and the analytical methods may be used for future decontamination assessment studies using contaminated skin or other materials.

Keywords: RSDL; Reactive Skin Decontamination Lotion Kit; decontamination; toxic; industrial chemicals

PMID: 32203607

DOI: COFJ-WMPA

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Delayed Diagnosis in Army Ranger Postdeployment Primaquine-Induced Methemoglobinemia

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Essendrop R, Friedline N, Cruz J. 19(3). 14 - 16. (Case Reports)

Abstract

Presumptive antirelapse therapy (PART) with primaquine for Plasmodium vivax malaria postdeployment is an important component of the US military Force Health Protection plan. While primaquine is well tolerated in the majority of cases, we present a unique case of an active duty Army Ranger without glucose-6-phosphatase dehydrogenase or cytochrome b5 reductase (b5R) deficiencies who developed symptomatic methemoglobinemia while taking PART following a deployment to Afghanistan.

Keywords: presumptive antirelapse therapy; Plasmodium vivax; primaquine; methemoglobinemia

PMID: 31539427

DOI: CB3T-UBQV

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Delayed Diagnosis of Pelvic hematoma without Fracture Due to Military Parachuting

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Cunningham CW, Kotwal RS, Kragh JF. 13(2). 4 - 7. (Case Reports)

Abstract

The U.S. military has been conducting static-line parachute jumps for nearly a century. Beginning with World War II, military forces have also employed full-scale airborne operations as a method for insertion into combat. Through the years, injuries from blunt trauma as a result of static-line parachute jumps have evolved little with the refinement of equipment, training, and tactics. Parachute jumps continue to invoke primarily musculoskeletal injuries, especially to the lower extremities, back, neck, and head. These injuries are usually straightforward in their presentation and diagnosis. We describe the delayed diagnosis of a pelvic hematoma due to an uncommon blunt trauma jump injury. The purpose of this case report is to increase awareness of injury patterns during paratrooper operations, as well as to review the diagnosis and management of occult hemorrhage. Specific objectives for the readers are to (1) know the common injury types and patterns for airborne operations, (2) know the descent rate of T-10C/D parachutes and factors influencing the rate, (3) recognize signs and symptoms associated with a pelvic hematoma, and (4) recognize common complications resulting from a pelvic hematoma.

Keywords: airborne; paratrooper; parachute (T-10, T-11, SF-10); pelvic trauma; hemorrhage; hematoma; ultrasound; combat-load

PMID: 24419827

DOI: NTX4-YUSC

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Deliberate Practice in Combat Application Tourniquet Placement by Loop Passage

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Kragh JF, Aden JK, Dubick MA. 19(3). 45 - 50. (Journal Article)

Abstract

Background: We sought opportunities to develop learning practices of individual first aid providers. In this study, we simulated deliberate practice in placing limb tourniquets. Methods: This study comprised tourniquet uses by two experienced persons. Their practice sessions focused on developing a motor skill with periodic coaching. The Combat Application Tourniquet is 1.5-inches wide and was used in a technique of loop passage around the end of the limb to place it 2-3 inches above the wound. The simulated limb was a Z-Medica Hemorrhage Control Trainer. Both users applied the tourniquet six times over 5 days to accrue 30 uses individually (N = 60 tourniquet applications for the study). Results: When represented as summary parameters, differences were small. For example, average ease of use was the same for both users, but such parameters only took a snapshot of performance, yielding a general assessment. However, for a learning curve by use number, a surrogate of experience accrual, application time revealed spiral learning. The amount that users compressed a limb averaged -15% compared with its unsqueezed state. Placement accuracy was classified relative to gap widths between the tourniquet and the wound, and of 60 performances, 55 were satisfactory and five were unsatisfactory (i.e., placement was <2 inches from the wound). When a tourniquet only overlaid the 2-inch edge of the placement zone (i.e., tourniquet was 2-3.5 inches away from the wound), no error was made, but errors were made in crossing that 2-inch edge. These gauging errors led us to create a template for learners to see and to demonstrate what the meaning of 2-3 inches is. Conclusion: Each metric had value in assessing first aid, but turning attention to gauging wound-tourniquet gaps revealed placement errors. Analysis of such errors uncovered what 2-3 inches meant in operation. Spiral learning may inform the development of best readiness practices such as coaching deliberate-practice sessions.

Keywords: Combat Application Tourniquet; tourniquet placement; limb wound; Stop the Bleed; motor control and learning; loop-passage technique

PMID: 31539433

DOI: MWP1-BIX7

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Dengue Infections

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Burnett MW. 13(2). 64 - 68. (Journal Article)

Abstract

Background: Dengue fever is one of the most common mosquito-borne viral illnesses in the world. It is usually transmitted to humans through the bite of an infected Aedes aegypti or Aedes albopictus mosquito. Dengue infections are caused by four antigenically distinct but closely related viruses (DEN 1-4). Infection with any one of the viruses is thought to provide lifetime immunity to future infections from the same virus but only short-term cross-immunity to the other types, leading to the possibility of secondary infections. Dengue hemorrhagic fever/dengue shock syndrome (DHF/DSS), more severe types of dengue infections, sometimes result when an individual is subsequently infected with a second virus serotype during their lifetime. The most commonly accepted theory for the development of these more severe dengue infections is that of antibody-dependent enhancement, although other factors likely play a role. Infections complicated by DHF/DSS in areas where dengue is endemic are most often seen in the later half of the first year of life, when waning maternal antibodies may enhance the development of a more severe infection, and in young school-age children experiencing secondary infections. Widespread infections are most commonly seen during the rainy season of endemic areas when the breeding habitat of the Aedes mosquito is most favorable.

Keywords: dengue hemorrhagic fever; dengue shock syndrome; mosquito-borne viral illness

PMID: 23817881

DOI: 3O8A-579J

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Deployed Assessment and Management of mTBI Casualties

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Garfin B. 13(3). 51 - 55. (Journal Article)

Abstract

The wars in Afghanistan and Iraq have placed a spotlight on screening, evaluation, and treatment of mild traumatic brain injury, otherwise known as concussion. The author presents a mass casualty case in which a Ranger company medical section assessed and managed 30 Servicemembers (SM) diagnosed with concussion. Through the process of treating these Servicemembers, a consolidated checklist was created based on existing Department of Defense, United States Special Operations Command (USSOCOM), and United States Army Special Operations Command (USASOC) guidelines. During this and subsequent clinical encounters, utilization of this checklist resulted in efficient identification of concussed personnel, appropriate treatment, and documentation.

Keywords: traumatic brain injury; concussion

PMID: 24048990

DOI: 0CQT-0I3K

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Design and Demonstration of a Battery-Less Fluid Warmer for Combat

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Ndao S, Jensen KF, Velmahos GC, King DR. 13(3). 31 - 36. (Journal Article)

Abstract

Background: Prehospital battlefield hypothermia remains an issue, with cold fluid resuscitation likely being a significant contributor. Currently, no prehospital battlefield technology exists to warm intravenous resuscitation fluids. Existing commercial fluid-warming technologies are either inadequate or unreliable or have an unacceptable weight and size, making them inappropriate for the austere combat environment. We propose the creation of a battery-less, flameless, portable, low- weight, small, chemically powered fluid warmer for the battlefield. Methods: A magnesium-based exothermic chemical reaction was used as the sole heating source. A low-weight, small insulated container was created to contain the reaction. The chemical reaction was manipulated to sustain fluid heating as long as required. Results: The exothermic reaction was used to boil a Fluorinert ™ liquid within an insulated container that heats resuscitation fluid passing through the heat exchanger. A working prototype device, 9 inches in length and 4 inches in diameter, was engineered and tested. Warming was maintained over a variety of clinically relevant flow rates. Conclusion: A chemically based, safe, battery-less, flameless, lightweight fluid warmer was created. This technology could represent a significant remote capability currently unavailable on the battlefield.

Keywords: trauma; bleeding; prehospital; resuscitation; warming; thermal

PMID: 24048986

DOI: 09EB-Z83O

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Detection of Increased Intracranial Pressure by Ultrasound

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Hightower S, Chin EJ, Heiner JD. 12(3). 19 - 22. (Journal Article)

Abstract

Increases in intracranial pressure (ICP) may damage the brain by compression of its structures or restriction of its blood flow, and medical providers my encounter elevated ICP in conventional and non-conventional medical settings. Early identification of elevated ICP is critical to ensuring timely and appropriate management. However, few diagnostic methods are available for detecting increased ICP in an acutely ill patient, which can be performed quickly and noninvasively at the bedside. The optic nerve sheath is a continuation of the dura mater of the central nervous system and can be viewed by ocular ultrasound. Pressure changes within the intracranial cavity affect the diameter of the optic nerve sheath. Data acquired from multiple clinical settings suggest that millimetric increases in the optic nerve sheath diameter detected via ocular ultrasound correlate with increasing levels of ICP. In this review, we discuss the use of ocular ultrasound to evaluate for the presence of elevated ICP via assessment of optic nerve sheath diameter, and describe critical aspects of this valuable diagnostic procedure. Ultrasound is increasingly becoming a medical fixture in the modern battlefield where other diagnostic modalities can be unavailable or impractical to employ. As Special Forces and other austere medical providers become increasingly familiar with ultrasound, ocular ultrasound for the assessment of increased intracranial pressure may help optimize their ability to provide the most effective medical management for their patients.

Keywords:

PMID: 23032316

DOI: 50CD-9MJD

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Detection of Potential Pathogenic Bacteria on the Surfaces of Female Urinary Diversion Devices Following a Short Duration Military Training Exercise

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Peters AM, Yu I, Menguito M, Morrow S, Barnhill JC, Washington MA. 21(2). 85 - 88. (Journal Article)

Abstract

Background: Female Servicemembers are increasingly being incorporated into the combat arms and Special Operations communities. Female urinary diversion devices (FUDDs) have been used to facilitate urination in the austere environments that are encountered by Servicemembers. Importantly, the potential for the bacterial contamination of these devices has not been evaluated. The goals of this study were to determine whether microorganisms adhere to the surfaces of FUDDs in the field environment and to demonstrate the presence of potential pathogens on the used devices. Materials and Methods: A total of 15 devices that were used in a comprehensive 18-24-hour military field exercise were tested for the presence of microorganisms. Briefly, each device was swabbed, and the swabs were used to inoculate blood agar plates to encourage bacterial growth. The resulting bacterial colonies were identified, and the surface topography of the devices was investigated with electron microscopy. Results: Although microscopy revealed few surface features capable of facilitating bacterial attachment, several species were recovered. Significantly, a biofilm-forming strain of Proteus mirabilis (P. mirabilis) was detected on two of the devices. P. mirabilis is a mobile urinary pathogen that can potentially migrate from the surface of the device into the urinary tract of the user. Conclusion: Commercial FUDDs can support bacterial growth and harbor potential pathogens. Care should be taken to ensure that Servicemembers are aware of the importance of the proper care and cleaning of these devices in the field environment. To this end, standard operating procedures should be developed and distributed.

Keywords: female Servicemembers; female urinary diversion devices; urination; austere environment; Proteus mirabilis

PMID: 34105128

DOI: YXLH-TBYD

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Developing TCCC Guidelines for Unmanned Aerial Vehicle Casualty Evacuation

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Parker PJ. 20(1). 40 - 42. (Editorial)

Keywords:

PMID: 32203604

DOI: EWFS-E180

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Development and Evolution of a Comprehensive Mild Traumatic Brain Injury Inpatient Rehabilitation Program: A Nursing Perspective

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Modi SS, Goff D, Guess D, Meigs K, Hoskin A, Doncevic S, Perla L, Pejoro S, Sallah C. 22(3). 15 - 18. (Journal Article)

Abstract

The James A. Haley Veterans' Hospital in Tampa, Florida has developed an innovative approach to the unique rehabilitation needs of active duty Special Operations Forces (SOF) and veterans with chronic conditions related to their military service. Tampa's program, the Post-Deployment Rehabilitation and Evaluation Program (PREP), was established in 2008. The interdisciplinary team includes one nurse practitioner and eight staff registered nurses. The Veterans Health Administration (VHA) is using Tampa's established and successful PREP as a model to actively expand the program to other Veterans Administration (VA) Polytrauma Rehabilitation Centers over the next several years. There are several important nursing and rehabilitation team considerations for the successful development of these mild traumatic brain injury (mTBI) inpatient rehabilitation programs.

Keywords: polytrauma; multiple trauma; cognition disorders; traumatic brain injuries; veterans health services; military medicine; nursing care

PMID: 35862839

DOI: CXG4-QXS6

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Development of a Field-Expedient Vascular Trauma Simulator

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Martin CJ, Plackett TP, Rush RM. 19(2). 73 - 76. (Journal Article)

Abstract

The past few years have noted significant declines in combat casualty exposure over the course of a deployment. As a result, overall confidence and comfort in performing potentially life-saving therapies may wane during a deployment. Development of training simulators provides a method for bridging this gap. Herein, a field-expedient vascular trauma trainer for noncompressible torso hemorrhage is described. A low-fidelity simulator was created using a Penrose drain, intravenous tubing, suture, and a cardboard box. A higher-fidelity simulator was created using an aortobifemoral bypass graft, double-lumen endotracheal tube, suture, and an upper torso mannequin. The two trainers were successfully used to train for peripheral shunt placement and definitive vascular repair. The trainer makes use of supplies readily found at most Role 2 and 3 facilities and that are obtainable for Role 1 facilities providing damage control surgery. It provides a just-in-time way to develop and sustain confidence in the damage control principles applicable to vascular injuries.

Keywords: noncompressible torso hemorrhage; training simulator; vascular trauma trainer

PMID: 31201754

DOI: 4PQQ-IQ58

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Development of a New Vented Chest Seal Dressing for Treatment of Open Pneumothorax

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Hoggarth A, Grist M, Board B, Murch T. 20(3). 159 - 165. (Journal Article)

Abstract

The most common life-threatening complications from both blunt and penetrating thoracic injury are hemothorax, pneumothorax, or a combination of both. New guidelines, set out by the Tactical Combat Casualty Care (TCCC), advises that vented chest seal dressings are used to manage open or sucking chest wounds. Designing out risk is a fundamental criterion for ensuring the optimal performance of a device is obtained that offers the casualty the greatest chance of survival. Two key areas of risk in the application of vented chest seal dressings are adhesion failure and vent failure. This study assesses a new design of vented chest seal dressing for both adhesion and vent profile. The development of this new design for a vented chest seal has been tested for adhesion and venting properties and shown to have performance criteria suitable for the treatment of open pneumothorax and design features that minimize the risk of product failure during use.

Keywords: thoracic injury; hemothorax; pneumothorax; chest seal dressing

PMID: 32990941

DOI: 28BO-67AK

Development of a Rugged handheld Device for Real-Time Analysis of heart Rate: Entropy in Critically Ill Patients

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Mejaddam AY, van der Wilden GM, Chang Y, Cropano CM, Sideris AC, Hwbejire JO, Velmahos GC, Alam HB, de Moya MA, King DR. 13(1). 29 - 33. (Journal Article)

Abstract

Introduction: The usefulness of heart rate variability (HRV) and heart rate complexity (HRC) analysis as a potential triage tool has been limited by the inability to perform real-time analysis on a portable, handheld monitoring platform. Through a multidisciplinary effort of academia and industry, we report on the development of a rugged, handheld and noninvasive device that provides HRV and HRC analysis in real-time in critically ill patients. Methods: After extensive re-engineering, real-time HRV and HRC analyses were incorporated into an existing, rugged, handheld monitoring platform. Following IRB approval, the prototype device was used to monitor 20 critically ill patients and 20 healthy controls to demonstrate real-world discriminatory potential. Patients were compared to healthy controls using a Student's t test as well as repeated measures analysis. Receiver operator characteristic (ROC) curves were generated for HRV and HRC. Results: Critically ill patients had a mean APACHE-2 score of 15, and over 50% were mechanically ventilated and requiring vasopressor support. HRV and HRC were both lower in the critically ill patients compared to healthy controls (ρ < 0.0001) and remained so after repeated measures analysis. The area under the ROC for HRV and HRC was 0.95 and 0.93, respectively. Conclusions: This is the first demonstration of real-time, handheld HRV and HRC analysis. This prototype device successfully discriminates critically ill patients from healthy controls. This may open up possibilities for real-world use as a trauma triage tool, particularly on the battlefield.

Keywords: heart rate complexity; heart rate variability; entropy; triage; combat

PMID: 23526319

DOI: RT7J-ZXWP

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Development of a Swine Polytrauma Model in the Absence of Fluid Resuscitation

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Abdou H, Patel N, Edwards J, Richmond MJ, Elansary N, Du J, Poliner D, Morrison JJ. 21(4). 77 - 82. (Journal Article)

Abstract

Background: In locations in which access to resuscitative therapy may be limited, treating polytraumatized patients present a challenge. There is a pressing need for adjuncts that can be delivered in these settings. To assess these adjuncts, a model representative of this clinical scenario is necessary. We aimed to develop a hemorrhage and polytrauma model in the absence of fluid resuscitation. Materials and Methods: This study consisted of two parts: pulmonary contusion dose-finding (n = 6) and polytrauma with evaluation of varying hemorrhage volumes (n = 6). We applied three, six, or nine nonpenetrating captive bolt-gun discharges to the dose-finding group and obtained computed tomography (CT) images. We segmented images to assess contusion volumes. We subjected the second group to tibial fracture, pulmonary contusion, and controlled hemorrhage of 20%, 30%, or 40% and observed for 3 hours or until death. We used Kaplan-Meier analysis to assess survival. We also assessed hemodynamic and metabolic parameters. Results: Contusion volumes for three, six, and nine nonpenetrating captive bolt-gun discharges were 24 ± 28, 50 ± 31, and 63 ± 77 cm3, respectively (p = .679). Animals receiving at least six discharges suffered concomitant parenchymal laceration, whereas one of two swine subjected to three discharges had lacerations. Mortality was 100% at 12 and 115 minutes in the 40% and 30% hemorrhage groups, respectively, and 50% at 3 hours in the 20% group. Conclusion: This study characterizes a titratable hemorrhage and polytrauma model in the absence of fluid resuscitation. This model can be useful in evaluating resuscitative adjuncts that can be delivered in areas remote to healthcare access.

Keywords: Polytrauma model; pulmonary contusion; controlled hemorrhage; tibial fracture; delayed medical care; prolonged casualty care; prolonged field care

PMID: 34969131

DOI: PU3S-FWL7

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Diagnosis and Treatment of Anaphylaxis During Law Enforcement Operations

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Gerold KB. 18(1). 113 - 117. (Case Reports)

Keywords:

PMID: 29533445

DOI: KZQO-W113

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Diagnostic Accuracy of Emergency Bedside Ultrasonography to Detect Cutaneous Wooden Foreign Bodies: Does Size Matter?

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Fleming ME, Heiner JD, Summers S, April MD, Chin EJ. 17(4). 72 - 75. (Journal Article)

Abstract

Background: Soft-tissue occult foreign bodies are a concerning cause of morbidity in the emergency department. The identification of wooden foreign bodies is a unique challenge because they are often not detectable by plain radiography. The purpose of this study was to determine the diagnostic accuracy of emergency physician-performed ultrasonography to detect wooden foreign bodies of varying sizes. We hypothesized that sonographic sensitivity would improve with increasing foreign body size. Methods: We conducted a blinded, prospective evaluation using a previously validated, chicken, soft-tissue model to simulate human tissue. We inserted wooden toothpicks of varying lengths (1mm, 2.5mm, 5mm, 7.5mm, 10mm) to a depth of 1cm in five tissue models. Five additional models were left without a foreign body to serve as controls. Fifty emergency physicians with prior ultrasonography training performed sonographic examinations of all 10 models and reported on the presence or absence of wooden foreign bodies. Results: Subjects performed 10 ultrasonography examinations each for a total of 500 examinations. For the detection of wooden foreign bodies, overall test characteristics for sonography included sensitivity 48.4% (95% confidence interval [CI], 42.1%-54.8%) and specificity 67.6% (95% CI, 61.3%- 73.2%). Sensitivity did not change as object size increased (ρ = s.709). Conclusion: Emergency physician bedside ultrasonography demonstrated poor diagnostic accuracy for the detection of wooden foreign bodies. Accuracy did not improve with increasing object size up to 10mm. Providers should consider alternative diagnostic modalities if there is persistent clinical concern for a retained, radiolucent, soft-tissue foreign body.

Keywords: ultrasound; foreign body; wooden object

PMID: 29256199

DOI: 85XR-NO49

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Dietary Supplements for Musculoskeletal Pain: Science Versus Claims

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Crawford C, Saldanha L, Costello R, Deuster PA. 18(2). 110 - 114. (Journal Article)

Abstract

Special Operations Forces (SOF) face unique challenges that manifest themselves both mentally and physically. The extremes of training and combat can affect the readiness to perform at peak levels, especially when confronted with musculoskeletal pain. Many SOF Operators turn to dietary supplements in hopes of gaining an edge. Although some supplements are now being marketed for pain, decisions to use these products need to be driven by information that is evidence based. We describe SOF-specific evidence-based recommendations for the use of dietary ingredients for pain that emerged from a rigorous scientific evaluation. These recommendations are compared with the label claims made in the commercial market by companies selling products to combat musculoskeletal pain. This information can be used by the SOF medical community to assist Operators in making informed decisions when considering or selecting dietary supplements for maintaining and optimizing performance.

Keywords: dietary supplements; military personnel; evidence-based medicine; decision aid; musculoskeletal pain

PMID: 29889966

DOI: 8VTS-JFKO

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Differences in Stress Shoot Performance Among Special Forces Operators Who Participate in a Human Performance Program Versus Those Who Do Not

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Canada DM, Dawes JJ, Lindsay KG, Elder C, Goldberg P, Bartley N, Werth K, Bricker D, Fischer T. 18(4). 64 - 68. (Journal Article)

Abstract

Background: The purpose of this investigation was to determine if Army Special Operation Forces (ARSOF) Operators who participate in the Tactical Human Optimization, Rapid Rehabilitation and Reconditioning program perform significantly better on a simulated stress shoot scenario than ARSOF Operators who do not participate in the program. Methods: Deidentified archival data from 64 male ARSOF Operators (mean ± standard deviation: age, 31.1 ± 4.96 years; SOF experience, 3.44 ± 4.10 years) who participated in the Special Forces Advanced Urban Combat stress shoot were assessed to determine if differences in performance existed between program users (n = 25) and nonusers (n = 39). A series of bootstrapped analyses of variance in conjunction with effect-size calculations was conducted to determine if significant mean score differences existed between users and nonusers on raw and total course completion times, high-value target acquisition (positive identification time), and penalties accrued. Results: Small to medium effect sizes were observed between users and nonusers in raw time, penalties, and total time. Although there were no significant differences between users and nonusers, there was less variation in raw time and total time in users compared with nonusers. Conclusion: Our findings becomes a question of practical versus statistical significance, because less performance variability while under physical and psychological duress could be life saving for ARSOF Operators.

