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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)

Abstract

-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)

Keywords:

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

Keywords:

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)

Keywords:

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.

Keywords:

PMID: 23032315

DOI: 76HZ-GKIO

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13 Hours: The Inside Account of What Really Happened in Benghazi

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Graverson SP. 22(4). 130 - 130. (Book Review)

Abstract

Zuckhoff M; With the Annex Security Team. 13 Hours: The Inside Account of What Really Happened in Benghazi. Twelve; 2015. 352 pp. ISBN: 9781455538447

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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.

Keywords:

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)

Keywords:

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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PMID: 36122558

DOI: FEFK-VMGL

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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3D-Printed Tourniquets Used at the Battlefront in Ukraine: A Pilot Study

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Melau J, Bergan-Skar P, Callender N, Rognhaug M, Bekkestad E. 23(4). 87 - 91. (Journal Article)

Abstract

Background: The war in Ukraine urged a need for prompt deliverance and resupply of tourniquets to the front. Producing tourniquets near the battlefront was a feasible option with respect to resupply and cost. Methods: A locally produced 3D-printed tourniquet (Ukrainian model) from the "Tech Against Tanks" charity was tested against commercially available and Committee of Tactical Combat Casualty Care (CoTCCC)-recommended tourniquets (C-A-T™ and SOF™TT-W). We tested how well the tourniquets could hold pressure for up to 2 hours. Results: A Kruskal-Wallis test revealed significant differences between the groups (p<.05). Post-hoc testing revealed a significant difference between the C-A-T and the Ukrainian tourniquet (p=.004). A similar significance was not found between the SOF™TT-W Wide and the Ukrainian model (p=.08). Discussion: The Ukrainian model can hold pressure as well as the commercially available tourniquets. There is much value if this can be produced close to the battlefield. Factors including logistics, cost, and self-sufficiency are important during wartime. Conclusion: We found that our sample of 3D-printed tourniquets, currently used in the war in Ukraine, could maintain pressure as well as the commercially available tourniquets. Indeed, our tests demonstrated that it could maintain a significantly higher pressure.

Keywords: tourniquet; hemorrhage; armed conflicts; 3D printing; battlefront resupply

PMID: 38133635

DOI: 7NII-VT7T

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5th Combat Medical Care Conference, 5 and 6 July 2023

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Lenard D, Josse F. 23(4). 112 - 121. (Clinical Conference)

Keywords: trauma; combat medicine; prolonged field care; tactical casualty care; Special Operations

PMID: 38133634

DOI: TYR7-1DLL

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 Brief Primer on the Concept of the Neuroweapon for U.S. Military Medical Personnel

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Washington M, Dinh DT, Ibarra C, Kua SC. 23(4). 70 - 74. (Journal Article)

Abstract

The malevolent application of neuroscience is an emerging threat to the U.S. military. At present, U.S. military medical personnel are not capable of adequately diagnosing or treating the injuries and illnesses that may result from exposure to potential neuroweapons. This fact was illustrated in 2016 when U.S. diplomats serving in Havana, Cuba reported hearing strange noises accompanied by a constellation of unexplained health effects. Similar incidents have been reported in China and Russia. Although various hypotheses have been put forward to explain these symptoms, none of them have been verified. The reported symptoms were analogous to the physiological responses that have been produced in the laboratory by exposing volunteers to pulsed microwave energy. However, these incidents of undetermined origin demonstrate that widespread neurological illness can be disruptive to U.S. government operations and that it is currently not possible to identify the cause, determine the correct treatment, or ascribe attribution to potential neuroweapon use in an overseas setting. Since it is likely that Special Operations medical personnel will be among the first to respond to neuroweapon attacks in the deployed environment, it is essential that they be made aware of this emerging threat and that efforts be made to incorporate potential directed energy neuroweapons and other neuroweapon configurations into future Chemical, Biological, Radiological, Nuclear, and high yield Explosives (CBRN-E) training modules. The intention of this article is to introduce the concept of the neuroweapon to military medical personnel and to provide a brief review of the relevant literature.

Keywords: neuroweapon; neuroscience; Havana syndrome; microwave weapon; neurological injury

PMID: 37976420

DOI: SX1S-ZO4J

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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.

Keywords:

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.