Keywords: Tactical Human Optimization; Rapid Rehabilitation and Reconditioning program; human performance; stress shoot; duress

PMID: 30566725

DOI: I508-07U6

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Different Width and Tightening System: Emergency Tourniquets on Distal Limb Segments

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Wall PL, Sahr SM, Buising CM. 15(4). 28 - 38. (Journal Article)

Abstract

Background: Tourniquets are used on distal limb segments. We examined calf and forearm use of four thigh-effective, commercial tourniquets with different widths and tightening systems: 3.8cm windlass Combat Application Tourniquet® (CAT, combattourrniquet.com) and Special Operations Forces® Tactical Tourniquet-Wide (SOFTTW, www.tacmedsolutions.com), 3.8cm ratchet Ratcheting Medical Tourniquet - Pediatric (RMT-P, www.ratchetingbuckles. com), and 10.4cm elastic Stretch-Wrap-And-Tuck Tourniquet® (SWATT, www.swattourniquet.com). Methods: From Doppler-indicated occlusion, windlass completion was the next securing opportunity; ratchet completion was one additional tooth advance; elastic completion was end tucked under a wrap. Results: All applications on the 16 recipients achieved occlusion. Circumferences were calf 38.1 ± 2.5cm and forearm 25.1 ± 3.0cm (p < .0001, t-test, mean ± SD). Pressures at Occlusion, Completion, and 120-seconds after Completion differed within each design (p < .05, one-way ANOVA; calf: CAT 382 ± 100, 510 ± 108, 424 ± 92mmHg; SOFTT-W 381 ± 81, 457 ± 103, 407 ± 88mmHg; RMT-P 295 ± 35, 350 ± 38, 301 ± 30mmHg; SWATT 212 ± 46, 294 ± 59, 287 ± 57mmHg; forearm: CAT 301 ± 100, 352 ± 112, 310 ± 98mmHg; SOFTT-W 321 ± 70, 397 ± 102, 346 ± 91mmHg; RMT-P 237 ± 48, 284 ± 60, 256 ± 51mmHg; SWATT 181 ± 34, 308 ± 70, 302 ± 70mmHg). Comparing designs, pressures at each event differed (p < .05, one-way ANOVA), and the elastic design had the least pressure decrease over time (p < .05, one-way ANOVA). Occlusion losses differed among designs on the calf (p < .05, χ²; calf: CAT 1, SOFTT-W 5, RMT-P 1, SWATT 0; forearm: CAT 0, SOFTT-W 1, RMT-P 2, SWATT 0). Conclusions: All four designs can be effective on distal limb segments, the SWATT doing so with the lowest pressures and least pressure losses over time. The pressure change from Occlusion to Completion varies by tourniquet tightening system and can involve a pressure decrease with the windlass tightening systems. Pressure losses occur in as little as 120 seconds following Completion and so can loss of Occlusion. This is especially true for nonelastic strap tourniquet designs.

Keywords: tourniquet; hemorrhage control; first aid; emergency treatment

PMID: 26630093

DOI: 0TO3-FCS5

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Differential Diagnosis of an Unusual Snakebite Presentation in Benin: Dry Bite or Envenomation?

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Benjamin JM, Chippaux J, Jackson K, Ashe S, Tamou-Sambo B, Massougbodji A, Akpakpa OC, Abo BN. 19(2). 18 - 22. (Case Reports)

Abstract

A 20-year-old man presented to a rural hospital in Bembéréké, northern Benin, after a witnessed bite from a small, dark snake to his left foot that occurred 3 hours earlier. The description of the snake was consistent with several neurotoxic elapids known to inhabit the area in addition to various species from at least 10 different genera of non-front-fanged colubroid (NFFC) venomous snakes. The presentation was consistent with the early signs of a neurotoxic snakebite as well as a sympathetic nervous system stress response. Diagnosis was further complicated by the presence of a makeshift tourniquet, which either could have been the cause of local signs and symptoms or a mechanical barrier delaying venom distribution and systemic effects until removal. Systemic envenomation did not develop after the removal of the constricting band, but significant local paresthesias persisted for longer than 24 hours and resolved after the administration of a placebo injection of normal saline in place of antivenom therapy. This was an unusual case of snakebite with persistent neuropathy despite an apparent lack of envenomation and a number of snakebite- specific variables that complicated the initial assessment, diagnosis, and treatment of the patient. This case presentation provides clinicians with an opportunity to familiarize themselves with the differential diagnosis and approach to a patient bitten by an unidentified snake, and it illustrates the importance of symptom progression as a pathognomonic sign during the early stages of a truly serious snake envenomation. Treatment should be based on clinical presentation and evolution of symptoms rather than on snake identification alone.

Keywords: snakebite; envenomation; clinical diagnosis; non-front-fanged colubroid; antivenom; dry bite

PMID: 31201747

DOI: YQR3-UZJN

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Differential Diagnosis Of Shoulder Pain Followed By Progressive Weakness: A Case Report

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Rosenthal MD. 09(1). 16 - 19. (Case Reports)

Abstract

Upper extremity weakness can be the result of a myriad of conditions ranging from contractile tissue injury, joint injury, or injury to central or peripheral nervous system components. Accurate diagnosis is important in establishing an optimal treatment regimen and sound prognosis. This report provides an overview of the diagnosis and treatment of Parsonage-Turner Syndrome, a relatively rare cause of upper extremity weakness and dysfunction. OBJECTIVES 1. Distinguish between Parsonage-Turner Syndrome and other causes of neurological upper extremity weakness. 2. Recognize key subjective findings of Parsonage-Turner Syndrome. 3. Recognize appropriate ancillary tests to aide in the differential diagnosis of Parsonage-Turner Syndrome

Keywords:

PMID: 19813344

DOI: 6PX1-DBEO

Difficult Diagnoses in an Austere Environment: A Clinical Vignette-The Presentation, Diagnosis, and Management of Ichthyosis

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Pickard-Gabriel CJ, Rudinsky S. 13(1). 61 - 65. (Journal Article)

Abstract

Lamellar ichthyosis (LI) is a rare inherited skin disorder of cornification, with an incidence of approximately 1 in 200,000 births. It is one of three types of autosomal recessive congenital ichthyosis (ARCI), a collective term for the spectrum of nonsyndromic ichthyoses caused by a number of well-described genetic mutations. We describe the case of LI diagnosed in a 10-day-old child of a Somali refugee at a free clinic in downtown Djibouti. Initial concern was for staphylococcal infection versus congenital disease. With the use of digital photographs, consultation with experts accessed through the Army Teledermatology Consultation Service supported a diagnosis of ARCI. Providing care to patients in austere environments can present numerous medical challenges. A provider cannot be expected to be able to diagnose and treat every disease and disorder alone, especially if there is a language barrier. Telemedicine can help close the gap in knowledge, particularly when presented with a challenging case. With a novel presentation, simply taking a photograph and e-mailing a consultant can quickly augment one's medical acumen, ensuring appropriate diagnosis and treatment.

Keywords:

PMID: 23526325

DOI: PGFE-Y5GL

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Digital Intubation: The Two-Fingered Solution to Securing an Airway

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Cashwell MJ, Wilcoxen AC, Meghoo CA. 13(3). 42 - 44. (Journal Article)

Abstract

Digital intubation is a useful technique that is rarely taught in conventional airway management courses. With limited equipment and minimal training, a Special Operations Forces (SOF) medic can use this technique to intubate an unconscious patient with a high degree of success. The objectives of this report are to (1) learn the sequence of events for successful digital intubation, (2) recognize and appreciate the advantages and limitations of this technique, and (3) appreciate the requirements for establishing a unit-level training program.

Keywords: digital intubation; airway

PMID: 24048988

DOI: 8C8R-ZWFM

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Dislocation Of The Knee: Imaging Findings

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Shearer D, Lomasney L, Pierce K. 10(1). 43 - 47. (Journal Article)

Abstract

Dislocations of the knee are relatively uncommon injuries. However, the incidence of this injury appears to be increasing. Knee dislocations are most often high velocity blunt injuries, with motor vehicle accidents being a frequent etiology. Other causes include falls from height, athletic injuries, farming and industrial accidents, and even low velocity mechanisms such as a misstep into a hole. Likewise, minor trauma in the morbidly obese is increasingly recognized as a mechanism of knee dislocation. Multiple forms of dislocation exist, with the common factor being disruption of the tibiofemoral articulation. Dislocation can occur in a variety of directions depending on the mechanism of injury. The most common dislocation is anterior, which may be seen in hyperextension injuries such as martial arts kicking. The "dashboard injury" of motor vehicle accidents can result in a posterior dislocation of the knee. Lateral and rotary dislocations are less common. Knee dislocation is more commonly diagnosed in men, with a mean age of 23 to 31 years old. This is the very patient population encountered by Special Operations Forces (SOF) healthcare providers. Given the mechanisms of injury noted above, it is reasonable to conclude that knee dislocations may be seen in a young, active SOF patient population, particularly those engaged in parachuting, fast-roping/rappelling, driving at high speeds during military operations, and mixed martial arts.

Keywords:

PMID: 20306414

DOI: 47CL-DEH7

Diving Medicine: A Review Of Current Evidence

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Lynch JH, Bove AA. 09(4). 72 - 79. (Previously Published)

Previously published in The Journal of the American Board of Family Medicine 22 (4): 399-407 (2009) Reprinted in the JSOM with permission granted by the Chief Editor of the The Journal of the American Board of Family Medicine

Abstract

Recreational scuba diving is a growing sport worldwide, with an estimated 4 million sport divers in the United States alone. Because divers may seek medical care for a disorder acquired in a remote location, physicians everywhere should be familiar with the physiology, injury patterns, and treatment of injuries and illnesses unique to the underwater environment. Failure to properly recognize, diagnose, and appropriately treat some diving injuries can have catastrophic results. In addition, recreational dive certification organizations require physical examinations for medical clearance to dive. This article will review both common and potentially life-threatening conditions associated with diving and will review current evidence behind fitness to dive considerations for elderly divers and those with common medical conditions.

Keywords:

PMID: 20112651

DOI: H2N1-5QHN

Documentation in Prolonged Field Care

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Loos PE, Glassman E, Doerr D, Dail R, Pamplin JC, Powell D, Riesberg JC, Keenan S, Shackelford S. 18(1). 126 - 132. (Journal Article)

Keywords:

PMID: 29533447

DOI: ID7F-Q4WE

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Does Pain Have a Role When It Comes to Tourniquet Training?

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Alterie J, Dennis AJ, Baig A, Impens A, Ivkovic K, Joseph KT, Messer TA, Poulakidas S, Starr FL, Wiley DE, Bokhari F, Nagy KK. 18(3). 71 - 74. (Journal Article)

Abstract

Background: One of the greatest conundrums with tourniquet (TQ) education is the use of an appropriate surrogate of hemorrhage in the training setting to determine whether a TQ has been successfully used. At our facility, we currently use loss of audible Doppler signal or loss of palpable pulse to represent adequate occlusion of vasculature and thus successful TQ application. We set out to determine whether pain can be used to indicate successful TQ application in the training setting. Methods: Three tourniquet systems (a pneumatic tourniquet, Combat Application Tourniquet® [C-A-T], and Stretch Wrap and Tuck Tourniquet™ [SWAT-T]) were used to occlude the arterial vasculature of the left upper arm (LUA), right upper arm (RUA), left forearm (LFA), right forearm (RFA), right thigh (RTH), and right calf (RCA) of 41 volunteers. A 4MHz, handheld Doppler ultrasound was used to confirm loss of Doppler signal (LOS) at the radial or posterior tibial artery to denote successful TQ application. Once successful placement of the TQ was noted, subjects rated their pain from 0 to 10 on the visual analog scale. In addition, the circumference of each limb, the pressure with the pneumatic TQ, number of twists with the C-A-T, and length of TQ used for the SWAT-T to obtain LOS was recorded. Results: All 41 subjects had measurements at all anatomic sites with the pneumatic TQ, except one participant who was unable to complete the LUA. In total, pain was rated as 1 or less by 61% of subjects for LUA, 50% for LFA, 57.5% for RUA, 52.5% RFA, 15% for RTH, and 25% for RCA. Pain was rated 3 or 4 by 45% of subjects for RTH. For the C-A-T, data were collected from 40 participants. In total, pain was rated as 1 or less by 57.5% for the LUA, 70% for the LFA, 62.5% for the RUA, 75% for the RFA, 15% for the RTH, and 40% for the RCA. Pain was rated 3 or 4 by 42.5%. The SWAT-T group consisted of 37 participants for all anatomic locations. In total, pain was rated as 1 or less by 27% for LUA, 40.5% for the LFA, 27.0% for the RUA, 43.2 for the RFA, 18.9% for the RTH, and 16.2% for the RCA. Pain was rated 5 by 21.6% for RTH application, and 3 or 4 by 35%. Conclusion: The unexpected low pain values recorded when loss of signal was reached make the use of pain too sensitive as an indicator to confirm adequate occlusion of vasculature and, thus, successful TQ application.

Keywords: tourniquet; pain; vasculature occlusion

PMID: 30222841

DOI: YC9F-GMU1

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Don't Let the Word "Myopic" Blind You

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Callaway DW. 16(3). 120 - 122. (Classical Conference)

Keywords:

PMID: 27734454

DOI: E6LJ-IIBL

Draw-over Anesthesia Bringing the "Dark Art" Back Into the Light

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Graves MW, Billings S. 18(3). 125 - 133. (Journal Article)

Keywords:

PMID: 30222851

DOI: CBVV-A67P

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Drug-Induced Liver Injury Secondary to Testosterone Prohormone Dietary Supplement Use

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Hoedebecke KL, Rerucha C, Maxwell K, Butler JN. 13(4). 1 - 5. (Journal Article)

Abstract

Dietary supplementation has become progressively more prevalent, with over half of the American population reporting use of various products. An increased incidence of supplement use has been reported in the military especially within Special Operations Forces (SOF) where training regimens rival those of elite athletes. Federal regulations regarding dietary supplements are minimal, allowing for general advertisement to the public without emphasis on the potentially harmful sideeffects. Subsequent medical care for these negative effects causes financial burden on the military in addition to the unit's loss of an Operator and potential mission compromise. This report reviews a case of an Operator diagnosed with drug-induced liver injury secondary to a testosterone prohormone supplement called Post Cycle II™. Clinical situations like this emphasize the necessity that SOF Operators and clinicians be aware of the risks and benefits of these minimally studied substances. Providers should also be aware of the Human Performance Resource Center for Health Information and Natural Medicines Comprehensive Database supplement safety ratings as well as the Food and Drug Administration's MedWatch and Natural Medicines WATCH, to which adverse reactions should be reported.

Keywords: liver injury; prohormone; testosterone; supplement

PMID: 24227554

DOI: TYAS-NM63

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Early, Prehospital Activation of the Walking Blood Bank Based on Mechanism of Injury Improves Time to Fresh Whole Blood Transfusion

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Bassett AK, Auten JD, Zieber TJ, Lunceford NL. 16(2). 5 - 8. (Journal Article)

Abstract

Balanced component therapy (BCT) remains the mainstay in trauma resuscitation of the critically battle injured. In austere medical environments, access to packed red blood cells, apheresis platelets, and fresh frozen plasma is often limited. Transfusion of warm, fresh whole blood (FWB) has been used to augment limited access to full BCT in these settings. The main limitation of FWB is that it is not readily available for transfusion on casualty arrival. This small case series evaluates the impact early, mechanism-of-injury (MOI)-based, preactivation of the walking blood bank has on time to transfusion. We report an average time of 18 minutes to FWB transfusion from patient arrival. Early activation of the walking blood bank based on prehospital MOI may further reduce the time to FWB transfusion.

Keywords: blood bank, walking; blood, fresh whole; therapy, blood component

PMID: 27450595

DOI: 81AP-OD8B

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Ease of Use of Emergency Tourniquets on Simulated Limbs of Infants: Deliberate Practice

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Kragh JF, Wright-Aldossari B, Aden JK, Dubick MA. 19(2). 41 - 47. (Journal Article)

Abstract

Background: To investigate questions about application of emergency tourniquets in very young children, we investigated practices of Combat Application Tourniquet (C-A-T) use on a simulated infant-sized limb to develop ways to improve readiness for caregiving. Methods: This study was conducted as investigations of C-A-Ts used by two individuals in deliberate practice. The practice setup simulating a limb of infants aged 3-5 months included a handrail (circumference, 5.25 in.). This setup needed a specific modification to the instructions for use to adhere the band between the clips. Each user performed 100 practices. Results: With accrual of experience, application time was shorter for each user, on average in a power law of practice, and more ease was associated when less time was taken to apply the tourniquet. The ease of use was associated with accrued experience through deliberate practice of a tourniquet user while under coached learning. A check of tourniquet fit on a 4.25-in. limb also entailed the modification used in the 5.25-in. limb. However, an additional modification of wrapping the band in a figure-8 pattern around the rod was needed because the rod and clip could not meet. The fit on a 3.25-in. limb was impracticable for a workaround. Tourniquet use was harder for smaller limbs (i.e., 4.25 in. and 3.25 in.). A map of tourniquet fit was sketched of which sized limbs were too big, too small, within the fit zone, or at its borders. Conclusion: C-A-Ts mechanically fit the simulated limbs of infants aged 3-5 months, and C-A-T use was practicably easy enough to allow experienced users to fit tourniquets to limbs well using a specific modification of the routine technique. The findings and knowledge generated in this study are available to inform researches and developments in best preparation practices for instructing first aid.

Keywords: Combat Application Tourniquet; limb tourniquet; Stop the Bleed; medical device; combat injury first aid; use instruction; resuscitation; emergency

PMID: 31201750

DOI: OVG4-5ZRE

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Easy Scan and Easy Fix for the Shoulder Injury in a Difficult Environment

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Urbaniak MK, Hampton K. 17(2). 150 - 150. (Journal Article)

Keywords:

PMID: 28599048

DOI: 892K-JOKV

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Ebola Hemorrhagic Fever

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Burnett MW. 14(3). 93 - 94. (Journal Article)

Abstract

Ebola hemorrhagic fever is an often-fatal disease caused by a virus of the Filoviridae family, genus Ebolavirus. Initial signs and symptoms of the disease are nonspecific, often progressing on to a severe hemorrhagic illness. Special Operations Forces Medical Providers should be aware of this disease, which occurs in sporadic outbreaks throughout Africa. Treatment at the present time is mainly supportive. Special care should be taken to prevent contact with bodily fluids of those infected, which can transmit the virus to caregivers.

Keywords: Ebolavirus; hemorrhagic fever

PMID: 25344714

DOI: JBMR-T6LY

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Edith Nourse Rogers: A Pioneer for Women, Military Veterans, and US Medical Education

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Bellaire CP, Ditzel RM, Meade ZS, Love ZD, Appel JM. 22(3). 62 - 64. (Journal Article)

Abstract

This year is the 80th anniversary of the Women's Army Auxiliary Corps. The passage of this seminal legislation - sponsored by Edith Nourse Rogers - formalized the role of women in the US military and compensated them for their service and in the event of injury or illness. Rogers was a pioneer in her own right. A trailblazer for women and a staunch advocate for military veterans' healthcare, Rogers was forged by her wartime experiences. The authors describe Rogers' contributions as a congresswoman during World War II and during her 35 years of public service in the House of Representatives. Congresswoman Rogers was foundational to the modern US healthcare system.

Keywords: veterans; military personnel; military medicine; school admission criteria; schools, medical; education, medical; women

PMID: 35661983

DOI: TE5I-GJWB

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Editorial Comment on "Psychological Resilience and Postdeployment Social Support Protect Against Traumatic Stress and Depressive Symptoms in Soldiers Returning from Operations Enduring Freedom and Iraqi Freedom"

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Myatt CA, Johnson DC. 09(3). 79 - 79. (Editorial)

Keywords:

PMID: 19739481

DOI: YIKD-EAOP

Editorial Comment On "psychsocial Buffers Of Traumatic Stress, Depressive Symptoms, And Psychosocial Difficulties In Veterans Of Operations Enduring Freedom And Iraqi Freedom: The Role Of Resilience, Unit Support, And Post-Deployment Social Support"

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Myatt CA, Johnson DC. 09(3). 80 - 80. (Editorial)

Keywords:

PMID: 19739482

DOI: 3R3D-M4BH

Editorial on the Approach to Prolonged Field Care for the Special Forces Medical Sergeant: Balancing the Opportunity Cost

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Nicholson JA, Searor JN, Lane AD. 20(3). 117 - 119. (Editorial)

Abstract

America's adversaries will contest US military superiority in the domains of land, sea, air, space, and cyberspace. Fundamentally, these foes seek to disrupt the dominance of American fighting forces through anti-access and area denial (A2AD) systems, such as cyber exploitation, electromagnetic jamming, air defense networks, and hypersonic capabilities. According to Training and Doctrine Command (TRADOC) Pamphlet 525- 3-1, these A2AD capabilities create multiple layers of stand-off that inhibit the US ability to focus combat power and achieve strategic objectives in a contested, increasingly lethal, inherently complex, and challenging operational environment.1 The Department of Defense (DoD) plans to mitigate this shift in enemy strategy through the adoption of multidomain operations (MDO).1 MDO is defined as operations that converge capabilities to overcome an adversary's strengths across various domains by imposing simultaneous dilemmas that achieve operational and tactical objectives.1 Within this MDO construct, medical treatment expectations must shift accordingly as the ability to rapidly treat and evacuate patients may be constrained by enemy action. Thus, the notion of prolonged field care (PFC) may be a necessity on the future battlefield. As Special Operations Forces (SOF) continue to refine what PFC entails, it is imperative that an understanding of the incidence and type of diseases that require medical evacuation to higher levels of care be thoughtfully estimated. Armed with an understanding of the anticipated epidemiology, effective prioritization of training requirements and equipment acquisition is possible in a manner that is complementary to the overall success of the assigned mission. Furthermore, this prior planning mitigates risk, as the limitations of money and time impose significant opportunity costs in the short run should the disproportionate mix of disease states be pursued, which in turn, avoids jeopardizing Soldiers' lives over the long term.

Keywords: prolonged field care; Special Forces Medical Sergeants; evacuation; medical care

PMID: 32969015

DOI: N1TD-UE0E

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Editorial Response

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Keenan S. 18(1). 139 - 140. (Editorial)

Keywords:

PMID: 29533449

DOI: MCUG-4R3T

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Effect of Hetastarch Bolus in Trauma Patients Requiring Emergency Surgery

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Ryan ML, Ogilvie MP, Pereira BM, Gomez-Rodriguez JC, Livingstone AS, Proctor KG. 12(3). 57 - 67. (Journal Article)

Abstract

If blood products are not available, current military guidelines recommend a hetastarch bolus (HEX, Hextend ™ 6% hetastarch in lactated electrolyte buffer, www. hospira.com) for initial treatment of hypovolemic shock in the field. We previously reported that a HEX bolus plus standard of care (SOC = crystalloid plus blood products) was safe during initial resuscitation in 1714 trauma patients. This study tests the hypothesis that HEX+SOC is more effective than SOC alone for volume expansion in trauma patients requiring urgent operation. Methods: From July 2009 to August 2010, the records from all adults who required emergency surgery within 4 hours of admission were screened for a retrospective cohort observational study. Burns, and those with primary neurosurgical or orthopedic indications, were excluded. The study population was comprised of 281 patients with blunt (n = 72) or penetrating (n = 209) trauma; 141 received SOC and 140 received SOC+HEX in the emergency room only (ER, n = 81) or the ER and operating room (OR, n = 59). Each case was reviewed with waiver of consent. Results: After penetrating injury, with SOC, the injury severity score was 17 and mortality was 12%; the corresponding values in the HEX(ER) and HEX(OR) groups were 19-21 and 8%, but these apparent differences did not reach significance. However, in patients receiving HEX, initial heart rate was higher, base deficit was lower, and hematocrit was lower (consistent with relative hypovolemia), even though blood product requirements were reduced, and urine output was greater (all ρ < 0.05). These effects were absent in patients with blunt trauma. Platelet consumption was higher with HEX after either penetrating (ρ = 0.004) or blunt trauma (ρ = 0.045), but coagulation tests were unchanged. Conclusion: HEX is safe for initial resuscitation in young patients who required urgent operation after penetrating trauma, but there was no apparent effect after blunt trauma. A bolus of HEX reduced transfusion requirements without inducing coagulopathy or causing renal dysfunction, but a randomized controlled trial is necessary to eliminate the possibility of selection bias.

Keywords: hydroxyethyl starch; Hextend®; trauma resuscitation; colloid; Tactical Combat Casualty Care; first responder; field medic

PMID: 23032322

DOI: BZD7-VDKY

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Effect of Spearmint Extract Containing Rosmarinic Acid on Physical and Executive Functioning After a Tactical Operation

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Ostfeld I, Ben-Moshe Y, Hoffman MW, Shalev H, Hoffman JR. 18(4). 92 - 96. (Journal Article)

Abstract

We examined the effect of a proprietary spearmint extract containing rosmarinic acid (PSE) on physical, cognitive, and executive functioning of study participants after a high-risk tactical operation while sleep deprived for 24 hours. Ten Operators (mean ± standard deviation: age, 35.1 ± 5.2 years; height, 177.6 ± 5.3cm; weight, 81.3 ± 9.3kg) from an elite counterterrorism unit volunteered to participate in this randomized, double-blind, parallel-design study. Participants were randomly assigned into either the PSE or placebo (PL) group and ingested 900mg/day PSE or an equivalent amount of PL for 17 days. Physical, cognitive, and executive functioning was tested before PST supplementation (PRE) and within 1 hour of the operation's conclusion (POST). Magnitude-based inferences indicated that differences between PSE and PL in jump power, reactive agility, eye-hand coordination, and cognition were unclear. However, subjective feelings of energy, alertness, and focus were very likely, likely, and possibly better for PSE than PL, respectively. There was no difference (ρ = .64) between groups in identifying the correct target; however, all participants in the PSE group correctly identified the target, whereas 60% of participants in the PL group correctly identified the target at POST. Although the results of this study do not provide conclusive evidence regarding the efficacy of PSE, they do suggest additional research is warranted in a larger sample of participants.

Keywords: dietary intervention; Special Operations; performance; nutrition; sleep deprivation

PMID: 30566730

DOI: HVYN-6PAG

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Effect of Special Operations Training on Testosterone, Lean Body Mass, and Strength and the Potential for Therapeutic Testosterone Replacement: A Review of the Literature

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Linderman JK, O'Hara R, Ordway J. 20(1). 94 - 100. (Journal Article)

Abstract

Objective: Due to physical demands, Special Operations Forces (SOF) endure changes in body composition, work capacity, and endocrine function. These changes result in energy deficits and sleep deprivation, where sleep averaged 3 hours/ day, independently known to decrease testosterone levels. The use of exogenous testosterone shows increases in lean body mass (LBM) and muscle function in healthy males and reverses cachexia in diseased populations. Therefore, the review's primary purpose is to summarize and contrast literature in both SOF and nonmilitary personnel regarding the correlation between negative energy balance, sleep deprivation, and decreased testosterone. The secondary purpose summarizes the effects of exogenous testosterone therapy in healthy males as well as reversing the effects of muscle wasting diseases. Methods: An online literary search from 1975 to 2015 identified 46 of 71 sources addressing both purposes, and data were summarized into tables providing mean observations. Conclusions: SOF training results in decreased testosterone (-6.3%), LBM (-4.6%), and strength (-11.7%), tied to energy deficits (-3,351 kcal/day) and sleep deprivation (3 hours/ day). Exogenous testosterone therapy increases LBM (6.2%), strength (7.9-14.8%), reverses cachexia (2.0%) and increases strength (12.7%) in those with chronic diseases. Therefore, testosterone supplementation in SOF may attenuate changes in body composition and muscle function during training and sustained Special Operations (SUSOPS).

Keywords: androgenic; anabolic; cachexia; fatigue; Special Operations; military

PMID: 32203613

DOI: FPEQ-KDM2

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Effective Monitoring and Evaluation of Military Humanitarian Medical Operations

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Waller SG, Powell C, Ward JB, Riley K. 11(1). 9 - 14. (Journal Article)

Abstract

Non-military government agencies and non-governmental organizations (NGOs) have made great strides in the evaluation of humanitarian medical work, and have learned valuable lessons regarding monitoring and evaluation (M&E) that may be equally as valuable to military medical personnel. We reviewed the recent literature by the worldwide humanitarian community regarding the art and science of M&E, with focus toward military applications. The successes and failures of past humanitarian efforts have resulted in prolific analyses. Alliances of NGOs set the standard for humanitarian quality and M&E standards. Military medical personnel can apply some of these standards to military humanitarian M&E in complex and stability operations. The authors believe that the NGO community's M&E standards should be applied to improve evaluation of U.S. military medical humanitarian operations.

Keywords:

PMID: 22113720

DOI: 2LLP-JW6O

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Effectiveness of Pulse Oximetry Versus Doppler for Tourniquet Monitoring

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Wall PL, Buising CM, Grulke L, Troester A, Bianchina N, White S, Freymark R, Hassan A, Hopkins JW, Renner CH, Sahr SM. 17(1). 36 - 44. (Journal Article)

Abstract

Background: Pulse oximeters are common and include arterial pulse detection as part of their methodology. The authors investigated the possible usefulness of pulse oximeters for monitoring extremity tourniquet arterial occlusion. Methods: Tactical Ratcheting Medical Tourniquets were tightened to the least Doppler-determined occluding pressure at mid-thigh or mid-arm locations on one limb at a time on all four limbs of 15 volunteers. A randomized block design was used to determine the placement locations of three pulse oximeter sensors on the relevant digits. The times and pressures of pulsatile signal absences and returns were recorded for 200 seconds, with the tourniquet being tightened only when the Doppler ultrasound and all three pulse oximeters had pulsatile signals present (pulsatile waveform traces for the pulse oximeters). Results: From the first Doppler signal absence to tourniquet release, toe-located pulse oximeters missed Doppler signal presence 41% to 50% of the times (discrete 1-second intervals) and missed 39% to 49% of the pressure points (discrete 1mmHg intervals); fingerlocated pulse oximeters had miss rates of 11% to 15% of the times and 13% to 19% of the pressure points. On toes, the pulse oximeter ranges of sensitivity and specificity for Doppler pulse detection were 71% to 90% and 44% to 51%, and on fingers, the respective ranges were 65% to 77% and 78% to 83%. Conclusion: Use of a pulse oximeter to monitor limb tourniquet effectiveness will result in some instances of an undetected weak arterial pulse being present. If a pulse oximeter waveform is obtained from a location distal to a tourniquet, the tourniquet should be tightened. If a pulsatile waveform is not detected, vigilance should be maintained.

Keywords: tourniquet; hemorrhage; first aid; emergency treatment

PMID: 28285479

DOI: XSOP-5MDO

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Effectiveness of Short Training in Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) by Emergency Physicians: The Applied Course for Internal Aortic Clamping on Field Mission

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Thabouillot O, Boddaert G, Travers S, Dubecq C, Derkenne C, Kedzierewicz R, Bertho K, Prunet B. 21(3). 36 - 40. (Journal Article)

Abstract

Background: Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a technique that uses internal clamping of the aorta to control abdominal, pelvic, or junctional bleeding. We created a course to train military physicians in both civilian prehospital use and battlefield use. To determine the effectiveness of this training, we conducted REBOA training for French military emergency physicians. Methods: We trained 15 military physicians, organizing the training as follows: a half-day of theoretical training, a half-day of training on mannequins, a half-day on human corpses, and a half-day on a living pig. The primary endpoint was the success rate after training. We defined success as the balloon being inflated in zone 1 of a PryTime mannequin. The secondary endpoints were the progression of each trainee during the training, the difference between the median completion duration before and after training, the median post-training duration, and the median duration for the placement of the sheath introducer before and after training. Results: Fourteen of the physicians (93%) correctly placed the balloon in the mannequin at the end of the training period. During the training, the success rate increased from 73% to 93% (p = .33). The median time for REBOA after training was only 222 seconds (interquartile range [IQR] 194-278), significantly faster than before training (330 seconds, IQR 260-360.5; p = .0033). We also found significantly faster sheath introducer placement (148 seconds, IQR 126-203 versus 145 seconds, IQR 115.5 - 192.5; p = .426). Conclusion: The training can be performed successfully and paves the way for the use of REBOA by emergency physicians in austere conditions.

Keywords: accident and emergency medicine; education and training; trauma management; REBOA; military

PMID: 34529802

DOI: NYAW-F69L

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Effects of a New Cooling Technology on Physical Performance in US Air Force Military Personnel

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O'Hara R, Vojta C, Henry A, Caldwell L, Wade M, Swanton S, Linderman JK, Ordway J. 16(2). 57 - 61. (Journal Article)

Abstract

Introduction: Heat-related illness is a critical factor for military personnel operating in hyperthermic environments. Heat illness can alter cognitive and physical performance during sustained operations missions. Therefore, the primary purpose of this investigation was to determine the effects of a novel cooling shirt on core body temperature in highly trained US Air Force personnel. Methods: Twelve trained (at least 80th percentile for aerobic fitness according to the American College of Sports Medicine, at least 90% on the US Air Force fitness test), male Air Force participants (mean values: age, 25 ± 2.8 years; height, 178 ± 7.9cm; body weight 78 ± 9.6kg; maximal oxygen uptake, 57 ± 1.9mL/kg/ min; and body fat, 10% ± 0.03%) completed this study. Subjects performed a 70-minute weighted treadmill walking test and 10-minute, 22.7kg sandbag shuttle test under two conditions: (1) "loaded" (shirt with cooling inserts) and (2) "unloaded" (shirt with no cooling inserts). Results: Core body temperature, exercise heart rate, capillary blood lactate, and ratings of perceived exertion were recorded. Core body temperature was lower (ρ = .001) during the 70-minute treadmill walking test in the loaded condition. Peak core temperature during the 70-minute walking test was also significantly lower (ρ = .038) in the loaded condition. Conclusion: This lightweight (471g), passive cooling technology offers multiple hours of sustained cooling and reduced core and peak body temperature during a 70-minute, 22.7kg weighted-vest walking test.

Keywords: cooling; Special Forces; physical activity; hyperthermia; fatigue, volitional

PMID: 27450604

DOI: 67L0-EZBK

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Effects of Distance Between Paired Tourniquets

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Wall PL, Buising CM, Nelms D, Grulke L, Renner CH, Sahr SM. 17(4). 37 - 44. (Journal Article)

Abstract

Background: In practice, the distance between paired tourniquets varies with unknown effects. Methods: Ratcheting Medical Tourniquets were applied to both thighs of 15 subjects distally (fixed location) and proximally (0, 2, 4, 8, 12cm gap widths, randomized block). Applications were pair, single distal, single appropriate proximal. Tightening ended one-ratchet tooth advance past Doppler-indicated occlusion. Pairs had alternating tightening starting distal. Results: Occlusion pressures were higher for: each single than respective individual pair tourniquet, each pair distal than respective pair proximal, and each single distal than respective single proximal (all p < .0001). Despite thigh circumference increasing proximally, occlusion pressures were lower with proximal tourniquet involvement (pair or single, p < .0001). Occlusion losses before 120 seconds occurred most frequently with pairs (0cm 4, 2cm 4, 4cm 6, 8cm 7, 12cm 5 for 26 of 150), in increasing frequency with increasingly proximal singles (0cm 0, 2cm 1, 4cm 1, 8cm 2, 12cm 6 for 10 of 150, p < .0001 for trend), and least with single distal (2 of 150, p < .0001). Paired tourniquets required fewer ratchet advances per tourniquet (pair distal 5 ± 1, pair proximal 4 ± 1, single distal 6 ± 1, single proximal 6 ± 1). Final ratchet tooth advancement pressure increases (mmHg) were greatest for singles (distal 61 ± 10, proximal 0cm 53 ± 7, 2cm 51 ± 9, 4cm 50 ± 7, 8cm 45 ± 7, 12cm 36 ± 7) and least in pairs (distal 41 ± 8, proximal 32 ± 7) with progressively less pair interaction as distance increased (pressure change for the pair tourniquet not directly advanced: 0cm 13 ± 4, 2cm 10 ± 4, 4cm 6 ± 3, 8cm 1 ± 2, 12cm -1 ± 2). Conclusions: Occlusion pressures are lower for paired than single tourniquets despite variable intertourniquet distances. Very proximal placement has a pressure advantage; however, pairs and very proximal locations may be less likely to maintain occlusion. Increasingly proximal placements also increase tissue at risk; therefore, distal placements and minimal intertourniquet distances should still be recommended.

Keywords: tourniquet; hemorrhage; first aid; emergency treatment

PMID: 29256192

DOI: AQ40-J458

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Effects of Donning and Wearing Personal Protective Equipment on Tourniquet Use and Conversion

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Kragh JF, Le TD, Dubick MA. 20(4). 40 - 46. (Journal Article)

Abstract

Background: We sought to gather data about the effects of personal protective equipment (PPE) use on tourniquet interventions by preliminarily developing a way to simulate delay effects, particularly on time and blood loss. Such knowledge might aid readiness. Field calls to emergency departments may indicate donning of PPE before patient arrival. The purpose of this study was to investigate (1) delay effects of donning the PPE studied on field-tourniquet control of hemorrhage and (2) delay effects of wearing the PPE on application of a field tourniquet and its conversion to a pneumatic tourniquet. Methods: The experiment simulated 30 tests of nonpneumatic field tourniquet use (http://www.combattourniquet.com/wp -content). The research intervention was the use of PPE. Data were grouped. The control group had no PPE (PPE0). PPE1 and PPE2 groups had mostly improvised and off-the-shelf equipment, respectively. PPE1 included donning a coat, goggles, face covering, cap, booties, and gloves. PPE2 had analogous items. The group order was randomized. A test included paired trials: field tourniquet, followed by conversion. An investigator simulated the caregiver. A task trainer simulated a thigh amputation. Donning delays were evaluated as differences in mean times to stop bleeding compared with PPE0. Blood loss results from donning PPE were calculated as the delay multiplied by its bleeding rate, 500mL/min. Results: PPE0 had no delay: its mean blood loss was 392mL. PPE1 had 805mL more blood loss than PPE0 did. PPE2 exceeded PPE0 by 1004mL. Donning time (blood loss) for PPE1 and PPE2 were 1.4 minutes (712mL) and 1.7 minutes (863mL), respectively. The wearing of PPE did not slow down field tourniquet application or its conversion. Conclusions: How long it took to don PPE delayed the time to stop bleeding and increased blood loss, but wearing PPE slowed down neither field tourniquet application nor its conversion.

Keywords: bleeding control and prevention; precautions; emergency; simulation; readiness practices; device removal

PMID: 33320311

DOI: 4AQ2-BCU9

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Effects of Intraosseous and Intravenous Administration of Hextend® on Time of Administration and Hemodynamics in a Swine Model

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Johnson D, Dial J, Ard J, Yourk T, Burke E, Paine C, Gegel B, Burgert J. 14(1). 79 - 85. (Journal Article)

Abstract

Introduction: The military recommends that a 500mL bolus of Hextend® be administered via an intravenous (IV) 18-gauge needle or via an intraosseous (IO) needle for patients in hypovolemic shock. Purposes: The purposes of this study were to compare the time of administration of Hextend and the hemodynamics of IV and IO routes in a Class II hemorrhage swine model. Methods: This was an experimental study using 27 swine. After 30% of their blood volume was exsanguinated, 500mL of Hextend was administered IV or IO, but not to the control group. Hemodynamic data were collected every 2 minutes until administration was complete. Results: Time for administration was not significant (p = .78). No significant differences existed between the IO and IV groups relative to hemodynamics (p > .05), but both were significantly different than the control group (p < .05). Conclusions: The IO route is an effective method of administering Hextend.

Keywords: hemorrhage; shock; Hextend®; hetastarch; battlefield

PMID: 24604442

DOI: 83H7-PQIY

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Effects of Oral Chondroitin Sulfate on Osteoarthritis-Related Pain and Joint Structural Changes: Systematic Review and Meta-Analysis

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Knapik JJ, Pope R, Hoedebecke SS, Schram B, Orr R. 19(1). 113 - 124. (Journal Article)

Abstract

Osteoarthritis (OA) is a disorder involving the deterioration of articular cartilage and underlying bone and is associated with symptoms of pain and disability. In military personnel, the incidence of OA has increased between 2000 and 2012 and was the first or second leading cause of medical separations in this period. It has been suggested that consumption of chondroitin sulfate (CS) may reduce the pain and joint deterioration associated with OA. This article reports on a systematic review and meta-analysis of the effectiveness of CS on reducing OA-related pain and joint deterioration. PubMed and Ovid Embase databases and other sources were searched to find randomized, double-blind, placebo-controlled trials on the effects of orally consumed CS on pain and/or joint structure. The outcome measure was the standardized mean difference (SMD) which was the improvement in the placebo groups minus the improvement in the CS groups divided by the pooled standard deviation. There were 18 trials meeting the review criteria for pain with SMD -0.41, 95% confidence interval (95% CI) -0.57 to -0.25 (negative SMD favors CS). Six studies met the review criteria for joint space narrowing with SMD -0.30, 95% CI -0.61 to +0.00. Two studies meet the review criteria for cartilage volume with SMD -0.11, 95% CI -0.48 to +0.26. Larger dosages (1200mg/d) had greater pain reduction efficacy than lower dosages (≤ 1000mg/d). These data suggest that CS has small to moderate effectiveness in reducing OA-related pain but minimal effects on joint space narrowing and no effect on cartilage volume. It is important that clinicians recommend pharmaceutical-grade CS to their patients due to the variability in the amount of CS in dietary supplements purporting to contain CS.

Keywords: osteoarthritis; articular deterioration; bone deterioration; pain; disability; chrondroitin sulfate

PMID: 30859538

DOI: JLSS-PG9B

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Effects of Oral Glucosamine Sulfate on Osteoarthritis-Related Pain and Joint-Space Changes: Systematic Review and Meta-Analysis

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Knapik JJ, Pope R, Hoedebecke SS, Schram B, Orr R, Lieberman HR. 18(4). 139 - 147. (Journal Article)

Abstract

Background: Osteoarthritis (OA) is a disorder involving deterioration of articular cartilage and underlying bone and is associated with symptoms of pain and disability. Glucosamine is a component of articular cartilage naturally synthesized in the body from glucose and incorporated into substances contained in the cartilage. It has been suggested that consumption of glucosamine may reduce the pain of OA and may have favorable effects on structural changes in the cartilage. This article presents a systematic review and meta-analysis of the effectiveness of orally consumed glucosamine sulfate (GS) on OA-related pain and joint structural changes. Methods: PubMed and Ovid Embase were searched using specific search terms to find randomized, double-blinded, placebo-controlled trials on the effects of GS on pain and/or joint-space narrowing. The outcome measure was the standardized mean difference (SMD), which was the improvement in the placebo groups minus the improvement in the GS groups divided by the pooled standard deviation. Results: There were 17 studies meeting the review criteria for pain, and the summary SMD was -0.35, with a 95% confidence interval (95% CI) = -0.54 to -0.16 (negative SMD is in favor of GS). Of the 17 studies, 7 showed a statistically significant reduction in pain from GS use. Four studies met the review criteria for joint space narrowing with a summary SMD = -0.10 (95% CI = -0.23 to +0.04). Studies without involvement of the commercial glucosamine industry had a lower (but still significant) pain reduction efficacy (summary SMD = -0.19, 95% CI = -0.39 to -0.02) than those with industry involvement. Several smaller dosages throughout the day had larger pain reduction effects than a single daily large dose (1500 mg). Conclusion: These data indicate that GS may have a small to moderate effect in reducing OA-related pain but little effect on joint-space narrowing. Until there is more definitive evidence, healthcare providers should be cautious in recommending use of GS to their patients. Because GS dosages used in studies to date resulted in mild and transient adverse effects, and these were similar to that experienced by patients receiving placebos, larger GS doses possibly could be investigated in future studies.

Keywords: glucosamine sulfate; meta-analysis; osteoarthritis; dietary supplements

PMID: 30566740

DOI: AUC0-QM7H

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Efficacy of Commercial Chest Seal Adherence and Tension Pneumothorax Prevention: A Systematic Review of Quantitative Studies

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Paquette R, Quinene M, Blackbourne LH, Allen PB. 21(3). 78 - 85. (Journal Article)

Abstract

Background: Penetrating thoracic injuries account for an essential subset of battlefield and civilian injuries that result in death. Current recommendations are to use commercially available nonocclusive chest seals. We review current evidence for which chest seal(s) is likely to be the most effective in treating open pneumothoraces. Methods: A systematic review was conducted in accordance with the PRIMSA 2009 standard systematic review methodology, except where noted. The databases Pubmed, MEDLINE, CINAHL, Scopus, and gray sources were searched for all English-language, full-manuscript, experimental, quantitative studies of humans and animals concerning seal adherence or their efficacy at preventing tension pneumothoraces published between 1990 and 2020. A numerical analysis was used to provide the consensus recommendation. Results: Of 683 eligible identified articles [PubMed 528 (77.3%), Scopus 87 (12.7%), CINAHL 67 (9.8%), one (0.1%) unpublished], six (0.9%) articles were included. Synthesis of all studies' results suggests a consensus recommendation for the Hyfin Vent Chest Seal and Russell Chest Seal. These two were the most effective chest seals, as previously investigated in a quantifiable, experimental study. Conclusion: While chest seals are recommended in civilian and military prehospital medicine to improve patient survival, current evidence concerning the individual device's efficacy is limited. Further scientific, quantitative research is needed to clarify which commercially available chest seals are most effective and provide patients with penetrating chest trauma the best possible method for preventing or mitigating tension pneumothoraces.