Keywords:

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)

Keywords:

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)

Keywords:

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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DOI:

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 Digital Research Methodology for Continuous Health Assessment of the Special Operations Warfighter: The Digital cORA Study

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Saxon L, Faulk RT, Barrett T, McLelland S, Boberg J. 22(4). 78 - 82. (Journal Article)

Abstract

The role of US Special Operations Forces (SOF) globally has expanded greatly in the past 20 years, leaving SOF serving multiple deployments with little time or ability to recover in between. Currently, assessments of the health and human performance capabilities of these individuals are episodic, precluding an accurate assessment of physical and mental load over time, and leading to high rates of acute and chronic injury to the mind and body. The collection of personal health-related continuous datasets has recently been made feasible with the advancement of digital technologies. These comprehensive data allow for improved assessment, and consequently better results, partly due to the warfighters' real-time access to their data. Such information allows Soldiers to engage in their own health optimization. This article describes a research platform that allows for collection of data via a custom-made secure mobile application that extends the type, scope, and frequency of data collection beyond what is feasible during an in-person encounter. By digitizing existing assessments and by incorporating additional physical, neurocognitive, psychological, and lifestyle assessments, the platform provides individuals with the ability to better understand their mental and physical load, as well as reserve. The results of this interactive exchange may help to preserve the health of users as well as the stability and readiness of units.

Keywords: mobile applications; military personnel; digital technology; data visualization; wearable electronic devices; health behavior; computer security

PMID: 36525017

DOI: 4SSJ-AHIB

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A Novel Scale to Assess Psychological Strategies in Explosive Ordnance Disposal Technicians

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Taylor M, Barczak-Scarboro NE, Hernandez L. 23(3). 44 - 49. (Journal Article)

Abstract

Purpose: This report describes the development and validation of the U.S. Navy Explosive Ordnance Disposal (EOD) Combat Mindset Scale-Training (CMS-T), a population-specific measure of psychological strategy use in EOD training environments. Methods: Scale items were developed by a working group composed of active-duty technicians from EOD Training and Evaluation Unit 1, Naval Health Research Center scientists, and a psychometrician. The working group developed 30 candidate items, which were administered to EOD accessions (new recruits), advanced students, and technicians (N = 164). Factor structure was explored with principal axis factoring and Varimax rotation with Kaiser normalization. Internal consistencies were established via Cronbach alpha, and convergent validity was evaluated with correlational and ANOVA models. Results: Five internally stable subscales were derived from 19 essential items, explaining 65% of total variance. The subscales were named relaxation, attentional-emotional control (AEC), goal setting-visualization (GSV), internal dialogue (ID), and automaticity. The most frequently used strategies were GSV and ID. Expected relationships emerged between strategies, most notably AEC and mental health. The scale also differentiated between subgroups. Conclusion: The EOD CMS-T demonstrates a stable factor structure, internal reliability, and convergent validity. This study yields a valid, practical, and easily administered instrument to support EOD training and evaluation.

Keywords: stress; military; psychological strategies; explosive ordnance disposal; Special Operations

PMID: 37224390

DOI: GWEL-MBF5

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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

PMID: 36122555

DOI: 9AQ9-XEXQ

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A Review of Medical Evacuations Related to Dental Emergencies and Oral-Maxillofacial Injuries

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Qureshi I, Simecek J, Mitchener TA. 23(2). 82 - 87. (Journal Article)

Abstract

A literature review was performed to determine the frequency of medical evacuations (MEDEVAC) that are required for dental emergencies (DE) and oral-maxillofacial (OMF) injuries. Fourteen studies were reviewed altogether - eight which quantified evacuation of DEs or OMF injuries in military personnel (from 1982-2013) and six studies that discussed medical evacuation of DEs occurring in civilians working in offshore oil and gas rigs and wilderness expeditions (from 1976-2015). Among military personnel, DE/OMF issues were frequently among one of the top categories of medical evacuations, ranging from 2-16% of all evacuations. Among oil and gas industry workers, 5.3-14.6% of evacuations were dental-related, while one study of wilderness expeditions found that DEs ranked as the third most frequent type of injury that required evacuation. Previous studies have shown that dental and OMF problems often account for one of most frequently cited reasons for evacuation. However, due to the limited study base of DE/OMF medical evacuations, further research is needed to determine their impact on the cost of health care delivery