Keywords: pneumothorax; chest seal; chest trauma; Tactical Combat Casualty Care; advanced trauma life support; systematic review

PMID: 34529810

DOI: FZ33-7RLL

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Efficacy of the Abdominal Aortic Junctional Tourniquet-Torso Plate in a Lethal Model of Noncompressible Torso Hemorrhage

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Bonanno AM, Hoops HE, Graham T, Davis BL, McCully BH, Wilson LN, Madtson BM, Ross JD. 18(4). 106 - 110. (Journal Article)

Abstract

Background: The Abdominal Aortic Junctional Tourniquet, when modified with an off-label, prototype, accessory pressure distribution plate (AAJT-TP), has the potential to control noncompressible torso hemorrhage in prolonged field care. Methods: Using a lethal, noncompressible torso hemorrhage model, 24 male Yorkshire swine (81kg-96kg) were randomly assigned into two groups (control or AAJT-TP). Anesthetized animals were instrumented and an 80% laparoscopic, left-side liver lobe transection was performed. At 10 minutes, the AAJT-TP was applied and inflated to an intraabdominal pressure of 40mmHg. At 20 minutes after application, the AAJT-TP was deflated, but the windlass was left tightened. Animals were observed for a prehospital time of 60 minutes. Animals then underwent damage control surgery at 180 minutes, followed by an intensive care unit-phase of care for an additional 240 minutes. Survival was the primary end point. Results: Compared with Hextend, survival was not significantly different in the AAJT-TP group (ρ = .564), nor was blood loss (3.3L ± 0.5L and 3.0L ± 0.5L, respectively; p = .285). There was also no difference in all physiologic parameters between groups at the end of the study or end of the prehospital phase. Three of 12 AAJT-TP animals had an inferior vena cava thrombus. Conclusion: The AAJT-TP did not provide any survival benefit compared with Hextend alone in this model of noncompressible torso hemorrhage.

Keywords: noncompressable torso hemorrhage; junctional tourniquet; swine; Sus scrofa; hemorrhage control; trauma; prolonged field care

PMID: 30566733

DOI: RJX5-NB1M

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Efficacy of the Mnemonic Device "MARCH PAWS" as a Checklist for Pararescuemen During Tactical Field Care and Tactical Evacuation

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Kosequat J, Rush SC, Simonsen I, Gallo I, Scott A, Swats K, Gray CC, Mason B. 17(4). 80 - 84. (Journal Article)

Abstract

Background: The application of Tactical Combat Casualty Care (TCCC) represents evidence-based medicine to improve survival in combat. Over the past several years, US Air Force Pararescuemen (PJs) have expanded the mnemonic device "MARCH" to "MARCH PAWS" for use during tactical field care and tactical evacuation (TACEVAC). The mnemonic stands for massive bleeding, airway, respiration, circulation, head and hypothermia, pain, antibiotics, wounds, and splinting. We undertook this performance improvement project to determine the efficacy of this device as a treatment checklist. Methods: The mission reports of a 16-PJ combat rescue deployment to Operation Enduring Freedom (OEF) from January through June 2012 were reviewed. The triage category, mechanism of injury, injury, and treatments were noted. The treatments were then categorized to determine if they were included in MARCH PAWS. Results: The recorded data for missions involving 465 patients show that 45%, 48%, and 7%, were in category A, B, and C, respectively (urgent, priority, routine); 55% were battle injuries (BIs) and 45% were nonbattle injuries (NBIs). All treatments for BI were accounted for in MARCH PAWS. Only 9 patients' treatments with NBI were not in MARCH PAWS. Conclusion: This simple mnemonic device is a reliable checklist for PJs, corpsmen, and medics to perform TACEVAC during combat Operations, as well as care for noncombat trauma patients.

Keywords: Tactical Combat Casualty Care; survival; Pararescuemen; mnemonic; MARCH PAWS; tactical field care; tactical evacuation

PMID: 29256201

DOI: 4R92-ESFR

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Efficacy of Vancomycin Powder in Mitigating Infection of Open Penetrating Trauma Wounds on the Battlefield: An Evidence-Based Review

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TerBeek BR, Loos PE, Pekari TB, Tennent DJ. 22(1). 76 - 80. (Journal Article)

Abstract

Background: Open penetrating trauma wounds to the extremities remain the most common injuries encountered in combat and are frequently complicated by bacterial infections. These infections place a heavy burden on the Servicemember and the healthcare system as they often require multiple additional procedures and can frequently cause substantial debility. Previous studies have shown that vancomycin powder has demonstrated efficacy in decreasing infection risks in clean and contaminated orthopedic surgical wounds. Methods: This review evaluates the most prevalent organisms cultured post-trauma, the current Tactical Combat Casualty Care (TCCC) guidelines for antibiotic prophylaxis, and relevant research of vancomycin's prophylactic use. Results: Results from previous studies have shown a time-dependent reduction in bacterial load when vancomycin powder is introduced early post injury in traumatic orthopedic wounds. Furthermore, perioperative application affords a cost-effective method to prevent infection with minimal adverse effects. Discussion: The current TCCC guidelines advocate for the use of antibiotics at the point of injury. When vancomycin powder is used in synergy with these guidelines, it can contribute a timely and powerful antibiotic to prevent infection. Conclusion: The prophylactic use of vancomycin powder is a promising adjunctive agent to current Clinical Practice Guidelines (CPG), but it cannot be conclusively determined to be effective without further research into its application in traumatic combat wounds.

Keywords: vancomycin; trauma; combat; TCCC; prehospital; osteomyelitis; infection

PMID: 35278318

DOI: W02H-UKSI

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Embedded Fragment Removal and Wound Debridement in a Non-US Partner Force Soldier

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McLeroy RD, Spelman S, Jacobson E, Gurney J, Keenan S, Powell D, Riesberg JC, Pamplin JC. 16(4). 114 - 116. (Journal Article)

Abstract

Objective: Review application of telemedicine support for removal of fragment and wound management. Clinical Context: Special Forces Operational Detachment- Alpha deployed in Central Command area of responsibility operating out of a small aid station ("house" phase of prolonged field care) Organic expertise: 18D Special Operations Combat medic Closest Medical Support: Combined Joint Special Operations Task Force (CJSOTF) surgeon located in another country; thus, all consults were either via telephone or over Secret Internet Protocol Router e-mail. Earliest Evacuation: NA

Keywords: critical care; telemedicine; military personnel; emergency treatment; patient transfer; combat casualty care

PMID: 28088830

DOI: 85SB-A938

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Emergency Cricothyroidotomy in Tactical Combat Casualty Care

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Mabry RL, Frankfurt A, Kharod C, Butler FK. 15(3). 11 - 19. (Journal Article)

Keywords:

PMID: 26360349

DOI: KYGI-F0VF

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Emergency Department Patients Support the Use of Combat Medics in Their Clinical Care

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Schauer SG, Mabry RL, Varney SM, Howard JT. 15(2). 74 - 78. (Journal Article)

Abstract

Background: As US military combat operations draw down in Afghanistan, the military health system will shift focus to garrison- and hospital-based care. Maintaining combat medical skills while performing routine healthcare in military hospitals and clinics is a critical challenge for Combat medics. Current regulations allow for a wide latitude of Combat medic functions. The Surgeon General considers combat casualty care a top priority. Combat medics are expected to provide sophisticated care under the extreme circumstances of a hostile battlefield. Yet, in the relatively safe and highly supervised setting of contiguous US-based military hospitals, medics are rarely allowed to perform the procedures or administer medications they are expected to use in combat. This study sought to determine patients' opinions on the use of combat medics in their healthcare. Methods: Patients in hospital emergency department (EDs) were offered anonymous surveys. Examples of Combat medic skills were provided. Participants expressed agreement using the Likert scale (LS), with scores ranging from "strongly agree" (LS score, 1) to "strongly disagree" (LS score, 5). The study took place in the ED at Bayne-Jones Army Community Hospital, Fort Polk, Louisiana. Surveys were offered to adult patients when they checked into the ED or to adults with other patients. Results: A total of 280 surveys were completed and available for analysis. Subjects agreed that Combat medic skills are important for deployment (LS score, 1.4). Subjects agreed that Combat medics should be allowed to perform procedures (LS score, 1.6) and administer medications (LS score, 1.6). Subjects would allow Combat medics to perform procedures (LS score, 1.7) and administer medications (LS score, 1.7) to them or their families. Subjects agreed that Combat medic activities should be a core mission for military treatment facilities (MTFs) (LS score, 1.6). Conclusion: Patients support the use of Combat medics during clinical care. Patients agree that Combat medic use should be a core mission for MTFs. Further research is needed to optimize Combat medic integration into patient healthcare.

Keywords: medics, Combat; medics, Special Forces; patients, emergency department; surveys

PMID: 26125168

DOI: HI77-S19W

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Emergency Intraosseous Access: A useful, Lifesaving Device used in Afghanistan

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Pozza M, Lunardi F, Pflipsen M. 13(1). 25 - 27. (Journal Article)

Abstract

Intraosseous access is becoming a lifesaving procedure under emergency conditions in Afghanistan's battlefield. The EZ-IO system (Vidacare, San Antonio, TX, USA) was successfully used in five patients in whom there was difficulty finding a peripheral venous access. The EZIO is an indispensable medical device to be used on the battlefield and during the evacuation of the wounded in a moving vehicle or helicopter.

Keywords:

PMID: 23526318

DOI: TGSS-A2P8

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Emergency Lateral Canthotomy And Cantholysis: A Simple Procedure To Preserve Vision From Sight Threatening Orbital Hemorrhage

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Ballard SR, Enzenauer RW, O'Donnell T, Fleming JC, Risk G, Waite AN. 09(3). 26 - 32. (Journal Article)

Abstract

Retrobulbar hemorrhage is an uncommon, but potentially devastating complication associated with facial trauma. It can rapidly fill the orbit and cause an "orbital compartment syndrome" that subsequently cuts off perfusion to vital ocular structures, leading to permanent visual loss. Treatment must be initiated within a limited time in order to prevent these effects; however, specialty consultation is not always available in remote field environments. This article addresses the mechanism, diagnosis, and treatment of retrobulbar hemorrhage via lateral canthotomy and cantholysis, and recommends that 18D medical sergeants be properly trained to evaluate and perform this sight-saving procedure in emergent settings where upper echelons of care are not immediately available.

Keywords:

PMID: 19739474

DOI: 1CLD-XJUV

Emergency Medical Services Provider Self-Reported Occupational Safety

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Luk JH, Chang BF, Albus ML, Morgan SA, Szymanski TJ, Hamid OS, Keller L, Daher AF, Sheele JM. 21(4). 66 - 70. (Journal Article)

Abstract

Background: Emergency medical services (EMS) providers are at high risk for occupational violence, and some tactical EMS providers carry weapons. Methods: Anonymous surveys were administered to tactical and nontactical prehospital providers at 180 prehospital agencies in northeast Ohio between September 2018 and March 2019. Demographics were collected, and survey questions asked about workplace violence and comfort level with tactical EMS carrying weapons. Results: Of 432 respondents, 404 EMS providers (94%) reported a history of verbal or physical assault on scene, and 395 (91%) reported working in a setting with a direct active threat at least rarely. Of those reporting a history of assault on scene, 46.5% reported that it occurred at least sometimes. Higher rates of assault on scene were associated with being younger, white, or an emergency medical technician-paramedic, working in an urban environment, having more frequent direct active threats, and having more comfort with tactical EMS carrying firearms (p ≤ .03). Most respondents (306; 71%) reported that they were prepared to defend themselves from someone who originally called for help. Most (303; 70%) reported a comfort level of 8 or higher (from 1, not comfortable to 10, completely comfortable) with tactical EMS providers carrying weapons. Comfort with tactical EMS providers carrying weapons was associated with being white, not having a bachelor's degree, and feeling prepared to defend oneself from a patient (p ≤ .02). Conclusion: EMS providers in the survey report high rates of verbal and physical violence while on scene and are comfortable with tactical EMS providers carrying weapons.

Keywords: assault; emergency medical services; EMS; firearm; safety; Special Weapons and Tactics; SWAT; tactical EMS; weapon

PMID: 34969129

DOI: DO11-UDJU

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Emergency Tourniquet Effectiveness in Four Positions on the Proximal Thigh

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Kragh JF, Wallum TE, Aden JK, Dubick MA, Billings S. 14(1). 26 - 29. (Journal Article)

Abstract

Objective: The purpose of the present study is to determine the performance of tourniquet use by the placement of the tourniquet's windlass on the extremity in four positions-medial, lateral, anterior, and posterior-to inform tourniquet instructors and develop best tourniquet practices. Methods: A HapMed™ Leg Tourniquet Trainer was used as a manikin to test the effectiveness of an emergency tourniquet, the Special Operations Forces Tactical Tourniquet. Two users made 10 tests, each in four positions. Results: Effectiveness rates of tourniquet use were 100% in all four positions. The two tourniquet users were both right-hand dominant and used their right hand to turn the windlass. One user turned the windlass clockwise, and the other turned it counterclockwise. The association between time to stop bleeding and tourniquet position was statistically significant but associations between time to stop bleeding and the user, user-by-position, and windlass turn number were not statistically significant. The association between tourniquet position and pressure under the tourniquet was statistically significant, and the association between user and pressure under the tourniquet was statistically significant, but the user-by-position and windlass turn number were not statistically significant. The associations between tourniquet position and blood loss volume, user and blood loss volume, and user-by-position and blood loss volume were statistically significant. Conclusions: The present study found that tourniquet effectiveness rates were uniformly 100% irrespective of whether the windlass position was medial, lateral, anterior, or posterior. These excellent clinical and statistical results indicate that users may continue to place the tourniquets as they prefer upon the proximal thigh.

Keywords: first aid; resuscitation; damage control; hematoma; trauma; shock

PMID: 24604435

DOI: 5FEG-59MG

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Endovascular Resuscitation Techniques for Severe Hemorrhagic Shock and Traumatic Arrest in the Presurgical Setting

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True NA, Siler S, Manning JE. 13(2). 33 - 37. (Journal Article)

Abstract

Novel aortic catheter-based resuscitation interventions aimed at control of noncompressible torso hemorrhage and resuscitative perfusion are undergoing active research and development. These methods have been reported as resuscitative endovascular balloon occlusion of the aorta, selective aortic arch perfusion, and profound hypothermia (emergency preservation and resuscitation). These interventions are advanced options to treat noncompressible torso hemorrhage and hemorrhage-induced traumatic cardiac arrest in the presurgical environment. However, to achieve maximum potential benefit, such interventions need to be initiated as soon as possible. This means that these advanced interventions should be adapted for use in austere military treatment facilities and, when feasible, initiated at the point of injury. This report argues for the feasibility of advanced endovascular resuscitation interventions in the austere military theater.

Keywords: resuscitation; traumatic hemorrhage; noncompressible torso hemorrhage; traumatic cardiac arrest; technology; austere setting; hemorrhagic shock

PMID: 23817876

DOI: 88CR-K1RG

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Endovascular Resuscitation Techniques for Severe Hemorrhagic Shock and Traumatic Arrest in the Presurgical Setting

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Glassberg E, Nadler R, Dagan D. 13(3). 101 - 101. (Letter)

Keywords:

PMID: 24048999

DOI: OCAT-DPUA

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Energy Balance and Diet Quality During the US Marine Corps Forces Special Operations Command Individual Training Course

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Sepowitz JJ, Armstrong NJ, Pasiakos SM. 17(4). 109 - 113. (Journal Article)

Abstract

Methods: This study characterized the total daily energy expenditure (TDEE), energy intake (EI), body weight, and diet quality (using the Healthy Eating Index-2010 [HEI]) of 20 male US Marines participating in the 9-month US Marine Corps Forces Special Operations Command Individual Training Course (ITC). Results: TDEE was highest (ρ < .05) during Raider Spirit (RS; 6,376 ± 712kcal/d) compared with Survival, Evasion, Resistance, and Escape (SERE; 4,011 ± 475kcal/d) School, Close-Quarters Battle (CQB; 4,189 ± 476kcal/d), and Derna Bridge (DB; 3,754 ± 314kcal/d). Body mass was lost (ρ < .05) during SERE, RS, and DB because EI was less than TDEE (SERE, -3,665kcal/d ± 475kcal/d; RS, -3,966 ± 776kcal/d; and DB, -1,027 ± 740kcal/d; p < .05). However, body mass was restored before the start of each subsequent phase and was not different between the start (86.4 ± 9.8kg) and end of ITC (86.7 ± 9.0kg). HEI score declined during ITC (before, 65.6 ± 11.2 versus after, 60.9 ± 9.7; p < .05) because less greens or beans and more empty calories were consumed (ρ < .05). Dietary protein intake was lowest during RS (0.9 ± 0.4g/kg) compared with all other phases, and carbohydrate intake during RS (3.6 ± 1g/kg), CQB (3.6 ± 1.0g/kg), and DB (3.7 ± 1.0g/kg) was lower than during the academic phase of SERE (5.1 ± 1.0g/kg; p < .05). Conclusion: These data suggest that ITC students, on average, adequately restore body mass between intermittent periods of negative energy balance. Education regarding the importance of maintaining healthy eating patterns while in garrison, consuming more carbohydrate and protein, and better matching EI with TDEE during strenuous training exercises may be warranted.

Keywords: Special Operations Forces; protein; carbohydrate; fatigue, volitional; military dietary reference intakes; weight loss

PMID: 29256207

DOI: RKM3-KDFU

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Epidemiologic Evidence and Possible Mechanisms for the Association Between Cigarette Smoking and Injuries. Part 2: Is the Relationship Between Smoking and Injuries Causal?

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Knapik JJ, Bedno SA. 18(2). 117 - 122. (Journal Article)

Abstract

Part 1 of this series reviewed the epidemiologic evidence for the association between cigarette smoking and injuries and possible biological and psychosocial mechanisms to account for this relationship. In the present article, nine criteria are explored to determine if smoking is a direct cause of injuries (i.e., a causal relationship). There is substantial evidence that individuals who smoked in the past have a higher subsequent risk of injury. A recent meta-analysis found that smokers in the military were 1.31 times more likely to be injured than nonsmokers and Servicemembers with low, medium, and high levels of smoking had 1.27, 1.37, and 1.71 times, respectively, the risk of injury compared with nonsmokers. The association between smoking and injuries has been reported in at least 18 US military studies and in 14 civilian studies in seven countries. The biological plausibility of the association was discussed extensively in part 1 of this series. A possible alternative explanation with sufficient data was that smokers may be risk takers and it is the risk-taking behavior that increases injury risk (not smoking per se). Once an individual no longer smokes, a decrease in injury risk has been reported for at least bone health and wound healing. The effects of smoking do not appear to be specific to one type of injury, possibly because of the numerous compounds in tobacco smoke that could affect tissues and physiological processes, with evidence provided for bones, tendons, and healing processes. The association was consistent with other knowledge, with some evidence provided from other types of medical problems and trends in smoking and injury-related mortality. In summary, the association between smoking and injuries appears to meet many of the criteria for a causal relationship.

Keywords: smoking; mortality; injury; epidemiology

PMID: 29889968

DOI: MDBC-Z2E9

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Epidemiological Evidence and Possible Mechanisms for the Association Between Cigarette Smoking and Injuries (Part 1)

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Knapik JJ, Bedno SA. 18(1). 108 - 112. (Journal Article)

Abstract

Surveys indicated that 24% of military personnel are current cigarette smokers. Smoking is well known to increase the risk of cancers, cardiovascular and respiratory diseases, reproductive problems, and other medical maladies, but one of the little known effects of smoking is that on injuries. There is considerable evidence from a variety of sources that (1) smoking increases overall injury risk, (2) the greater the amount of smoking, the higher is the injury risk, and (3) smoking is an independent injury risk factor. Smoking not only affects the overall injury risk but also impairs healing processes following fractures (e.g., longer healing times, more nonunions, more complications), ligament injury (e.g., lower subjective function scores, greater joint laxity, lower subsequent physical activity, more infections), and wounding (e.g., delayed healing, more complications, less satisfying cosmetic results). Smoking may elicit effects on fractures through low bone mineral density (BMD), lower dietary intake of calcium and vitamin D, altered calcium metabolism, and effects on osteogenesis and sex hormones. Effects on wound healing may be mediated through altered neutrophils and monocytes functions resulting in reduced ability to fight infections and remove damaged tissue, reduced gene expression of cytokines important for tissue healing, and altered fibroblast function leading to lower density and amount of new tissue formation. Limited data suggest smoking cessation has favorable effects on various aspects of bone health over periods of 1 to 30 years. Favorable effects on neutrophil and monocyte functions may occur as early as 4 weeks, but fibroblast function and collagen metabolism (important for wound remodeling) appear to take considerably longer and may be dependent on the amount of prior smoking. Part 2 of this series will use this information to explore the possibility of a causal relationship between smoking and injuries.

Keywords: smoking; injury; cigarettes; tobacco

PMID: 29533444

DOI: Z90F-IPF2

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EpiNATO-2: Enhancing Situational Awareness and Overall Force Health Protection While Deployed in the Combined Joint NATO Environment: Describing the Identified 2016 Q Fever Outbreak in Kosovo Force (KFOR)

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Hoysal N, McCown ME, Fazekas L, Krabbe C. 19(1). 76 - 80. (Journal Article)

Abstract

EpiNATO-2 is the only interoperable health surveillance system that is defined in North Atlantic Treaty Organization (NATO) doctrine. It was first implemented in the Kosovo Force and European Union Training Mission Mali in 2013. EpiNATO-2 is mandated for use during all NATO operations. Its coverage has steadily increased and now includes all NATO Joint and Component Command Operations and several non-NATO operations. The system monitors morbidity predominately for Role 1 sites by using weekly reports from the medics and other medical providers. The reports for all sites in theater are sent to the Combined Joint Medical (CJMED), which consolidates and submits them to NATO Deployment Health Surveillance Capability (DHSC), the satellite branch of NATO Centre of Excellence for Military Medicine (MILMED COE), for analysis and feedback. Although EpiNATO-2 will likely have a number of overlaps with most nations' disease and nonbattle injury trackers, a distinguishing characteristic is that it has specific categories for classifying more clinical activity. Sustaining the quality of data collection is paramount and achieved through contemporaneous analysis and feedback that are disseminated via CJMED to all providers. This enhances situational awareness about evolving trends in health issues across the deployed force and is intended to provide information for action and medical decision-making and force health protection assurance at the local and theater levels. The awareness imparted by this article can add to the Special Operations Forces (SOF) medics' tool kit to ensure success for the SOF medic and SOF community while deployed or collaborating with NATO and NATO partner nation militaries at any level in theater.

Keywords: EpiNATO-2; NATO; force health protection; NATO MILMED COE; NATO DHSC; surveillance; Q fever; interoperability; international military collaboration; SOF

PMID: 30859532

DOI: EDX8-AQPZ

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Erythema Ab Igne

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Gregory JF, Beute TC. 13(4). 115 - 119. (Journal Article)

Abstract

Erythema ab igne is a reticulated, erythematous, hyperpigmented dermatosis resulting from chronic mild to moderate heat exposure. The authors present two cases of erythema ab igne, one from a hot water bottle to treat chronic low back pain and another from a heated automobile seat. They review other reported etiologies and highlight scenarios in which military medical providers may encounter erythema ab igne.

Keywords: erythema ab igne; thermal injury; heating blanket; heated seat; reticular dermatosis; hyperpigmentation

PMID: 24227571

DOI: 5AVH-NZHY

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Erythema Multiforme

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Sola CA, Beute TC. 14(3). 90 - 92. (Journal Article)

Abstract

An active duty male Soldier presents to your clinic with concerns of blister-like lesions on both hands and feet several weeks after receiving immunizations. He is diagnosed with erythema multiforme (EM), a hypersensitivity reaction that is typically self-resolving. This article reviews the etiologies, pathophysiology, course, diagnosis, and treatment of erythema multiforme.

Keywords: erythema multiforme; vaccines; smallpox; typhoid; anthrax

PMID: 25344713

DOI: BL7L-501P

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Erythema Nodosum

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Vigilante JA, Scribner J. 14(4). 122 - 123. (Journal Article)

Abstract

An active duty female Sailor reports to your clinic complaining of tender nodules to her legs beginning 1.5 weeks ago. She is diagnosed with erythema nodosum (EN), a painful disorder of the subcutaneous fat that is usually self-limited but may be a clue to an additional underlying medical diagnosis. This article reviews the pathophysiology, causes, course, diagnosis, and management of EN.

Keywords: subcutaneous nodules; erythema nodosum; panniculitis

PMID: 25399380

DOI: OH7B-T4DR

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Establishing TEMS Training Standards for Patrol Officers and Initial Responders

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Pennardt A. 15(1). 146 - 146. (Journal Article)

Keywords:

DOI: A462-R81X

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Estimation of Dog-Bite Risk and Related Morbidity Among Personnel Working With Military Dogs

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Schermann H, Eiges N, Sabag A, Kazum E, Albagli A, Salai M, Shlaifer A. 17(3). 51 - 54. (Journal Article)

Abstract

Background: Soldiers serving in the Israel Defense Force Military Working Dogs (MWD) Unit spend many hours taming dogs' special skills, taking them on combat missions, and performing various dogkeeping activities. During this intensive work with the aggressive military dogs, bites are common, and some of them result in permanent disability. However, this phenomenon has not been quantified or reported as an occupational hazard. Methods: This was a retrospective cohort study based on self-administered questionnaires. Information was collected about soldiers' baseline demographics, duration of the experience of working with dogs, total number of bites they had, circumstances of bite events, and complications and medical treatment of each bite. Bite risk was quantified by incidence, mean time to first bite, and a Cox proportional hazards model. Rates of complications and the medical burden of bites were compared between combat soldiers and noncombat dogkeepers. Bite locations were presented graphically. Results: Seventy-eight soldiers participated and reported on 139 bites. Mean time of working with dogs was 16 months (standard deviation, ±9.4 months). Overall bite incidence was 11 bites per 100 person-months; the mean time to first bite event was 6.3 months. The Cox proportional hazards model showed that none of baseline characteristics significantly increased bite hazard. About 90% of bites occurred during routine activities, and 3.3% occurred on combat missions. Only in 9% of bite events did soldiers observed the safety precautions code. Bite complications included fractures, need for intravenous antibiotic treatment and surgical repair, prominent scarring, diminished sensation, and stiffness of proximal joints. Bite complications were similar between combat soldiers and dogkeepers. Most bites (57%) were located on hands and arms. Conclusion: MWD bites are an occupational hazard resulting in significant medical burden. Hands and arms were most common bite locations. Observance of safety precautions may be the most appropriate first-line preventive intervention. Barrier protection of upper extremities may reduce bite severity and complication rates.

Keywords: canine; combat; bites, dog; dogs, military working; Israeli Army; dog keepers

PMID: 28910468

DOI: 2F8X-FNZF

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Ether Anesthesia in the Austere Environment: An Exposure and Education

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Morgans LB, Graham N. 18(2). 142 - 146. (Journal Article)

Abstract

Medical services in the austere and limited environment often require therapeutics and practices uncommon in modern times due to a lack of availability, affordability, or expertise in remote areas. In this setting, diethyl ether, or simply ether anesthesia, still serves a role today as an effective inhalation agent. An understanding of ether as an anesthetic not only illustrates the evolution in surgical anesthesia but also demonstrates ether's surviving function and durable use as a practical agent in developing nations. Although uncommon, it is not unseen, so a working knowledge should be understood if observation and advocacy for patients receiving this method of anesthesia are experienced.

Keywords: austere; primitive; anesthesia; ether; diethyl-ether; inhalation agents; drawover; unconventional medicine

PMID: 29889973

DOI: 3U1M-4OIB

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Evaluating Alternatives to Traditional Cotton Laparotomy Sponges for Blood Absorption in the Austere and Mobile Surgical Environment

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Sirkin MR, Cook P, Davis KG. 15(4). 54 - 58. (Journal Article)

Abstract

Background: The operative control of noncompressible hemorrhage is the single largest impact that could be addressed in reducing the mortality on the battlefield. Laprotomy pads, traditionally used for hemorrhage evacuation, are made of woven cotton, and, while effective, their use requires a substantial amount of space and adds weight. This poses no concern in traditional operating rooms but is a hindrance for mobile providers and providers in austere environments. We sought to compare different absorptive compunds to ascertain their utility as alternatives for traditional laparotomy pads. Methods: Samples of cotton laparotomy pads, pure rayon sheets, rayon-polypropylene composite sheets, and non-polyester composite "microfiber" sheets were weighed and submerged in heparinized whole bovine blood. After saturation, the favrics were weighed, wrung dry, reweighed, and resubmerged. This process was performed for a total of three sequential submersions. The saturated weights and dry weights of each fabric were used to calculate how much blood each fabric could absorb initially and after multiple repeated uses. The initial densities of the four fabrics was calculated and compared. Results: The initial submersions demonstrated that 1g each of cotton, rayon, rayon-polypropylene, and nylon-polyester were able to absorb 7.58g, 12.98g, 10.16g, and 9.73g of blood respectively. The second and third sequential trials, which were statistically similar, demonstrated that 1g of cotton, rayon, rayon-polypropolyene, and nylon-polyester were able to absorb 1.73g, 2.83g, 2.3g, and 2.3g of blood, respectively. The calculated densities of cotton, rayon, rayon-polypropylene, and nylon-polyester were 0.087g/cm³, .012g/cm³, 0.098g/cm³, and 0.093g/cm³, respectively. Conclusion: Per gram, rayon absorbed approximately 1.7 times more blood thancotton and three-quarters the amount of the storage space. Rayon also retained its superior absorption abilites on repeated uses, demonstrating the potential for re-use in remote and austere environments. Thus, rayon could serve as a viable alternative to traditional cotton laparotomy pads in the austere environments.

Keywords: hemorrhage; laparotomy; cotton; rayon; sponge; austere; surgery; packing; combat casualty care; absorption; density

PMID: 26630095

DOI: RQRS-X838

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Evaluation and Testing of Junctional Tourniquets by Special Operation Forces Personnel: A Comparison of the Combat Ready Clamp and the Junctional Emergency Treatment Tool

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Theodoridis CA, Kafka KE, Perez AM, Curlee JB, Yperman PC, Oppermann N, Holmstroem E, Niegsch DD, Mannino A, Ramundo N. 16(1). 44 - 50. (Journal Article)

Abstract

Background: Previous research has shown that external hemorrhage from proximal leg amputations and junctional sites represents 19.2% of potentially survivable lethal hemorrhage. A recent effort to address this problem has resulted in the development of various junctional tourniquets. This study assessed and compared two Tactical Combat Casualty Care Committee-approved junctional tourniquets, the Combat Ready Clamp (CRoC) and the Junctional Emergency Treatment Tool (JETT), to contribute to their future development and to better inform on the decisions for device selection by military units. Aims of the study also were to provide concrete feedback and suggestions on how to effectively apply the devices. Methods: Via a specific questionnaire, 75 international attendees of the International Special Training Centre Medical Branch Special Operations Forces Advanced Medical First Responder course evaluated the CRoC and the JETT on different parameters. Both devices were tested objectively through timed applications aimed at stopping unilateral lower-extremity distal pulse on 33 of these 75 students, verified by palpation by Medical Branch instructors. Subjective and objective data were examined for mutual correlation. Results: Users ranked the JETT higher than the CRoC on all parameters, including effectiveness on the battlefield (ρ < .001), ease of use (ρ < .039), speed of application (ρ < .001), and not slipping in use (ρ < .001), although the difference on other parameters such as effectiveness in hemorrhage control was not statistically significant. Considering all parameters together, the JETT was evaluated as a better device than the CRoC (ρ < .001). The application time measurement suggested that the JETT was applied faster (by approximately 15 seconds on average; p < .001). The fastest CRoC and JETT applications were 37 and 29 seconds, respectively. The JETT was not easier to use or more effective than the CRoC; there was a 9% failure rate of the JETT occluding a unilateral common femoral artery. The JETT's efficacy in occluding a unilateral common femoral artery can be compromised if the device's pelvic binder is not sufficiently tightened prior to threading the T-handled pad. The CRoC's application time can be drastically reduced if the device is kept assembled and firm pressure is immediately asserted upon placement on the intended location through the vertical arm, then threading the device. Both devices were applied safely; no adverse effects were reported during or after application. Conclusion: Even though the JETT might be preferred by military medical providers, the CRoC still has merits. As both devices proved to occlude the arterial flow in no less than 54 seconds on average, they could be used to supplement direct pressure and wound packing, the latter two still being considered the immediate actions for inguinal bleeding control. Considering that the CRoC and the JETT can be applied in as little as 37 and 29 seconds, respectively, users should be effectively trained and entirely proficient on either device to justify their election as the primary countermeasure to hemorrhage not amenable to regular tourniquets.

Keywords: hemorrhage, junctional; tourniquet, junctional; Combat Ready Clamp; Junctional Emergency Treatment Tool; Tactical Combat Casualty Care Committee; hemorrhage control

PMID: 27045493

DOI: U93V-TMCJ

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Evaluation and Treatment of Ocular Injuries and Vision-Threatening Conditions in Prolonged Field Care

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Reynolds ME, Hoover C, Riesberg JC, Mazzoli RA, Colyer M, Barnes S, Calvano CJ, Karesh JW, Murray CK, Butler FK, Keenan S, Shackelford S. 17(4). 115 - 126. (Journal Article)

Keywords: ocular injuries; vision-threatening conditions; prolonged field care; clinical practice guidelines

PMID: 29256209

DOI: J2J0-XVJQ

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Evaluation And Treatment Of Persistent Cognitive Dysfunction Following Mild Traumatic Brain Injury

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Cozzarelli TA. 10(1). 39 - 42. (Journal Article)

Abstract

The Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury (DCoE) and the Defense and Veterans Brain Injury Center (DVBIC) hosted a consensus conference to address persistent cognitive impairments following mild traumatic brain injury (mTBI) and the role of cognitive rehabilitation in this population. Fifty military and civilian subject matter experts developed clinical guidance for cognitive rehabilitation of Service members with cognitive symptoms persisting three or more months following injury. This article highlights the initial evaluation, comprehensive assessment and treatment recommendations contained within the guidance "Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury and Defense and Veterans Brain Injury Center Consensus Conference on Cognitive Rehabilitation for Mild Traumatic Brain Injury." The full clinical guidance is available at: (http://www.dcoe.health.mil/Resources.aspx).

Keywords:

PMID: 20306413

DOI: MLMK-TDEK

Evaluation for Testosterone Deficiency

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Grumbo R, Haight D. 15(3). 4 - 9. (Journal Article)

Abstract

There has been a recent increase in the number of Operators presenting to clinics for evaluation of possible low testosterone. In response, USASOC recently released an Androgen Deficiency Clinical Practice Guideline (CPG) to help guide providers through the initial evaluation and treatment of patients. The diagnosis of hypogonadism is based on consistent signs and symptoms of androgen deficiency and unequivocally low serum testosterone (below 300ng/dL). Testosterone levels can change for a variety of reasons and an adequate evaluation requires multiple laboratory tests over a period of time. If a diagnosis of hypogonadism is confirmed, differentiating between primary and secondary hypogonadism can help guide further care. Testosterone replacement therapy options are available, but careful monitoring for side-effects is required. Controversy still exists surrounding the safety of testosterone replacement therapy, and referral to endocrinology should strongly be considered before initiating treatment.

Keywords: testosterone; hypogonadism; Low T

PMID: 26360348

DOI: 6I4W-SPUY

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Evaluation of a Concept for a Military Expedition Performance Environment

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Berendsen RR, Vieyra B, Rietjens GJ, Beckers RT, van Hulst RA, Boumeester CE, Hoencamp R. 18(4). 75 - 81. (Journal Article)

Abstract

To evaluate four factors essential in the preparation of high-altitude expeditions and of the performance during these expeditions, the Manaslu 2016 Medical Team, as part of the medical team of the Royal Netherlands Marine Corps (RNLMC), developed the Military Expedition Performance Environment (MEPE) concept. The scope of this concept is intended to cover (1) selection of a team, (2) medical planning and support, (3) competencies in the field (team work and human factors), and (4) and chain of command.

Keywords:

PMID: 30566727

DOI: FTKS-NTHP

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Evaluation of a Removable Intraoral Soft Stabilization Splint for the Reduction of headaches and Nightmares in Military PTSD Patients: A Large Case Series

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Moeller DR. 13(1). 49 - 54. (Journal Article)

Abstract

This large case series reports the results of using a removable soft intraoral stabilization splint in the treatment of chronic headaches and chronic nightmares in 60 military post-traumatic stress disorder (PTSD) patients of the Vietnam, Desert Storm, Operation Iraqi Freedom, and Operation Enduring Freedom conflicts. Patient treatment criteria included meeting all of the following requirements: minimum of three headaches per week; minimum of three nightmares per week; minimum of three sleep interruptions per week; minimum of three intraoral or extraoral (craniofacial) trigger points; and previous PTSD diagnosis by the U.S. Army or Veterans Administration with duration of this disorder for a minimum of three years. Significant reduction (60%-90%) in headache and nightmare severity, intensity, and duration was obtained in 75% of the 44 patients who completed the three-month follow-up.

Keywords: PTSD; splint; headaches; nightmares; Sleep disruption

PMID: 23526322

DOI: JY7G-94LF

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Evaluation of Commercially Available Traction Splints for Battlefield Use

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Studer NM, Grubb SM, Horn GT, Danielson PD. 14(2). 46 - 55. (Journal Article)

Abstract

Background: Femoral fracture is a common battlefield injury with grave complications if not properly treated. Traction splinting has been proved to decrease morbidity and mortality in battlefield femur fractures. However, little standardization of equipment and training exists within the United States Armed Forces. Currently, four traction splints that have been awarded NATO Stock Numbers are in use: the CT-6 Leg Splint, the Kendrick Traction Device (KTD), the REEL Splint (RS), and the Slishman Traction Splint (STS). Objective: The purpose of this study was to determine the differences between the four commercially available traction devices sold to the U.S. Government. Methods: After standardized instruction, subjects were timed and evaluated in the application of each of the four listed splints. Participant confidence and preferences were assessed by using Likert-scaled surveys. Free response remarks were collected before and after timed application. Results: Subjects had significantly different application times on the four devices tested (analysis of variance [ANOVA], ρ < .01). Application time for the STS was faster than that for both the CT-6 (t-test, ρ < .0028) and the RS (ρ < .0001). Subjects also rated the STS highest in all post-testing subjective survey categories and reported significantly higher confidence that the STS would best treat a femoral fracture (ρ < .00229). Conclusions: The STS had the best objective performance during testing and the highest subjective evaluation by participants. Along with its ability to be used in the setting of associated lower extremity amputation or trauma, this splint is the most suitable for battlefield use of the three devices tested.

Keywords: combat medic; medical training; traction splinting; Tactical Combat Casualty Care; femoral

PMID: 24952040

DOI: 074X-GZAQ

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Evaluation of Commercially Available Traction Splints for Battlefield Use

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Lee RW. 14(4). 95 - 97. (Letter)

Keywords:

PMID: 25399375

DOI: 1P56-Z11P

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Evaluation of Commercially Available Traction Splints for Battlefield Use: Response

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Studer NM, Grubb SM, Horn GT, Danielson PD. 14(4). 98 - 98. (Letter)

Keywords:

PMID: 25399376

DOI: F2BF-70ZR

Evaluation of Contingency Telemedical Support to Improve Casualty Care at a Simulated Military Intermediate Resuscitation Facility: The EM-ANGEL Study

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Gerhardt RT, Berry J, Mabry RL, Flournoy L, Arnold RG, Hults C, Robinson JB, Thaxton RA, Cestero R, Heiner JD, Koller AR, Cox KM, Patterson JN, Dalton WR, McKeague AL, Gilbert G, Manemeit C, Adams BD. 14(1). 50 - 57. (Journal Article)

Abstract

Objective: We sought to determine whether Contingency Telemedical Support (CTS) improves the success rate and efficiency of primary care providers performing critical actions during simulated combat trauma resuscitation. Critical actions included advanced airway, chest decompression, extremity hemorrhage control, hypothermia prevention, antibiotics and analgesics, and hypotensive resuscitation, among others. Background: Recent studies report improved survival associated with skilled triage and treatment in the out-of-hospital/preoperative phase of combat casualty care. Historically, ground combat units are assigned primary care physicians and physician assistants as medical staff, due to resource limitations. Although they are recognized as optimal resuscitators, demand for military trauma surgeons and emergency physicians exceeds supply and is unlikely to improve in the near term. Methods: A prospective trial of telemedical mentoring during a casualty resuscitation encounter was studied using a high-fidelity patient simulator (HFPS). Subjects were randomized and formed into experimental (CTS) or control teams. CTS team leaders were equipped with a headset/microphone interface and telementored by a combat-experienced emergency physician or trauma surgeon. A standardized, scripted clinical scenario and HFPS were used with 14 critical actions. At completion, subjects were surveyed. Statistical approach included contingency table analysis, two-tailed t-test, and correlation coefficient. This study was reviewed and approved by our institutional review board (IRB). Results: Eighteen CTS teams and 16 control teams were studied. By intention-to-treat ITT analysis, 89% of CTS teams versus 56% of controls completed all life-threatening inventions (LSIs) (p < .01); 78% versus 19% completed all critical actions (p < .01); and 89% versus 56% established advanced airways within 8 minutes (p < .06). Average time to completion in minutes (95% confidence interval [CI] 95) was 12 minutes (10-14) for CTS versus 18 (16-20) for controls, with 75% of control teams not completing all critical actions. Conclusion: In this model, real-time telementoring of simulated trauma resuscitation was feasible and improved accuracy and efficiency of non-emergency-trained resuscitators. Clinical validation and replicated study of these findings for guiding remote damage control resuscitation are warranted.

Keywords: military medicine; war; emergency medical services; resuscitation; telemedicine; wounds and injuries

PMID: 24604439

DOI: G0D7-OBXG

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Evaluation of Models of Pneumatic Tourniquet in Simulated Out-of-Hospital Use

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Kragh JF, Aden JK, Dubick MA. 16(3). 21 - 29. (Journal Article)

Abstract

Background: Pneumatic field tourniquets have been recommended for Military medics to stop bleeding from limb wounds, but no comparison of commercially available pneumatic models of tourniquet has been reported. The purpose of this study is to provide laboratory data on the differential performance of models of pneumatic tourniquets to inform decision-making of potential field assessment by military users. Methods: Models included the Emergency and Military Tourniquet (EMT), Tactical Pneumatic Tourniquet 2-inch (TPT2), and Tactical Pneumatic Tourniquet 3-inch (TPT3). One user tested the three tourniquet models 30 times each on a manikin to collect data on effectiveness (yes-no bleeding control), pulse cessation, time to stop bleeding, total time of application, after time (after bleeding was stopped), pressure applied, blood loss volume, composite outcome (whether all individual outcomes were good or not), and pump count of the bulb used to inflate the tourniquet. Results: Neither tourniquet effectiveness nor pulse cessation (ρ = 1; likelihood ratio, 0 for both) differed among tourniquet models: all three models had 100% (30 of 30 tests) for both outcomes. The EMT had the best or tied for best performance in time to stop bleeding, total time, after time, pressure blood loss, composite outcome, and pump count. Conclusion: Each of the three models of pneumatic field tourniquet was 100% effective in stopping simulated bleeding. Among the three models, the EMT showed the best or tied for best performance in time to stop bleeding, blood loss, and composite outcomes. All models are suitable for future field assessment among military users.

Keywords: first aid; damage control; hemorrhage; shock; tourniquet; resuscitation

PMID: 27734438

DOI: EGF9-LBSQ

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Evaluation of NuStat®, a Novel Nonimpregnated Hemostatic Dressing, Compared With Combat Gauze™ in Severe Traumatic Porcine Hemorrhage Model

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Hillis GR, Yi CJ, Amrani DL, Akers TW, Schwartz RB, Wedmore I, McManus JG. 14(4). 41 - 47. (Journal Article)

Abstract

Background: Uncontrolled hemorrhage remains one of the most challenging problems facing emergency medical professionals and a leading cause of traumatic death in both battlefield and civilian environments. Survival is determined by the ability to rapidly control hemorrhage. Several commercially available topical adjunct agents have been shown to be effective in controlling hemorrhage, and one, Combat Gauze™ (CG), is used regularly on the battlefield and for civilian applications. However, recent literature reviews have concluded that no ideal topical agent exists for all injuries and scenarios. The authors compared a novel nonimpregnated dressing composed of cellulose and silica, NuStat® (NS), to CG in a lethal hemorrhagic groin injury. These dressings were selected for their commercial availability and design intended for control of massive hemorrhage. Methods: A complex penetrating femoral artery groin injury was made using a 5.5mm vascular punch followed by 45 seconds of uncontrolled hemorrhage in 15 swine. The hemostatic dressings were randomized using a random sequence generator and then assigned to the animals. Three minutes of manual pressure was applied with each agent after the free bleed. Hextend™ bolus (500mL) was subsequently rapidly infused using a standard pressure bag along with the addition of maintenance fluids to maintain blood pressure. Hemodynamic parameters were recorded every 10 minutes and additionally at critical time points defined in the protocol. Primary end points included immediate hemostasis upon release of manual pressure (T0), hemostasis at 60 minutes, and rebleeding during the 60-minute observation period. Results: NS was statistically superior to CG in a 5.5mm traumatic hemorrhage model at T0 for immediate hemostasis (ρ = .0475), duration of application time (ρ = .0093), use of resuscitative fluids (ρ = .0042) and additional blood loss after application (ρ = .0385). NS and CG were statistically equivalent for hemostasis at 60 minutes, rebleeding during the study, and the additional secondary metrics, although the trend indicated that in a larger sample size, NS could prove statistical superiority in selected categories. Conclusions: In this porcine model of uncontrolled hemorrhage, NS improved immediate hemorrhage control, stability, and use of fluid in a 60-minute severe porcine hemorrhage model. In this study, NS demonstrated equivalence to CG at achieving long-term hemostasis and the prevention of rebleed after application. NS was shown to be an efficacious choice for hemorrhage control in combat and civilian emergency medical service environments.