Keywords: medical evacuation; MEDEVAC; military personnel; dental emergencies; oil and gas industry; emergencies; dental care; health care costs; stomatognathic diseases

PMID: 37071889

DOI: JSEQ-S0JT

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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 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 Systematic Review of Prehospital Combat Airway Management

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Smith S, Liu M, Ball I, Meunier B, Hilsden R. 23(1). 31 - 37. (Journal Article)

Abstract

Medical leadership must decide how prehospital airways will be managed in a combat environment, and airway skills can be complicated and difficult to learn. Evidence informed airway strategies are essential. A search was conducted in Medline and EMBASE databases for prehospital combat airway use. The primary data of interest was what type of airway was used. Other data reviewed included: who performed the intervention and the success rate of the intervention. The search strategy produced 2,624 results, of which 18 were included in the final analysis. Endotracheal intubation, cricothyroidotomy, supraglottic airways, and nasopharyngeal airways have all been used in the prehospital combat environment. This review summarizes the entirety of the available combat literature such that commanders may make an evidence-based informed decision with respect to their airway management policies.

Keywords: endotracheal intubation; airway; cricothyroidotomy; supraglottic airways; and nasopharyngeal airways

PMID: 36753714

DOI: S3MI-TFX5

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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

PMID: 36122559

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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DOI:

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)

Keywords:

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.

Keywords:

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.

Keywords:

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

Admission Forced Vital Capacity Adds a Predictive Physiologic Tool to Triage Patients Suffering Rib Fractures: A Prospective Observation Trial

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Johnston LR, Nam JJ, Nissen AP, Sleeter JJ, Aden JK, Mills AC, Sams VG. 23(1). 107 - 113. (Journal Article)

Abstract

Background: Patients with rib fractures are at high risk for morbidity and mortality. This study prospectively examines bedside percent predicted forced vital capacity (% pFVC) in predicting complications for patients suffering multiple rib fractures. The authors hypothesize that increased % pFVC is associated with reduced pulmonary complications. Methods: Adult patients with =3 rib fractures admitted to a level I trauma center, without cervical spinal cord injury or severe traumatic brain injury, were consecutively enrolled. FVC was measured at admission and % pFVC values were calculated for each patient. Patient were grouped by % pFVC <30% (low), 30-49% (moderate), and =50% (high). Results: A total of 79 patients were enrolled. Percent pFVC groups were similar except for pneumothorax being most frequent in the low group (47.8% vs. 13.9% and 20.0%, p = .028). Pulmonary complications were infrequent and did not differ between groups (8.7% vs. 5.6% vs. 0%, p = .198). Discussion: Increased % pFVC was associated with reduced hospital and intensive care unit (ICU) length of stay (LOS) and increased time to discharge to home. Percent pFVC should be used in addition to other factors to risk stratify patients with multiple rib fractures. Bedside spirometry is a simple tool that can help guide management in resource-limited settings, especially in large-scale combat operations. Conclusion: This study prospectively demonstrates that % pFVC at admission represents an objective physiologic assessment that can be used to identify patients likely to require an increased level of hospital care.

Keywords: chest trauma; rib fracture; forced vital capacity; pulmonary function test; risk stratification; prolonged casualty care; prolonged field care; bedside spirometry

PMID: 36878850

DOI: 4DSK-9D0E

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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.

Keywords:

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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After Action Report: Lessons Learned From Simulating Unified Command In Response to an Active Shooter Incident Using a Command Competency Laboratory

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Neal DJ, Loconti P, Mengel T, Holway K, Wenner D. 22(4). 60 - 64. (Journal Article)