Keywords: EMS; hemostatic dressing; hemorrhage, uncontrolled; hemorrhage, severe; traumatic injuries; NuStat; NS; CG; silica; bamboo; cellulose; Combat Gauze™; kaolin

PMID: 25399367

DOI: NI9N-GYQ6

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Evaluation of the US Army Special Forces Tactical Human Optimization, Rapid Rehabilitation, and Reconditioning Program

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Grier T, Anderson MK, Depenbrock P, Eiserman R, Nindl BC, Jones BH. 18(2). 42 - 48. (Journal Article)

Abstract

Background: We sought to assess the rehabilitation process, training, performance, and injury rates among those participating and not participating in the Tactical Human Optimization, Rapid Rehabilitation, and Reconditioning (THOR3) program and determine injury risk factors. Methods: A survey inquiring about personal characteristics, injuries, physical performance, and THOR3 participation during the previous 12 months was administered to Army Special Operations Forces (SOF) Soldiers. Based on responses to physical training, Soldiers were categorized into three groups: a traditional physical training (TPT) group, a cross-training (CT) group, and a THOR3 group. To identify potential injury risk factors, risk ratios and 95% confidence intervals (95% CIs) were calculated. Backward- stepping multivariable logistic regression models were used to assess key factors associated with injury risk. Results: The survey was completed by 328 male Soldiers. Most of the Soldiers (62%) who scheduled an appointment with the physical therapist were seen within 1 day. Self-reported injury rates for the TPT, CT, and THOR3 groups were 70%, 52%, and 48%, respectively. When controlling for personal characteristics, unit training, and fitness, the TPT group had a marginally higher risk of being injured than the THOR3 group (odds ratio [OR], 2.72; 95% CI, 0.86-8.59; p = .09). Soldiers who did not perform any unit resistance training (ORnone/90-160 min, 3.62; 95% CI, 1.05-12.53; p = .04) or the greatest amount of resistance training (OR>160 min/90-160 min, 3.44; 95% CI, 1.64-7.20; p < .01) were more likely to experience an injury than the moderate-resistance training group. Conclusion: THOR3 appears to offer human performance optimization/injury prevention advantages over other SOF human performance programs.

Keywords: THOR3; physical fitness; physical training; musculoskeletal; athletic performance; injury

PMID: 29889954

DOI: ZMF1-LOAH

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Evaluation of Two Junctional Tourniquets Used on the Battlefield: Combat Ready Clamp® versus SAM® Junctional Tourniquet

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Meusnier J, Dewar C, Mavrovi E, Caremil F, Wey P, Martinez J. 16(3). 41 - 46. (Journal Article)

Abstract

Background: Junctional hemorrhage (i.e., between the trunk and limbs) are too proximal for a tourniquet and difficult to compress. These hemorrhages are responsible for 20% of preventable deaths by bleeding on the battlefield. The majority of these involve the groin area. Devices allowing a proximal compression for arterial axes have been recently developed. Objective: The purpose of this study was to compare the use of two junctional- tourniquet models, the Combat Ready Clamp (CRoC®) and the SAM® Junctional Tourniquet (SJT), in simulated out-of-hospital trauma care when tourniquets were ineffective to stop the arterial flow. Methods: During our clinical study, 84 healthy volunteers wearing battle dress performed a physical exercise to come approximate the operational context. The volunteers were randomly divided into two groups according to the device (the CRoC or SJT) used as supplement to a tourniquet self-applied to the root of the thigh. The primary study end point was the complete interruption of popliteal arterial flow, measured with Doppler auscultation. Time to effectiveness and subjective questionnaire data to evaluate the devices' application were also collected. Results: Junctional device effectiveness was almost 90% for both the CRoC and the SJT, and did not differ between them, either used with a tourniquet (ρ = .36) or alone (ρ = .71). The time to effectiveness of the SJT was significantly shorter than that of the CRoC (ρ = .029). Conclusion: The SJT and the CRoC were equally effective. The SJT was faster to apply and preferred by the users. Our study provides objective evidence to the French Tactical Casualty Care Committee for improving junctional hemorrhage treatment.

Keywords: junctional tourniquet; hemorrhage; groin; medical device; Combat Ready Clamp; SAM® Junctional Tourniquet

PMID: 27734441

DOI: 4GWF-K0AK

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Evaluation of XSTAT® and QuickClot® Combat Gauze® in a Swine Model of Lethal Junctional Hemorrhage in Coagulopathic Swine

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Cox JM, Rall JM. 17(3). 64 - 67. (Journal Article)

Abstract

Background: Hemorrhage is associated with most potentially survivable deaths on the battlefield. Effective and field-tested products are lacking to treat junctional and noncompressible injuries. XSTAT® is a newly developed, U.S. Food and Drug Administration-approved product designed to treat junctional hemorrhage. The Committee on Tactical Combat Casualty Care has recently approved the product for use as part of its treatment guidelines, but data are lacking to assess its efficacy in different wounding patterns and physiologic states. Methods: Dilutional coagulopathy was induced in 19 large (70-90kg), healthy, male swine by replacing 60% of each animal's estimated blood volume with room temperature Hextend ®. After dissection, isolation, and lidocaine incubation, uncontrolled hemorrhage was initiated by transection of both axillary artery and vein. Free bleeding was allowed to proceed for 30 seconds until intervention with either XSTAT or QuickClot® Combat Gauze® (CG) followed by standard backing. Primary outcomes were survival, hemostasis, and blood loss. Results: XSTAT-treated animals achieved hemostasis in less time and remained hemostatic longer than those treated with CG. Less blood was lost during the first 10 minutes after injury in the XSTAT group than the CG group. However, no differences in survival were observed between XSTAT-treated and CG-treated groups. All animals died before the end of the observation period except one in the XSTAT-treated group. Conclusion: XSTAT performed better than CG in this model of junctional hemorrhage in coagulopathic animals. Continued testing and evaluation of XSTAT should be performed to optimize application and determine appropriate indications for use.

Keywords: XStat™; trauma; hemorrhage; hemorrhage, junctional; combat casualty care

PMID: 28910471

DOI: RAYH-IZJP

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Evidence-based Diagnosis And Management Of Mtbi In Forward Deployed Settings: The Genesis Of The Usasoc Neurocognitive Testing And Post-injury Evaluation And Treatment Program

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Lutz RH, Kane S, Lay J. 10(1). 23 - 38. (Case Reports)

Abstract

A 28 year old 18-series Soldier was the driver in a vehicle which struck an improvised explosive device (IED). The vehicle was destroyed and the other occupant in the vehicle was killed instantly. The Soldier recalled hitting the roof of the vehicle a least once; however, he suffered no life-threatening injuries and was not initially evacuated to higher medical care. Immediately following the event the Soldier noticed a headache, mild dizziness, nausea, and short-term memory loss. Upon return to the forward operating base (FOB), he was evaluated by the forward surgical team physician who performed a military acute concussion exam (MACE). His score was 24 out of 30 and he was diagnosed with a mild concussion, his symptoms were treated with acetaminophen, and he was released. On day three, he participated in another combat patrol. During the operation he suffered from dizziness and headaches. He self-medicated with acetaminophen and meclizine transdermal for his symptoms. On this patrol, he was exposed to overpressure from explosions on two separate events. Each explosion was the equivalent of approximately 27 pounds of TNT (trinitrotoluene). Following this mission, he returned to his FOB and noticed increased dizziness, nausea, and memory loss. No other members of his team who were exposed to those two explosions reported any symptoms. He continued to self medicate with acetaminophen and meclizine transdermal. He did not seek follow-up medical care. Later that same day, he participated in a third mission as part of a quick reaction force which included a high altitude helicopter assault. He was not exposed to any additional blast or injuries. After returning from the third mission, the patient experienced significant fatigue. He went to sleep and later the same night experienced loss of consciousness after quickly standing from a lying position. Upon recovering consciousness, he experienced increased dizziness, nausea, and emesis. He was evaluated by the unit medical provider and evacuated to a Level III Theater Hospital. Over the next three days, his nausea and dizziness improved; however, he continued to have significant issues with short term memory loss, difficulty concentrating, short-term memory recall, and headaches. His MACE scores slowly improved to 27 out of 30 over several days. He was evacuated through Landstuhl Regional Medical Center to the United States for additional evaluation and treatment.

Keywords:

PMID: 20306412

DOI: D3ZT-JZAB

Exertional Heat Illness Resulting in Acute Liver Failure and Liver Transplantation

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Boni B, Amann C. 17(3). 15 - 17. (Case Reports)

Abstract

Heat illness remains a large medical burden for militaries around the world. Mitigating the incidence as well as the complications of heat illness must remain on the forefront of operational planning when operating in hot environments. We report the case of a 27-year-old male U.S. Marine who sustained a heat-related illness resulting in fulminant liver failure and permanent disability. The patient was transferred from the field to a civilian hospital. On hospital day 5, liver failure was identified. The patient was transferred to a transplant center, where he successfully received a liver transplant.

Keywords: heat-related illness; liver failure

PMID: 28910461

DOI: 4ON0-9QI5

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Exertional Heat Stroke: Clinical Significance and Practice Indications for Special Operations Medics and Providers

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Johnston J, Donham B. 12(2). 2 - 7. (Journal Article)

Abstract

Exertional heat stroke is an acute injury associated with high morbidity and mortality, and is commonly encountered within military and Special Operations environments. With appropriate planning, rapid diagnosis, and aggressive treatment significant mortality reduction can be obtained. Planning for both training and real world operations can decrease the patient's morbidity and mortality and increase the chances of successful handling of a patient with exertional heat stroke. The mainstay of treatment is rapid reduction of the core body temperature. This is paramount both at the field level of care as well as in a clinical setting. Diligent surveillance for commonly encountered complications includes anticipating electrolyte abnormalities, rhabdomyolysis, acute renal failure, and hepatic injuries. Treatment with dantrolene may be indicated in patients with continued hyperthermia despite aggressive traditional treatment.

Keywords:

PMID: 22707019

DOI: HPLG-8OC8

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Exertional Heat Stroke: Pathophysiology, Epidemiology, Diagnosis, Treatment, and Prevention

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Knapik JJ, Epstein Y. 19(2). 108 - 116. (Journal Article)

Abstract

Temperature increases due to climate changes and operations expected to be conducted in hot environments make heat-related injuries a major medical concern for the military. The most serious of heat-related injuries is exertional heat stroke (EHS). EHS generally occurs when health individual perform physical activity in hot environments and the balance between body heat production and heat dissipation is upset resulting in excessive body heat storage. Blood flow to the skin is increased to assist in dissipating heat while gut blood flow is considerably reduced, and this increases the permeability of the gastrointestinal mucosa. Toxic materials from gut bacteria leak through the gastrointestinal mucosa into the central circulation triggering an inflammatory response, disseminated intravascular coagulation (DIC), multiorgan failure, and vascular collapse. In addition, high heat directly damages cellular proteins resulting in cellular death. In the United States military, the overall incidence of clinically diagnosed heat stroke from 1998 to 2017 was (mean ± standard deviation) 2.7 ± 0.5 cases/10,000 Soldier-years and outpatient rates rose over this period. The cornerstone of EHS diagnosis is recognition of central nervous dysfunction (ataxia, loss of balance, convulsions, irrational behavior, unusual behavior, inappropriate comments, collapse, and loss of consciousness) and a body core temperature (obtained with a rectal thermometer) usually >40.5°C (105°F). The gold standard treatment is whole body cold water immersion. In the field where water immersion is not available it may be necessary to use ice packs or very cold, wet towels placed over as much of the body as possible before transportation of the victim to higher levels of medical care. The key to prevention of EHS and other heat-related injuries is proper heat acclimation, understanding work/rest cycles, proper hydration during activity, and assuring that physical activity is matched to the Soldiers' fitness levels. Also, certain dietary supplements (DSs) may have effects on energy expenditure, gastrointestinal function, and thermoregulation that should be considered and understood. In many cases over-motivation is a major risk factor. Commanders and trainers should be alert to any change in the Soldier's behavior. Proper attention to these factors should considerably reduce the incidence of EHS.

Keywords: temperature; hot environments; heat-related injuries; exertional heat stroke

PMID: 31201762

DOI: 5P2Q-1MBQ

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Exertional Rhabdomyolysis: Attrition Through Exercise, A Case Series and Review of the Literature

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Reese JM, Fisher SD, Robbins DP. 12(3). 52 - 56. (Journal Article)

Abstract

Rhabdomyolysis is a common syndrome that can range from asymptomatic to a severe life-threatening condition. It is the result of acute muscle fiber necrosis leading to cell lysis and subsequent transfer of those byproducts into the circulatory system. The most significant constituent of these byproducts is myoglobin, which has been known to cause renal failure in 10-50% of patients that develop rhabdomyolysis. In addition, the electrolytes contained within these cells are leached into the blood stream, which can lead to significant electrolyte abnormalities. The etiology of rhabdomyolysis is broad and includes inherited diseases, drugs, toxins, muscle compression or overexertion, infections, and more. This syndrome may carry a mortality rate ranging from 7-80%. We describe five patients assigned to various companies within 160th Special Operations Aviation Regiment (Airborne) that developed exertional rhabdomyolysis of the bilateral upper extremities between June 2011 and January 2012. In this case series we will describe the events leading up to the diagnosis, lack of risk factors or family history, diagnostic criteria, treatment, and future concerns related to the condition.

Keywords: rhabdomyolysis; acute renal failure; myoglobinuria; creatinine kinase; overexertion exercise

PMID: 23032321

DOI: 4XHJ-B7E8

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Exertional Rhabdomyolysis: Epidemiology, Diagnosis, Treatment, and Prevention

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Knapik JJ, O'Connor FG. 16(3). 65 - 71. (Journal Article)

Abstract

Exertional rhabdomyolysis (ER) is a medical condition whereby damage to skeletal muscle is induced by excessive physical activity in otherwise healthy individuals. The individual performs so much activity that he/ she presumably depletes local muscle energy stores and muscle cells are unable to maintain cellular integrity, resulting in cell damage and the release of cellular contents, with resultant secondary complications. In the military services, the incidence of ER appeared to increase in the period 2004 to 2015. Risk factors for ER include male sex, younger age, a prior heat injury, lower educational level, lower chronic physical activity, and activity in the warmer months of the year. Acute kidney injury is the most serious potential complication of ER and is thought to be due to a disproportionate amount of free myoglobin that causes renal vasoconstriction, nephrotoxic effects, and renal tubular obstructions. Patients typically present with a history of heavy and unaccustomed exercise with muscle pain, swelling, weakness, and decreased range of motion, largely localized to the muscle groups that were involved in the activity. Diagnostic criteria include the requisite clinical presentation with a serum creatine kinase level at least level 5 times higher than the upper limit of normal and/ or a urine dipstick positive for blood (due to the presence of myoglobin) but lacking red blood cells under microscopic urinalysis. Core treatment is largely supportive with aggressive fluid hydration. Although the great majority of individuals return to activity without consequence, patients should initially be stratified into high and low risk for recurrence, and those at high risk provided additional evaluation. Risk of ER in normal healthy individuals can be reduced by emphasizing graded, individual preconditioning before beginning a more strenuous exercise regimen after recommended work/rest and hydration schedules in hot weather, and discussing supplements and medications with knowledgeable medical personnel.

Keywords: exertional rhabdomyolysis; physical activity; kidney injury, acute; myoglobin, free

PMID: 27734446

DOI: 89YY-5BKC

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Expeditionary Mechanical Ventilation in Conjunction With Extracorporeal Life Support During Ground Transport

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Beely BM, Harea GT, Wendorff DS, Choi JH, Sieck K, Karaliou V, Cannon JW, Lantry JH, Cancio LC, Sams VG, Batchinsky AI. 22(1). 64 - 69. (Journal Article)

Abstract

Background: We assessed the use of an FDA-cleared transport ventilator with limited functions and settings during ground transport in a swine model of ground evacuation. We hypothesized that when used as an adjunct to extracorporeal life support (ECLS), the device would enable safe mobile ventilatory support during ground evacuation. Methods: Female Yorkshire swine (n = 11; mean, 52.4 ± 1.3 kg) were sedated and anesthetized and received mechanical ventilation (MV) with a standard intensive care unit (ICU) ventilator and were transitioned to the Simplified Automated Ventilator II (SAVe II; AutoMedx) during ground transport. MV served as an adjunct to ECLS in all animals. Ventilator performance was assessed in the uninjured state on day 1 and after bilateral pulmonary contusion on day 2. Data were collected pre- and post-transport on both days. Results: During 33 transports, the SAVe II provided similar ventilation support as the ICU ventilator. Mean total transport time was 38.8 ± 2.1 minutes. The peak inspiratory pressure (PIP) limit was the only variable to show consistent differences pre- and post-transport and between ventilators. No adverse events occurred. Conclusion: As an adjunctive supportive device during ground transport, the SAVe II performed adequately without failure or degradation in subject status. Further testing is warranted to elucidate the clinical limits of this device during standalone use.

Keywords: acute respiratory distress syndrome; trauma; extracorporeal life support; Mechanical Ventilation; expeditionary ground evacuation

PMID: 35278316

DOI: LI26-W9AR

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Expeditionary Resuscitation Surgical Team: The US Army's Initiative to Provide Damage Control Resuscitation and Surgery to Forces in Austere Settings

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D'Angelo M, Losch J, Smith B, Geslak M, Compton S, Wofford K, Seery JM, Morrison M, Wedmore I, Paimore J, Gross K, Cuenca PJ, Welder MD. 17(4). 76 - 79. (Journal Article)

Abstract

Improvements in surgical care on the battlefield have contributed to reduced morbidity and mortality in wounded Servicemembers. 1 Point-of-injury care and early surgical intervention, along with improved personal protective equipment, have produced the lowest casualty statistics in modern warfare, resulting in improved force strength, morale, and social acceptance of conflict. It is undeniable that point-of-care injury, followed by early resuscitation and damage control surgery, saves lives on the battlefield. The US Army's Expeditionary Resuscitation Surgical Team (ERST) is a highly mobile, interprofessional medical team that can perform damage control resuscitation and surgery in austere locations. Its configuration and capabilities vary; however, in general, a typical surgical element can perform one major surgery and one minor surgery without resupply. The critical care element can provide prolonged holding in garrison, but this diminishes in the austere setting with complex and acutely injured patients.

Keywords:

PMID: 29256200

DOI: ZTD6-Z3AA

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Experience in Treating Combat Burns in Afghanistan by Using Silver-Nylon Dressing

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Pozza M, Matthew P, Lunardi F. 14(1). 1 - 5. (Case Reports)

Abstract

Background: On the battlefield, insidious and devastating weapons like the improvised explosive device (IED) rapidly emit extreme heat (thousands of degrees), create a shock wave (overpressure) that can hurl bodies long distances (inducing secondary fall lesions), and deliver thousands of pieces of shrapnel over hundreds of meters. Materials and Methods: Very often, Soldiers injured by an IED blast are inside their vehicle. Subsequently, they are exposed to the thermal effects of the blast. Frequently, these patients have complex wounds that consist of extensive burn areas, bone fractures, and internal organ lesions. The use of silver-nylon burn wrap dressing is widely documented for its bactericidal properties. Silverlon® Burn Dressings is an elastic bandage made of nylon and plated with pure metallic silver. Results: In summer 2008, in a U.S. advanced Role 2 facility, two U.S. Soldiers with extensive second- and third-degree burn injuries were successfully treated with the use of Silverlon Burn Dressings and Silverlon® Burn Gloves. Conclusions: From this experience emerged the ease of use silver-nylon dressing in treating badly burned Soldiers on the battlefield.

Keywords: silver-nylon dressing; combat burns; emergency burn treatment

PMID: 24604431

DOI: 4HMG-7SO2

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Experience Of A US Air Force Surgical And Critical Care Team Deployed In Support Of Special Operations Command Africa

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Delmonaco BL, Baker A, Clay J, Kilburn J. 16(1). 103 - 108. (Journal Article)

Abstract

An eight-person team of conventional US Air Force (USAF) medical providers deployed to support US Special Operations Forces (SOF) in North and West Africa for the first time in November 2014. The predeployment training, operations while deployed, and lessons learned from the challenges of performing surgery and medical evacuations in the remote desert environment of Chad and Niger on the continent of Africa are described. The vast area of operations and far-forward posture of these teams requires cooperation between partner African nations, the French military, and SOF to make these medical teams effective providers of surgical and critical care in Africa. The continuous deployment of conventional USAF medical providers since 2014 in support of US Special Operations Command Africa is challenging and will benefit from more medical teams and effective air assets to provide casualty evacuation across the vast area of operations.

Keywords: US Special Operations Command North and West Africa; far-forward surgery; conventional US Air Force; Mobile Field Surgical Team; Niamey, Niger; N'Dhamena, Chad; CASEVAC; Boko Haram; al-Qaeda I the Islamic Maghreb; French Military

PMID: 27045506

DOI: MEUS-AR4J

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Experience With Prehospital Damage Control Capability in Modern Conflict: Results From Surgical Resuscitation Team Use

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DuBose JJ, Martens D, Frament C, Haque I, Telian S, Benson PJ. 17(4). 68 - 71. (Journal Article)

Abstract

Background: Early resuscitation and damage control surgery (DCS) are critical components of modern combat casualty care. Early and effective DCS capabilities can be delivered in a variety of settings through the use of a mobile surgical resuscitation team (SRT). Methods: Twelve years of after-action reports from SRTs were reviewed. Demographics, interventions, and outcomes were analyzed. Results: Data from 190 casualties (185 human, five canine) were reviewed. Among human casualties, 12 had no signs of life at intercept and did not survive. Of the remaining 173 human casualties, 96.0% were male and 90.8% sustained penetrating injuries. Interventions by the SRT included intravascular access (50.9%) and advanced airway establishment (29.5%). Resuscitation included whole blood (3.5%), packed red blood cells (20.8%), and thawed plasma (11.0%). Surgery was provided for 63 of the 173 human casualties (36.4%), including damage control laparotomy (23.8%) and arterial injury shunting or repair (19.0%). SRTs were effectively used to augment an existing medical treatment facility (70.5%), to facilitate casualty transport (13.3%), as an independent surgical entity at a forward ground structure (9.2%), and in mobile response directly to the point of injury (6.9%). Overall survival was 97.1%. Conclusion: An SRT provides a unique DCS capability that can be successfully used in a variety of flexible roles.

Keywords: resuscitation; damage control surgery; combat casualty care; mobile surgical resuscitation team

PMID: 29256198

DOI: 5XCX-TNCA

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Exploration Of Prehospital Vital Sign Trends For The Prediction Of Trauma Outcomes

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Chen L, Reisner AT, Gribok A, Reifman J. 10(3). 55 - 62. (Previously Published)

Reproduced with permission from Prehospital Emergency Care 2009, Vol. 13, No. 3, Pages 286294

Abstract

Objectives: We explored whether there are diagnostically useful temporal trends in prehospital vital signs of trauma patients. Methods: Vital signs were monitored during transport to a level I trauma center and electronically archived. Retrospectively, we identified reliable vital signs recorded from the 0- to 7-minute interval and from the 14 to 21-minute interval during transport, and, for each subject, we computed the temporal differences between the two intervals' vital signs, the intrasubject 95% data ranges, the values during the initial 2 minutes, and the 21-minute overall means. We tested for differences between subjects with major hemorrhage versus control subjects, and computed receiver operating characteristic (ROC) curves. We conducted sensitivity analyses, exploring alternative clinical outcomes, temporal windows, and methods of identifying reliable data. Results: Comparing major hemorrhage cases versus controls, there were no discriminatory differences in temporal vital sign trends. Hemorrhage cases had significantly wider intrasubject data ranges for systolic blood pressure (SBP), respiratory rate (RR), and shock index (SI) versus controls. All results were consistent in several sensitivity analyses. Conclusions: Our findings add to a growing body of evidence that prehospital vital sign trends over 21 minutes or less are unlikely to be diagnostically useful because of substantial nondirectional fluctuations in vital signs that would obscure any subtle, progressive temporal trends. SBP, RR, and SI values were significantly different for high-acuity patients, and had more variability. Taken together, these findings suggest that higher-acuity patients experience episodes of instability rather than gradual, steady decline. Measures that account for data variability, such as taking the average of multiple measurements, may improve the diagnostic utility of prehospital vital signs.

Keywords:

PMID: 21140982

DOI: 3QLX-JDTT

Explore the Space?

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Hampton K. 20(1). 145 - 145. (Journal Article)

Keywords:

PMID: 32203620

DOI: D1BV-DXA7

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Exploring Tourniquet Conversion in Simulation to Develop Concepts and Hypotheses

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Kragh JF, Le TD, Dubick MA. 21(3). 23 - 29. (Journal Article)

Abstract

Background: Compared with those of tourniquet application, tourniquet conversion concepts are underdeveloped. The purpose of this project was to develop tourniquet conversion concepts and generate hypotheses. Methods: One person performed 100 tests of tourniquet application and conversion. Testing varied by conversion types, materials, and assessments. Conversions were from improvised or Combat Application Tourniquets (C-A-T) to another C-A-T, a new site (with initial C-A-T only), a pneumatic Emergency and Military Tourniquet (EMT), or a pressure dressing (compression bandage or a roll gauze and an elastic wrap). Simulated limbs were created using plastic bottle-based manikins, pool noodle-based manikins, plastic pipes, glass bottles, a rain downspout, and a cardboard poster tube. Results: Tourniquet application, conversion, and total times averaged 105, 132, and 237 seconds, respectively. Improvised tourniquet time was longer than that of C-A-T (p ≤ .05, all three). By initial tourniquet site, the 2-3 inches site had longer conversion and total time (p ≤ .02, both) compared with highest site. By whether initial tourniquets placed were also used in conversion, total time was shorter if yes (p = .05). Conversion to a pressure dressing was longer in conversion and total time (p ≤ .02, both) compared with conversion to a tourniquet. One wrap was short; we switched to those longer to cover limbs better. Limb types varied for indentation. Conversion communications improved when we used abbreviations and symbols. Conclusions: This preliminary project simulated tourniquet conversion to develop clinical concepts and research hypotheses to build a better basis for later research.

Keywords: hemorrhage control and prevention; emergency; simulation; risk management; device removal; ischemia; reperfusion

PMID: 34529800

DOI: J859-5AWQ

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Expression of High Mobility Group Box 1 Protein in a Polytrauma Model During Ground Transport and Simulated High-Altitude Evacuation

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Choi JH, Roberts TR, Sieck K, Harea GT, Karaliou V, Wendorff DS, Beely BM, Cancio LC, Sams VG, Batchinsky AI. 20(1). 65 - 70. (Journal Article)

Abstract

Background: We investigated the expression of high mobility group box 1 (HMGB1) protein in a combat-relevant polytrauma/ acute respiratory distress syndrome (ARDS) model. We hypothesized that systemic HMGB1 expression is increased after injury and during aeromedical evacuation (AE) at altitude. Methods: Female Yorkshire swine (n =15) were anesthetized and cannulated with a 23Fr dual-lumen catheter. Venovenous extracorporeal life support (VV ECLS) was initiated via the right jugular vein and carried out with animals uninjured on day 1 and injured by bilateral pulmonary contusion on day 2. On both days, animals underwent transport and simulated AE. Systemic HMGB1 expression was measured in plasma by ELISA. Plasma-free Hb (pfHb) was measured with the use of spectrophotometric methods. Results: Plasma HMGB1 on day 1 was transiently higher at arrival to the AE chambers, increased significantly after injury, reaching highest values at 8,000 ft on day 2, after which levels decreased but remained elevated versus baseline at each time point. pfHb decreased on day 1 at 30,000 ft and significantly increased on day 2 at 8,000 ft and postflight. Conclusions: Systemic HMGB1 demonstrated sustained elevation after trauma and altitude transport and may provide a useful monitoring capability during en route care.

Keywords: acute respiratory distress syndrome; polytrauma; evacuation; altitude physiology; HMGB1

PMID: 32203609

DOI: XG1C-GUMN

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Extraglottic Airways in Tactical Combat Casualty Care: TCCC Guidelines Change 17-01 28 August 2017

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Otten EJ, Montgomery HR, Butler FK. 17(4). 19 - 28. (Journal Article)

Abstract

Extraglottic airway (EGA) devices have been used by both physicians and prehospital providers for several decades. The original TCCC Guidelines published in 1996 included a recommendation to use the laryngeal mask airway (LMA) as an option to assist in securing the airway in Tactical Evacuation (TACEVAC) phase of care. Since then, a variety of EGAs have been used in both combat casualty care and civilian trauma care. In 2012, the Committee on TCCC (CoTCCC) and the Defense Health Board (DHB) reaffirmed support for the use of supraglottic airway (SGA) devices in the TACEVAC phase of TCCC, but did not recommend a specific SGA based on the evidence available at that point in time. This paper will use the more inclusive term "extraglottic airway" instead of the term "supragottic airway" used in the DHB memo. Current evidence suggests that the i-gel® (Intersurgical Complete Respiratory Systems; http://www.intersurgical.com/info/igel) EGA performs as well or better than the other EGAs available and has other advantages in ease of training, size and weight, cost, safety, and simplicity of use. The gel-filled cuff in the i-gel both eliminates the need for cuff pressure monitoring during flight and reduces the risk of pressure-induced neuropraxia to cranial nerves in the oropharynx and hypopharynx as a complication of EGA use. The i-gel thus makes the medic's tasks simpler and frees him or her from the requirement to carry a cuff manometer as part of the medical kit. This latest change to the TCCC Guidelines as described below does the following things: (1) adds extraglottic airways (EGAs) as an option for airway management in Tactical Field Care; (2) recommends the i-gel as the preferred EGA in TCCC because its gel-filled cuff makes it simpler to use than EGAs with air-filled cuffs and also eliminates the need for monitoring of cuff pressure; (3) notes that should an EGA with an air-filled cuff be used, the pressure in the cuff must be monitored, especially during and after changes in altitude during casualty transport; (4) emphasizes COL Bob Mabry's often-made point that extraglottic airways will not be tolerated by a casualty unless he or she is deeply unconscious and notes that an NPA is a better option if there is doubt about whether or not the casualty will tolerate an EGA; (5) adds the use of suction as an adjunct to airway management when available and appropriate (i.e., when needed to remove blood and vomitus); (6) clarifies the wording regarding cervical spine stabilization to emphasize that it is not needed for casualties who have sustained only penetrating trauma (without blunt force trauma); (7) reinforces that surgical cricothyroidotomies should not be performed simply because a casualty is unconscious; (8) provides a reminder that, for casualties with facial trauma or facial burns with suspected inhalation injury, neither NPAs nor EGAs may be adequate for airway management, and a surgical cricothyroidotomy may be required; (9) adds that pulse oximetry monitoring is a useful adjunct to assess airway patency and that capnography should also be used in the TACEVAC phase of care; and (10) reinforces that a casualty's airway status may change over time and that he or she should be frequently reassessed.

Keywords: extraglottic airway; i-gel; TCCC; Tactical Combat Casualty Care; guidelines

PMID: 29256190

DOI: NQ9D-AT5X

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Extreme Conditioning Programs: Potential Benefits and Potential Risks

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Knapik JJ. 15(3). 108 - 113. (Journal Article)

Abstract

CrossFit, Insanity, Gym Jones, and P90X are examples of extreme conditioning programs (ECPs). ECPs typically involve high-volume and high-intensity physical activities with short rest periods between movements and use of multiple joint exercises. Data on changes in fitness with ECPs are limited to CrossFit investigations that demonstrated improvements in muscle strength, muscular endurance, aerobic fitness, and body composition. However, no study has directly compared Cross-Fit or other ECPs to other more traditional forms of aerobic and resistance training within the same investigation. These direct comparisons are needed to more adequately evaluate the effectiveness of ECPs. Until these studies emerge, the comparisons with available literature suggest that improvements in CrossFit, in terms of muscular endurance (push-ups, sit-ups), strength, and aerobic capacity, appear to be similar to those seen in more traditional training programs. Investigations of injuries in ECPs are limited to two observational studies that suggest that the overall injury rate is similar to that seen in other exercise programs. Several cases of rhabdomyolysis and cervical carotid artery dissections have been reported during CrossFit training. The symptoms, diagnosis, and treatment of these are reviewed here. Until more data on ECPs emerge, physical training should be aligned with US Army doctrine. If ECPs are included in exercise programs, trainers should (1) have appropriate training certifications, (2) inspect exercise equipment regularly to assure safety, (3) introduce ECPs to new participants, (4) ensure medical clearance of Soldiers with special health problems before participation in ECPs, (4) tailor ECPs to the individual Soldier, (5) adjust rest periods to optimize recovery and reduce fatigue, (6) monitor Soldiers for signs of overtraining, rhabdomyolysis, and other problems, and (7) coordinate exercise programs with other unit training activities to eliminate redundant activities and minimize the risk of overuse injuries.

Keywords: exercise; physical conditioning; extreme conditioning program; CrossFit

PMID: 26360365

DOI: 8J8E-2Q8D

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Facial Trauma Care in the Austere Environment

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Farber SJ, Kantar RS, Rodriguez ED. 18(3). 62 - 66. (Journal Article)

Abstract

As the United States continues to increase its use of Special Operations Forces worldwide, treatment of craniomaxillofacial (CMF) trauma must be adapted to meet the needs of the warfighter. The remoteness of Special Operations can result in potentially longer times until definitive treatment may be reached. A significant portion of Servicemembers incur injury to the CMF region (42%). Severe CMF trauma can result in substantial hemorrhage and airway compromise. These can be immediately life threatening and must be addressed expeditiously. Numerous devices and techniques for airway management have been made available to the forward provider. A thorough review of nonsurgical and surgical airway management of the patient with facial injury for the forward provider and providers at receiving facilities is provided in this article. Techniques to address flail segments of the facial skeleton are critical in minimizing airway compromise in these patients. There are many methods to control hemorrhage from the head and neck region. Hemorrhage control is critical to ensure survival in the austere environment and allow for transport to a definitive care facility. Associated injuries to the cervical spine, globe, skull base, carotid artery, and brain must be carefully evaluated and addressed in these patients. Management of vision- threatening orbital compartment syndrome is critical in patients with CMF injuries. Because the head and neck region remains relatively vulnerable in the warfighter, combat CMF trauma will continue to occur. Forward providers will benefit from a review of the acute treatment of CMF traumatic injury. Properly triaging and treating facial injuries is necessary to afford the best chance of survival for patients with a devastating combat CMF injury.

Keywords: craniomaxillofacial trauma; airway management; acute care; hemorrhage; ocular trauma

PMID: 30222839

DOI: ZZN2-AT3U

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Facing Adversity and Factors Affecting Resilience: A Qualitative Analysis of the Lived Experiences of Canadian Special Operations Forces

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Richer I, Frank C. 20(4). 60 - 67. (Journal Article)

Abstract

Special Operations Forces (SOF) personnel are required to withstand considerable physical and psychological hardship. Research examining resilience and mental health among SOF personnel is limited and has provided mixed results; in addition, minimal research has been undertaken on the subjective experiences of adversity and the process of resilience among SOF personnel. This unique qualitative study describes the lived experience of Canadian SOF personnel, the challenges they face, and the factors they believe impact their resilience. Seventy Canadian SOF personnel participated in in-depth, semistructured interviews. A thematic analysis of the interviews revealed that operational demands, paired with an organizational culture of performance, were important stressors for most participants, negatively affecting both themselves and their families. SOF organizations select members with resilient characteristics; however, the same characteristics that make these members resilient also lead to self-imposed pressure to perform and avoid taking time for proper recovery. Team members were reported to help such members process difficult or traumatic experiences and facilitate their seeking care. Findings provide insight into the adverse experiences that participants encountered while serving in an SOF organization and the intertwined individual, social, and organizational factors affecting their resilience. Results point to the importance of managing and mitigating the impact of high operational tempo and a culture of performance to protect the health and wellness of SOF personnel and their families

Keywords: Special Operations Forces members; mental health; coping; work-family conflicts; team cohesion; organizational and individual resilience factors

PMID: 33320314

DOI: 7SW9-B9Q8

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Far Forward Gaps in Hemorrhagic Shock and Prolonged Field Care: An Update of ALM Fluid Therapy for Field Use

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Dobson GP, Letson HL. 20(3). 128 - 134. (Journal Article)

Abstract

Future expeditionary missions are expected to occur in more remote austere environments where combat medics and casualties may have to wait up to 7 days before resupply or safe evacuation. Currently, there is no effective fluid therapy for hemorrhagic shock (HS) at the point-of-injury and continuum-of-care over this extended period. We have been developing a small-volume IV or IO ALM therapy for noncompressible HS and have shown in preclinical models that it extends survival to 3 days, reduces abdominal bleeding by 60%, blunts inflammation, corrects coagulopathy, preserves platelet function, and prevents immunodeficiency. The ALM-survival phenotype is associated with an upregulation of the master genes of metabolism and mitochrondrial biogenesis in heart and brain and a downregulation in the periphery. Future translational studies will investigate the timing and nature of the "switch" and extend survival to 7 days. We will also discuss some of the controversies of ALM resuscitation in pigs, present our Systems Hypothesis of Trauma (SHOT), and discuss future clinical safety trials before field use.

Keywords: hemorrhage; trauma; survival; genetics; metabolism; inflammation; military medicine; resuscitation

PMID: 32969018

DOI: 06VT-9IH4

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Far-Forward Blood Donation and Donor Performance

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Guillotte CA, Schilling BK. 21(2). 89 - 91. (Journal Article)

Abstract

Fresh whole blood transfusion is advantageous when operating far-forward for both its availability and its physiological advantages over component therapy. However, the far-forward environment may place high physical performance demands on the donor immediately after donation. The aim of this paper was to briefly review the current literature on the effects of whole blood donation on a male donor's immediate physical performance after a standard donation volume of one unit (~450mL). Studies demonstrate reductions in peak volume of oxygen (VO2peak) of ~4% to 15% and time to exhaustion (TTE) of ~10% to 19% in the first 24 to 48 hours after donation. Anaerobic or cognitive performance has not been shown to decrease, but data on these parameters are limited. Donor physical performance decrements after a standard 450mL donation are minimal and may be mitigated through proper exercise training because training status may positively affect many variables that blood donation temporarily attenuates.

Keywords: physical activity; exercise; whole blood transfusion

PMID: 34105129

DOI: XXWY-WH1K

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Fascioliasis and Fasciolopsiasis: Similar Names, Similar Diseases?

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Bowden L. 08(1). 58 - 67. (Journal Article)

Abstract

This article reviews plant-borne helminth infections caused by Fasciola hepatica/gigantica and Fasciolopsis buski. Besides having similar names, both infections are caused by trematodes (flatworms or flukes). As with nearly all helminth infections, eosinophilia may be present, there is usually a delayed clinical presentation, and diagnosis is made with the proper identification of parasite eggs in the stool or serological testing. However, fascioliasis and fasciolopsiasis have more similarities including: egg morphology, parasite development, the involvement of aquatic plants and snails in the lifecycle, and preventive measures. Despite these similarities there are some important differences including: geographical distribution, definitive hosts, clinical presentation, and treatment. The SOF medical professional will have a greater understanding and be able to more easily identify both of these infections by being able to compare and contrast the two. Though these are not the most common helminth infections, these diseases are prevalent and may be of particular importance to providers working in Southeast Asia or South America.

Keywords:

DOI:

Fast-Roping: Potential Consequences of Vibrations for Sensation and Regulation of Movement

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Goldmann J, Braunstein B, Sanno M, Kurzner S, Brüggemann G, Mester J. 14(2). 80 - 83. (Journal Article)

Abstract

Objectives: Short-term exposure (2-30 seconds) to segmental mechanical vibrations with frequencies between 20 and 80 Hz affects proprioception of the central nervous system and manual dexterity and strength of man. It could be supposed that during fast-roping, Soldiers are exposed to hand-arm vibrations caused by the geometry of the rope. After the maneuver, Soldiers are encouraged to operate with high precision (e.g., aiming and shooting) within a few seconds. For safety, disturbances of the sensory system should be strongly avoided. The purpose of the study was to determine the vibrations induced by different rope geometries during fast-roping. Methods: Eight men of the German Special Forces performed 10 fast-roping maneuvers with two different shaped ropes (slightly molded versus deeply molded). Vibration data and frequency spectrum for each trial were measured by using fast Fourier transformation. Results: The analysis of data showed that fast-roping with a slightly molded rope produced frequencies of up to 10 Hz, while the frequencies with a deeply molded rope accounted for 18 to 60 Hz. The ropes differed significantly (ρ < .001) in frequencies between 20 and 50 Hz. The exposure time of vibration lasted between 3 and 5 seconds. Conclusion: Considering the negative effects associated with vibrations, prudence is required when using deeply molded ropes due to the increased vibrations of about 20 Hz.

Keywords: fast-roping; vibrations; motion; rope; sensations; rappelling; abseiling; kinesthetic illusions; Special Operations Forces

PMID: 24952045

DOI: ZMM4-LQBN

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Faust's Gold: Inside the East German Doping Machine

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Farr WD. 16(1). 125 - 125. (Book Review)

Abstract

Ungerleider, Steven. Faust's Gold. Inside the East German Doping Machine.
New York, NY: St. Martin's Press, 2001. 249 pages. ISBN 0-312-26977-3.

Keywords:

DOI:

F-Cell World Drive 2011: Are Tactical Medicine Principles Applicable to a Civilian Scenario?

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Burkert MG, Kroencke A. 12(1). 62 - 70. (Journal Article)

Abstract

In 2011, a Mercedes Benz (MB) conducted the F-Cell World Drive tour around the globe in 125 days. While crossing Asia from SHANGHAI (CHINA) to HELSINKI (FINLAND) by car, en route medical care was provided by embedded emergency physicians. The designated route crossed four different countries, multiple climate zones, and challenging road conditions. There was only limited information provided about hospitals and emergency medical services within different hostnations in the planning phase, so we adopted tactical medical principles for mission planning and execution, as we were facing remote conditions and limitations to equipment, staffing, and patient transport.

Keywords:

PMID: 22427051

DOI: 1JSZ-1K1U

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Feasibility and Proposed Training Pathway for Austere Application of Resuscitative Balloon Occlusion of the Aorta

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Ross EM, Redman TT. 18(1). 37 - 43. (Case Reports)

Abstract

Background: Noncompressible junctional and truncal hemorrhage remains a significant cause of combat casualty death. Resuscitative endovascular balloon occlusion of the aorta (REBOA) is an effective treatment for many junctional and noncompressible hemorrhages. The current hospital standard for time of placement of REBOA is approximately 6 minutes. This study examined the training process and the ability of nonsurgical physicians to apply REBOA therapy in an austere field environment. Methods: This was a skill acquisition and feasibility study. The participants for this experiment were two board-certified military emergency medicine physicians with no prior endovascular surgery exposure. Both providers attended two nationally recognized REBOA courses for training. A perfused cadaver model was developed for the study. Each provider then performed REBOA during different phases of prehospital care. Time points were recorded for each procedure. Results: There were 28 REBOA catheter placement attempts in 14 perfused cadaver models in the nonhospital setting: eight placements in a field setting, eight placements in a static ambulance, four placements in a moving ambulance, and eight placements inflight on a UH-60 aircraft. No statistically significant differences with regard to balloon inflation time were found between the two providers, the side where the catheter was placed, or individual cadaver models. Successful placement was accomplished in 85.7% of the models. Percutaneous access was successful 53.6% of the time. The overall average time for REBOA placement was 543 seconds (i.e., approximately 9 minutes; median, 439 seconds; 95% confidence interval [CI], 429-657) and the average placement time for percutaneous catheters was 376 seconds (i.e., 6.3 minutes; 95% CI, 311-44 seconds) versus those requiring vascular cutdown (821 seconds; 95% CI, 655-986). Importantly, the time from the decision to convert to open cutdown until REBOA placement was 455 seconds (95% CI, 285-625). Conclusion: This study demonstrated that, with proper training, nonsurgical providers can properly place REBOA catheters in austere prehospital settings at speeds

Keywords: austere environments; noncompressable hemorrhage; resuscitative endovascular balloon occlusion of the aorta; battlefield REBOA; combat resuscitation team; prehospital REBOA; damage control resuscitation; helicopter REBOA; en route care REBOA

PMID: 29533432

DOI: QB5T-9JAQ

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Feasibility of Obtaining Intraosseous and Intravenous Access Using Night Vision Goggle Focusing Adaptors

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Iteen A, Koch EJ, Wojahn A, Gutierrez R, Hildreth A, Rudinsky S, Deaton TG, Zarow GJ. 22(1). 56 - 63. (Journal Article)

Abstract

Background: The optimal tactical lighting for performing medical procedures under low-light conditions is unclear. Methods: United States Navy medical personnel (N = 23) performed intravenous (IV) and intraosseous (IO) procedures on mannequins using a tactical headlamp, night vision goggles (NVGs), and night vision goggles with focusing adaptors (NVG+A) utilizing a randomized within-subjects design. Procedure success, time to completion, and user preferences were analyzed using analysis of variance (ANOVA) and nonparametric statistics at p < .05. Results: IV success rates were significantly greater for the headlamp (74%) than for NVG (35%; p < .03) and somewhat greater than for NVG+A (52%; p = .18). IO success rates were high under each lighting condition (96% to 100%). Time to completion was significantly faster using headlamp (IV, 106 ± 28 s; IO, 47 ± 11 s) than NVG (IV, 168 ± 80 s; IO, 56 ± 17 s) or NVG-A (IV, 157 ± 52 s; IO, 59 ± 27 s; each p < .01). Posttesting confidence on a 1-to-5 scale was somewhat higher for NVG+A (IV, 2.9 ± 0.2; IO, 4.2 ± 0.2) than for NVG (IV, 2.6 ± 0.2; IO, 4.0 ± 0.2). Participants cited concerns with NVG+A depth perception and with adjusting the adaptors, and that the adaptors were not integrated into the NVG. Conclusion: While this mannequin study was limited by laboratory conditions and by the lack of practice opportunities, we found some small advantages of focusing adaptors over NVG alone but not over headlamp for IV and IO access in low-light conditions.