Abstract

On October 10, 2019, the Loudoun County Sheriff's Office (LCSO) and Loudoun County Fire and Rescue (LCFR) led one of the largest act of violence (AVI) exercises ever conducted in Loudoun County, Virginia. Over 300 participants and 50 role-players participated across 15 county departments and agencies within Loudoun County. The exercise identified an important recommendation: "future joint unified command trainings are needed throughout the fire and law enforcement command structures." Effective, unified command is an essential NFPA 3000 principle of responding to an AVI. "The success or failure of the response will hinge on the quality of unified command." After-action reports from AVIs across the United States emphasized the importance of unified command. A second exercise recommendation proposed "a joint AVI unified command competency scenario between LCFR and LCSO should be developed and delivered across all levels of supervision... this scenario should demonstrate 'best practices' for establishing and operating unified command between LCFR and LCSO." The authors developed two active shooter command competency simulations that require LCSO and LCFR to form unified command and manage the initial response. The simulations reinforced accepted response practices, such as identification of cold/warm/hot zones, early unified command, rescue task force team deployment, and protected corridor establishment. The simulations were packaged into a unified command competency training and simulation program. Through the facilitated debriefings with participants and facilitator debriefs, three types of lessons learned were identified: 1) high threat incident response lessons, 2) lessons for conducting AVIs in the command competency lab, and 3) active threat operational considerations for command officers.

Keywords: active shooter training; Rescue Task Force; unified command; mass casualty; training

PMID: 36525014

DOI: VU55-6JG4

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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 and Hypothermia Prevention: and Treatment via STEAM The System for Thermogenic Emergency Airway Management

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Stevens R, Pierce B, Tilley L. 22(4). 72 - 76. (Journal Article)

Abstract

Military medicine has made significant advancements in decreasing mortality by addressing the lethal triad - metabolic acidosis, coagulopathy, and hypothermia. However, casualties are still succumbing to injury. Recent conflict zones have led to the development of remarkable life-saving innovations, including the management of compressible hemorrhage and whole blood transfusions. Nevertheless, hypothermia prevention and treatment techniques remain relatively unchanged. Hypothermia prevention is anticipated to become more critical in future operations due to a predicted increase in evacuation times and reliance on Prolonged Casualty Care (PCC). This is likely secondary to increasingly distanced battlespaces and the mobility challenges of operating in semi-/non-permissive environments. Innovation is essential to combat this threat via active airway rewarming in the vulnerable patient. Thus, we propose the development, fabrication, and efficacy testing of a device in which we estimate being able to control temperature and humidity at physiologic levels in the PCC setting and beyond.

Keywords: Advanced Trauma Life Support care; airway management; critical care; emergency medicine; intellectual property; military medicine; patent; prehospital emergency care; prolonged casualty care; prolonged field care; resuscitation; technological innovations; war-related trauma; wilderness medicine hypothermia

PMID: 36525016

DOI: V1FB-01LU

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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.

Keywords:

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.

Keywords:

PMID: 21455907

DOI: A0GI-NNIE

Altered Sympathoadrenal Activity Following Cold-Water Diving

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Kelly K, Pautz CM, Palombo LJ, Jensen AE, Melau J, Turcotte LP, Solberg PA. 23(3). 74 - 81. (Journal Article)

Abstract

Introduction: Little data exist on the effect of extremely cold-water diving on thermo-metabolic hormone secretion. Moreover, the impact of repetitive dives on the stress response is unknown. The purpose of this study was to determine the effects of two daily bouts of cold-water diving on the hormonal and metabolic profile of elite military personnel and to measure the stress response. Methods: Healthy, male, Norwegian Special Forces operators (n = 5) volunteered for this study. Physiological and hormone data were analyzed prior to and following twice-daily Arctic dives (3.3°C). Results: Core temperature was maintained (p > .05), whereas skin temperature was significantly reduced over the course of each dive (p < .01). Pairwise comparisons revealed adrenocorticotropic hormone (ACTH) and cortisol concentration significantly decreased across both dives and days (p < .001). Adrenaline and noradrenaline significantly increased across both time and day (p < .001). Leptin, testosterone, and IGF-1 significantly decreased over time but recovered between days. Conclusion: The main findings of this effort are that there is a rapid sympathetic-adreno-medullary (SAM/SNS) response to cold-water diving and a suppression of the hypothalamic-pituitary-adrenal (HPA) axis and hormones related to repair and recovery. While the sample size was too small to determine the role of SAM/SNS, HPA, and thyroid hormone effect on thermoregulation, it addresses a gap in our understanding of physiological adaptions that occurs in extreme environments.