Keywords: low light; military medicine; Special Operations; intravenous access; intraosseous access; night vision goggles; focusing adaptors

PMID: 35278315

DOI: WE0Q-YOCA

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Feasibility Study of Vascular Access and REBOA Placement in Quick Response Team Firefighters

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Borger van der Burg BL, Vrancken SM, van Dongen TT, DuBose JJ, Bowyer MW, Hoencamp R. 20(1). 81 - 86. (Journal Article)

Abstract

Background: Early hemorrhage control using resuscitative endovascular balloon occlusion of the aorta (REBOA) can save lives. This study was designed to evaluate the ability to train Quick Response Team Fire Fighters (QRT-FF) to gain percutaneous femoral artery access and place a REBOA catheter in a model, using a comprehensive theoretical and practical training program. Methods: Six QRT-FF participated in the training. SOF medics from a previous training served as the control group. A formalized training curriculum included basic anatomy and endovascular materials for percutaneous access and REBOA placement. Key skills included (1) preparation of an endovascular toolkit, (2) achieving vascular access in the model, and (3) placement and positioning of REBOA. Results: QRT-FF had significantly better scores compared with medics using endovascular materials (P = .003) and performing the procedure without unnecessary attempts (P = .032). Basic surgical anatomy scores for QRT-FF were significantly better than SOF medics (P = .048). QRT-FF subjects demonstrated a significantly higher overall technical skills point score than medics (P = .030). QRT-FF had a median total time from start of the procedure to REBOA inflation of 3:23 minutes, and medics, 5:05 minutes. All six QRT-FF subjects improved their procedure times-as did four of the five medics. Conclusions: Our training program using a task training model can be utilized for percutaneous femoral access and REBOA placement training of QRT-FF without prior ultrasound or endovascular experience. Training the use of advanced bleeding control options such as REBOA, as a secondary occupational task, has the potential to improve outcomes for severely bleeding casualties in the field.

Keywords: vascular access; training; aortic balloon occlusion; firefighters; first responder

PMID: 32203611

DOI: T8SL-61MD

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Feasibility Study Vascular Access and REBOA Placement: From Zero to Hero

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Borger van der Burg BL, Maayen RC, van Dongen TT, Gerben C, Eric C, DuBose JJ, Horer TM, Bowyer MW, Hoencamp R. 18(4). 70 - 74. (Journal Article)

Abstract

Background: Vascular access is a necessary prerequisite for REBOA placement in patients with severe hemorrhagic shock. Methods: During an EVTM workshop, 10 Special Forces (SOF) medics, five combat nurses, four military nonsurgeon physicians, and four military surgeons participated in our training program. The military surgeons functioned as the control group. A formalized curriculum was constructed including basic anatomy and training in access materials for resuscitative endovascular balloon occlusion of the aorta (REBOA) placement. Key skills were (1) preparation of endovascular toolkit, (2) achieving vascular access in the model, and (3) bleeding control with REBOA. Results: The baseline knowledge of anatomy for SOF medics was significantly less than that for nurses and physicians. Medics had a median time of 3:59 minutes to sheath insertion; nurses, 2:47; physicians, 2:34; and surgeons, 1:39. Military surgeons were significantly faster than medics and military nurses (ρ = .037 resp. 0.034). Medics had a median total time from start to REBOA inflation of 5:05 minutes; nurses, 4:06; military physicians, 3:36; and surgeons, 2:36. Conclusion: This study showed that a comprehensive theoretical and practical training program using a task training model can be used for percutaneous femoral access and REBOA placement training of military medical personnel without prior ultrasound or endovascular experience. Higher levels of training reduce procedure times.

Keywords: vascular access; training; aortic balloon occlusion; military; prehospital

PMID: 30566726

DOI: G53H-UM93

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Feedback To The Field: An Assessment Of Sternal Intraosseous (io) Infusion

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Harcke HT, Crawley G, Ritter BA, Mazuchowski EL. 11(2). 23 - 26. (Journal Article)

Abstract

Intraosseous vascular infusion (IO) is a recognized alternative to peripheral intravenous infusion when access is inadequate. The sternum and proximal tibia are the preferred sites. A review of 98 cases at autopsy revealed successful sternal IO placement in 78 cases (80%). Assuming a worst case scenario for placement (pin mark and no tip in bone [17 cases] and tip present and not in the sternum [3 cases]), attempts were unsuccessful in 20 cases (20%). We draw no specific conclusions regarding sternal IO use, but hope that personnel placing these devices and those providing medical training can use the information.

Keywords:

PMID: 21455906

DOI: JFQH-D0AH

Female Genital Mutilation as a Concern for Special Operations and Tactical Emergency Medical Support Medics

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Wittich AC. 17(4). 14 - 17. (Journal Article)

Abstract

Female genital mutilation (FGM), frequently called female genital cutting or female circumcision, is the intentional disfigurement of the external genitalia in young girls and women for the purpose of reducing libido and ensuring premarital virginity. This traditional, nontherapeutic procedure to suppress libido and prevent sexual intercourse before marriage has been pervasive in Northern Africa, the Middle East, and the Arabian peninsula for over 2,500 years. FGM permanently destroys the genital anatomy while frequently causing multiple and serious complications. The International Federation of Gynecology and Obstetrics proposed a classification system of FGM according to the specific genital anatomy removed and the extensiveness of genital disfigurement. Although it has been ruled illegal in most countries, FGM continues to be performed worldwide. With African, Asian, and Middle Eastern immigration to the United States and Europe, western countries are experiencing FGM in regions where these immigrants have concentrated. As deployments of Special Operations Forces (SOF) increase to regions in which FGM is pervasive, and as African, Asian, and Middle Eastern immigration to the United States increases, SOF and Tactical Emergency Medical Support (TEMS) medics will necessarily be called upon to evaluate and treat complications resulting from FGM. The purpose of this article is to educate SOF/TEMS medical personnel about the history, geographic regions, classification of procedures, complications, and medical treatment of patients with FGM.

Keywords: female genital mutilation; FGM; female circumcision; external genetalia; International Federation of Gynecology and Obstetrics

PMID: 29256189

DOI: DUXI-Z1ID

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Female Special Forces Agents in World War II Europe: D-Day at 75

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Farr WD. 19(3). 128 - 129. (Book Review)

Abstract

Rose S. D-Day Girls. The Spies Who Armed the Resistance, Sabotaged the Nazis, and Helped Win World War II. New York: Crown; 2019. ISBN 978-0-451-49508-2. Loftis L. Code Name: Lise. The True Story of the Woman Who Became WWII's Most Highly Decorated Spy. New York: Gallery Books; 2019. ISBN 1-5011-9865-6. Purnell S. A Woman of No Importance. The Untold Story of the American Spy Who Helped Win World War II. New York: Viking Press; 2019. ISBN 978-0-7352-2529-9 Stevenson WS. Spymistress. The True Story of the Greatest Female Secret Agent of World War II. New York: Arcade Publishing; 2007. ISBN 978-1-61145-231-0. Stevenson WS. Spymistress. The True Story of the Greatest Female Secret Agent of World War II. New York: Arcade Publishing; 2007. ISBN 978-1-61145-231-0. Olson L. Madame Fourcade's Secret War. The Daring Young Woman Who Led France's Largest Spy Network Against Hitler. New York: Random House; 2019. ISBN 978-0-8129-9476-6.

Keywords:

PMID: 31201768

DOI: A1IQ-DHQO

Fentanyl For Pain Control In Special Operations

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Kacprowicz RF, Johnson TR, Mosely DS. 08(1). 48 - 53. (Journal Article)

Abstract

Opiate medications have been used for the control of severe pain due to combat trauma for hundreds of years. Morphine has long been the drug of choice for use on the battlefield, but it has several limitations which can make it difficult to use in modern warfare. Since its discovery in 1963, fentanyl has gradually emerged as one of the most effective alternatives to morphine. With fewer adverse effects and multiple routes of administration, fentanyl appears to be a very effective choice for the management of moderate to severe pain due to combat trauma. Available data support the use of fentanyl in Special Operations, but only after a thorough review of the pharmacology, adverse effects, dosing, and routes of administration.

Keywords:

DOI:

Fever and Thrombocytopenia in a Returning Soldier

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Downs JW, Biggane PJ. 15(4). 75 - 78. (Journal Article)

Abstract

A case of fever and thrombocytopenia in a 33-year-old Special Forces Soldier with recent deployment to the Philippines is discussed, as are differential diagnosis and initial medical management at an overseas, fixed US military medical treatment facility. The authors discuss lessons learned that are applicable for Special Operations Forces (SOF) medical providers and recommend a renewed and continued emphasis on tropical medicine and infectious disease training for SOF medical providers.

Keywords: dengue fever; military medicine; tropical medicine; fever of unknown origin

PMID: 26630099

DOI: XD7L-9CPL

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Fever of Unknown Origin in US Soldier: Telemedical Consultation Limitations in a Deployment to West Africa

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Auchincloss PJ, Nam JJ, Blyth D, Childs G, Kraft K, Robben PM, Pamplin JC. 19(2). 123 - 126. (Journal Article)

Abstract

Objective: Review the application of telemedicine support for managing a patient with possible sepsis, suspected malaria, and unusual musculoskeletal symptoms. Clinical Context: Regionally Aligned Forces (RAF) supporting US Army Africa/Southern European Task Force (USARAF/ SETAF) in the Africa Command area of responsibility. Care provided by a small Role I facility on the compound. Organic Medical Expertise: Five 68W combat medics (one is the patient); one SOCM trained 68W combat medic. No US provider present in country. Closest Medical Support: Organic battalion physician assistant (PA) located in the USA; USARAF PA located in Italy; French Role II located in bordering West African country; medical consultation sought via telephone, WhatsApp® (communication with French physician) or over unclassified, encrypted e-mail. Earliest Evacuation: Estimated at 12 to 24 hours with appropriate country clearances and approval to fly from three countries including French forces support approval.

Keywords: critical care; telemedicine; military medicine; emergency treatment; prolonged field care; combat casualty care; patient transfer

PMID: 31201766

DOI: F5NR-5RF8

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Field Diagnosis and Treatment of Ophthalmic Trauma

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Calvano CJ, Enzenauer RW. 12(2). 58 - 64. (Journal Article)

Abstract

Identification and management of injuries to the eyes and ocular adnexa is commonly encountered by frontline medical personnel. This brief review is intended for the Special Forces Medic of all branches and describes the clinical presentation of common ophthalmic and periocular trauma with appropriate management strategies. Prompt recognition of these wounds facilitates early treatment and optimized visual outcomes for affected Soldiers and civilians alike.

Keywords: trauma; eye; ophthalmology; vision; open globe

PMID: 22707026

DOI: E6RQ-120P

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Field Electronic Medical Records

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Cauchi T, Cameron O. 16(2). 69 - 70. (Journal Article)

Keywords:

PMID: 27450606

DOI: 5ZH7-0C4O

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Field Evaluation And Management Of Non-Battle Related Knee And Ankle Injuries By The Advanced Tactical Practitioner (ATP) In The Austere Environment - Part Two

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Hammesfahr R. 09(2). 2 - 12. (Journal Article)

Keywords:

PMID: 19813514

DOI: H5SR-UR3Q

Field Evaluation And Management Of Non-battle Related Knee And Ankle Injuries By The Advanced Tactical Practitioner In An Austere Environment: Part One

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Hammesfahr R. 09(1). 33 - 42. (Journal Article)

Keywords:

PMID: 19813347

DOI: 1KQI-LAVB

Field Evaluation And Management On Non-battle Related Knee And Ankle Injuries By The ATP In The Austere Environment

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Hammesfahr R. 09(3). 1 - 6. (Journal Article)

Keywords:

PMID: 19739470

DOI: I24T-JOTV

Field Sterilization in the Austere and Operational Environment A Literature Review of Recommendations

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Will JS, Alderman SM, Sawyer RC. 16(2). 36 - 43. (Journal Article)

Abstract

Special Operations Forces medical providers are often deployed far beyond traditional military supply chains, forcing them to rely on alternative methods for field sterilization of medical equipment. This literature review proposes several alternative methods for both sterilization and disinfection of medical instruments after use and cleaning of skin and wounds before procedures. This article reviews recommendations from sources like the United Nations, the World Health Organization, the Special Operations Forces Medical Handbook, and the Centers for Disease Control and Prevention.

Keywords: prolonged field care; field sanitation; instrument sterilization; expedtionary medicine

PMID: 27450601

DOI: XI2V-AMMG

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Filling in the Gaps of Predeployment Fleet Surgical Team Training Using a Team-Centered Approach

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Hoang TN, Kang J, LaPorta AJ, Makler VI, Chalut C. 13(4). 22 - 33. (Journal Article)

Abstract

Background: Teamwork and successful communication are essential parts of any medical specialty, especially in the trauma setting. U.S. Navy physicians developed a course for deploying fleet surgical teams to reinforce teamwork, communication, and baseline knowledge of trauma management. Method: The course combines 22 hours of classroom didactics along with 28 hours of hands-on simulation and cadaver-based laboratories to reinforce classroom concepts. It culminates in a 6-hour, multiwave exercise of multiple, critically injured victims of a mass casualty and uses the "Cut Suit" (Human Worn Partial Task Surgical Simulator; Strategic Operations), which enables performance of multiple realistic surgical procedures as encountered on real casualties. Participants are graded on time taken from initial patient encounter to disposition and the number of errors made. Pre- and post-training written examinations are also given. The course is graded based on participants' evaluation of the course. Results: The majority of the participants indicated that the course promoted teamwork, enhanced knowledge, and gave confidence. Only 51.72% of participants felt confident in dealing with trauma patients before the course, while 82.76% felt confident afterward (ρ = .01). Both the time spent on each patient and the number of errors made also decreased after course completion. Conclusion: The course was successful in improving teamwork, communication and base knowledge of all the team members.

Keywords: fleet surgincal team predeployment training course; fleet surgical team; Cut Suit; human worn partial task surgical simulator; trauma team training; educational gap in teamwork and communication; teamwork-centered training; military trauma training

PMID: 24227558

DOI: N8YV-J27P

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First Aid UCV (Green Cross) for Prehospital Medicine in Social Commotion Situations

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Chacon-Lozsan F, Davila F. 21(3). 126 - 133. (Journal Article)

Abstract

Venezuela is living in a delicate social and political crisis that has taken thousands of lives. Beginning in March 2017, a series of continuous and increasingly violent demonstrations has taken place, with a high number of civilian casualties. These demonstrations typically have been outside the range of action of the government prehospital services. In addition, the number of casualties frequently overwhelmed the abilities of the available rescue services. Out of the need for a first aid team that could operate in this violent scenario, First Aid UCV (Central University of Venezuela) was created. A large number of professionals with medical, rescue, and tactical medicine experience integrated this new team, modifying their training and practice to adapt to a scenario in which unarmed medical students and medical doctors performed extractions, provided first aid, and managed the transport of demonstration casualties, doing so even when team members were sometimes targeted by the government police and military forces. This method has had successful results in all 60 operations conducted to date, with a total of 5,000 casualties being extracted among civilians, the military, and the police force. Only one member of the team was injured during the operations, and no deaths were reported during the process.

Keywords: prehospital medicine; tactical medicine; Venezuela; social commotion

PMID: 34529820

DOI: DYV4-WR3G

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First Case Report of SAM® Junctional Tourniquet Use in Afghanistan to Control Inguinal Hemorrhage on the Battlefield

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Klotz JK, Leo M, Andersen BL, Nkodo AA, Garcia G, Wichern AM, Chambers MJ, Gonzalez ON, Pahle MU, Wagner JA, Robinson JB, Kragh JF. 14(2). 1 - 5. (Journal Article)

Abstract

Junctional hemorrhage, bleeding that occurs at the junction of the trunk and its appendages, is the most common preventable cause of death from compressible hemorrhage on the battlefield. As of January 2014, four types of junctional tourniquets have been developed and cleared by the U.S. Food and Drug Administration (FDA). Successful use of the Abdominal Aortic Tourniquet (AAT™) and Combat Ready Clamp (CRoC™) has already been reported. We report here the first known prehospital use of the SAM® Junctional Tourniquet (SJT) for a battlefield casualty with inguinal junctional hemorrhage.

Keywords: SAM® Junctional Tourniquet; junctional hemorrhage; prehospital care; hemorrhage control; wounds and injuries

PMID: 24952032

DOI: YFSE-V7WE

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Flank Pain

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Meriano T. 14(3). 98 - 101. (Journal Article)

Abstract

The series objective is to review various clinical conditions/ presentations, including the latest evidence on management, and to dispel common myths. In the process, core knowledge and management principles are enhanced. A clinical case will be presented. Cases will be drawn from real life but phrased in a context that is applicable to the Special Operations Forces (SOF) or tactical emergency medical support (TEMS) environment. Details will be presented in such a way that the reader can follow along and identify how they would manage the case clinically depending on their experience and environment situation. Commentary will be provided by currently serving military medical technicians. The medics and author will draw on their SOF experience to communicate relevant clinical concepts pertinent to different operational environments including SOF and TEMS. Commentary and input from active special operations medical technicians will be part of the feature.

Keywords: flank pain; renal calculi; hydronephrosis

PMID: 25344716

DOI: KYUZ-MMCX

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Fluid Resuscitation for Hemorrhagic Shock in Tactical Combat Casualty Care: TCCC Guidelines Change 14-01 - 2 June 2014

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Butler FK, Holcomb JB, Schreiber MA, Kotwal RS, Jenkins DA, Champion HR, Bowling F, Cap AP, DuBose JJ, Dorlac WC, Dorlac GR, McSwain NE, Timby JW, Blackbourne LH, Stockinger Z, Strandenes G, Weiskopf RB, Gross K, Bailey JA. 14(3). 13 - 38. (Journal Article)

Abstract

This report reviews the recent literature on fluid resuscitation from hemorrhagic shock and considers the applicability of this evidence for use in resuscitation of combat casualties in the prehospital Tactical Combat Casualty Care (TCCC) environment. A number of changes to the TCCC Guidelines are incorporated: (1) dried plasma (DP) is added as an option when other blood components or whole blood are not available; (2) the wording is clarified to emphasize that Hextend is a less desirable option than whole blood, blood components, or DP and should be used only when these preferred options are not available; (3) the use of blood products in certain Tactical Field Care (TFC) settings where this option might be feasible (ships, mounted patrols) is discussed; (4) 1:1:1 damage control resuscitation (DCR) is preferred to 1:1 DCR when platelets are available as well as plasma and red cells; and (5) the 30-minute wait between increments of resuscitation fluid administered to achieve clinical improvement or target blood pressure (BP) has been eliminated. Also included is an order of precedence for resuscitation fluid options. Maintained as recommendations are an emphasis on hypotensive resuscitation in order to minimize (1) interference with the body's hemostatic response and (2) the risk of complications of overresuscitation. Hextend is retained as the preferred option over crystalloids when blood products are not available because of its smaller volume and the potential for long evacuations in the military setting.

Keywords: hemorrhage; fluid resuscitation; shock; plasma; blood products; damage control resuscitation

PMID: 25344706

DOI: DPOC-JWIY

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Fluid Resuscitation in Tactical Combat Casualty Care; TCCC Guidelines Change 21-01. 4 November 2021

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Deaton TG, Auten JD, Betzold R, Butler FK, Byrne T, Cap AP, Donham B, DuBose JJ, Fisher AD, Hancock J, Jourdain V, Knight RM, Littlejohn LF, Martin MJ, Toland K, Drew B. 21(4). 126 - 137. (Classical Conference)

Abstract

Hemorrhagic shock in combat trauma remains the greatest life threat to casualties with potentially survivable injuries. Advances in external hemorrhage control and the increasing use of damage control resuscitation have demonstrated significant success in decreasing mortality in combat casualties. Presently, an expanding body of literature suggests that fluid resuscitation strategies for casualties in hemorrhagic shock that include the prehospital use of cold-stored or fresh whole blood when available, or blood components when whole blood is not available, are superior to crystalloid and colloid fluids. On the basis of this recent evidence, the Committee on Tactical Combat Casualty Care (TCCC) has conducted a review of fluid resuscitation for the combat casualty who is in hemorrhagic shock and made the following new recommendations: (1) cold stored low-titer group O whole blood (CS-LTOWB) has been designated as the preferred resuscitation fluid, with fresh LTOWB identified as the first alternate if CS-LTOWB is not available; (2) crystalloids and Hextend are no longer recommended as fluid resuscitation options in hemorrhagic shock; (3) target systolic blood pressure (SBP) resuscitation goals have been redefined for casualties with and without traumatic brain injury (TBI) coexisting with their hemorrhagic shock; and (4) empiric prehospital calcium administration is now recommended whenever blood product resuscitation is required.

Keywords:

PMID: 34969143

DOI: JYLU-4OZ8

Force Health Protection In U.s. Army Special Operations Forces

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Forsyth L. 07(2). 51 - 54. (Journal Article)

Abstract

The ultimate goal of USASOC Force Health Protection programs is health sustainment of Army Special Operations Forces. Preventive medicine officers, environmental science officers, and preventive medicine Soldiers remain the cornerstone in providing health sustainment to ARSOF Soldiers. The lack of doctrine and understanding of preventive medicine core competencies may result in a degradation of unit medical readiness and individual health sustainment.

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DOI:

Force Health Protection Support Following a Natural Disaster: The 227th Medical Detachment's Role in Response to Superstorm Sandy

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Stanley SE, Faulkenberry JB. 14(4). 106 - 112. (Journal Article)

Abstract

On 3 November 2012, in the wake of Superstorm Sandy, the 227th Preventive Medicine Medical Detachment deployed to support relief operations in New Jersey and New York State. The unit was on the severe weather support mission (SWRF) and ordered to provide preventive medicine support to relief personnel within the affected area. In addition, teams from the 227th conducted environmental surveillance in the two-state region where Army Corps of Engineers were pumping floodwaters from affected neighborhoods. The 227th rapid deployment highlights