Keywords: military diving; Arctic; acute stress response; testosterone; leptin

PMID: 37490424

DOI: T5CZ-JXVK

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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 Exploratory Comparison of Water-Tamped and -Untamped Explosive Breaches: Practical Applications for the Tactical Community via a Pilot Study

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Kamimori GH, McQuiggan W, Ramos AN, LaValle CR, Misistia A, Salib J, Egnoto MJ. 22(4). 56 - 59. (Journal Article)

Abstract

Background: Tamping explosive charges used by breachers is an increasingly common technique. The ability to increase the directional effectiveness of the charge used, combined with the potential to reduce experienced overpressure on breachers, makes tamping a desirable tool not only from an efficacy standpoint for breachers but also from a safety standpoint for operational personnel. The long-term consequences of blast exposure are an open question and may be associated with temporary performance deficits and negative health symptomatology. Purpose: This work evaluates breaches of varying charge weight, material breached, and tamping device used to determine the value of tamping during various scenarios by measuring actual breaches conducted during military and law enforcement training for efficacy and blast overpressure on Operators. Methods: Three data collections across 18 charges of various construction were evaluated with blast overpressure sensors at various distances and locations where breachers would be located, to assess explosive forces on human personnel engaged in breaching activities. Results and Conclusions: Findings indicate that water tamping in general is a benefit on moderate and heavy charges but offers less benefit at a low charge with regard to mitigating blast overpressure on breachers. Reduced overpressure allows Operators to stage closer to explosives and lowers the potential for compromised reaction time. It also reduces the likelihood of negative consequences that can result from excessive overpressure exposure and allow Operators to "do more with less" in complex environments, where resource access may be limited by logistic or other limitations. However, tamping in all instances improved blast efficacy in creating successful breaches. Future studies are planned to investigate tamping mediums beyond water and environment changes, whether tamping can be used to mitigate acoustic insult, and other explosive types.

Keywords: breachers; blast; overpressure; tamping; water tamp

PMID: 36525013

DOI: ZERU-CA39

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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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Antibiotic Usage in the Management of Wartime Casualties

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Anderson JL, Kronstedt S, Bergens MA, Johannigman J. 23(1). 103 - 106. (Journal Article)

Keywords: Lest We Forget; combat casualty care; war wound therapy; antibiotic therapy; wound care

PMID: 36878852

DOI: L1WJ-8DQS

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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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Approach to Handling Atypical Field Blood Transfusion Scenarios

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Neading R, Scarborough T, O'Connell M, Leasiolagi J, Little M, Burgess J, Hargrove M, Goodfellow A, Scheiber C, Cap AP, Yazer MH. 23(1). 74 - 79. (Journal Article)

Abstract

Special Operations Forces (SOF) medical personnel have been at the forefront of administering blood products in the austere field medicine environment. These far-forward medical providers regularly treat patients and deliver blood transfusions in some of the world's most extreme environments with minimal resources. A multitude of questions have been raised on this topic based on the unique experiences of senior providers in this field. In this paper, we analyze the available literature and present the recommendations of several experts in transfusion medicine for managing atypical field transfusion scenarios.

Keywords: low titer O whole blood; field medicine; transfusion reactions; blood products

PMID: 36764289

DOI: KGHH-TT81

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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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Artificial Blood Development Implications for Military Medicine

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Melanson V, Hershfield J, Deegan MK, Cho H, Perinon D, Bateman SL, Barnhill JC. 23(3). 63 - 69. (Journal Article)

Abstract

Massive hemorrhaging remains the most common cause of preventable battlefield deaths. Blood used for trauma care requires a robust donation network, capacity for long-term storage, and extensive and accurate testing. Bioengineering technologies could offer a remedy to these constraints in the form of blood substitutes-fluids that could be transfused into patients to provide oxygen, carry away waste, and aid in coagulation-that would be used in prolonged casualty care and in far-forward settings, overcoming the obstacles of distance and time. The different molecular properties of red blood cells (RBCs), blood substitutes, and platelet replacements contribute to their respective utilities, and each type is currently represented in ongoing clinical trials. Hemoglobin oxygen carriers (HBOCs) are the most advanced RBC replacements, many of which are currently being evaluated in clinical trials in the United States and other countries. Despite recent advancements, challenges remaining in the development of blood alternatives include stability, oxygen capacity, and compatibility. The continued research and investment in new technologies has the potential to significantly benefit the treatment of life-threatening emergency injuries, both on the battlefield and in the civilian sector. In this review, we discuss military blood-management practices and military-specific uses of individual blood components, as well as describe and analyze several artificial blood products that could be options for future battlefield use.

Keywords: artificial blood; blood substitutes; red blood cell substitutes; platelet replacements; biomanufacturing

PMID: 37253155

DOI: OVOP-V2QC

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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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Association of Body Mass Index with Injuries: A Systematic Review and Meta-Analyses Comparing Healthy Weight Military Service Members with Underweight, Overweight, and Obese

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Knapik JJ, Hoedebecke SS. 23(1). 96 - 102. (Journal Article)

Abstract

Obesity is a worldwide health problem that has reached pandemic proportions. In the military, obesity and overweight are associated with health problems, attrition from military service, and reduced job performance. National and international organizations suggest body mass index (BMI) as a population screening tool to define overweight and obesity. BMI is calculated as weight/height2 (kg/m2). Four categories of adult BMI are underweight (<18.5 kg/m2), healthy weight (18.5-24.9 kg/m2), overweight (25.0-29.9 kg/m2), and obese (=30.0 kg/m2). This article reports on a systematic review and meta-analysis examining the association between BMI and injury risk among military service members (SMs). Studies were selected for review if they involved military personnel, were prospective or retrospective observational studies, and contained original quantitative data on injury risk at all four BMI levels. Nine studies met the review criteria. Pooled data from these investigations indicated that underweight, overweight, and obese individuals were at 1.17 (95% confidence interval [95%CI]=1.07-1.28), 1.03 (95%CI=1.01-1.06), and 1.15 (95%CI=1.11-1.20) times higher risk of injury than healthy weight individuals, respectively. Compared with healthy weight SMs, military personnel with both low and high BMI are at higher injury risk.

Keywords: body mass index; injury; Underweight; Overweight; Obese; meta-analysis; systematic review

PMID: 36800524

DOI: WHH7-63P7

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Association of Physical Domain Participation with POTFF Domains in Special Forces Operators

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Nelson T, Youngblade L, Goldberg P, Bricker D, Werth K, Riesberg JC, Surrett GW. 23(4). 92 - 108. (Journal Article)

Abstract

Background: The purpose of this study was to evaluate the effectiveness of the physical domain (PD) to improve performance in all the POTFF domains (physical, psychological, social/family, and spiritual) among Special Forces (SF) Operators. Methods: This was a cross-sectional study of active SF Operators assigned to the United States Army Special Operations Command (USASOC). Recruitment began in October 2016. Testing began on 1 January 2017, and concluded on 28 February 2020. Participants completed physical testing, blood draws, and questionnaires to determine domain metrics. Means, medians, and proportions were compared by level of participation in the PD. Results: A total of 231 Soldiers participated; n=63 in the control group, n=93 in the <4 days PD/week (PD <4) group, and n=66 in the >4 days PD/week (PD =4) group. The average age was 31 years (range 21-47 y). The average time in the Special Operations Forces (SOF) was 4 years (range 0-19 y). The PD =4 group showed significantly greater overall upper (p=.01) and lower (p=0) body strength, power (p=.01), and positive affect (p=.04). The PD =4 group also had significantly lower anxiety (p=.03), stress (p=.04), and depression (p=.02) than the control group. Conclusion: The PD and psychological domain metrics were most associated with PD participation. This finding is consistent with the goals of the PD, which are to increase physical and mental capabilities and decrease injury recovery time.

Keywords: physical domain; spiritual domain; POTFF; United States Army Special Operations Command; USASOC; Special Forces; psychological domain; social/family domain

PMID: 38109229

DOI: YKHX-E4YA

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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 Above the Knee Amputation in Afghanistan

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Schoenberger T, Foret B, Evans J, Shishido AA. 23(2). 114 - 117. (Journal Article)

Abstract

Prolonged Casualty Care (PCC) has become an essential component to Special Operations Forces (SOF) pre-mission training. However, it has not regularly been required in recent combat operations with the availability of medical evacuation (MEDEVAC) support. Poor weather conditions at an austere SOF outpost created an emergency unreachable by aeromedical evacuation. Herein, we report a case of an emergency bilateral above-the-knee amputation procedure performed by three Special Forces Medical Sergeants (18D(a), 18D(b), and 18D(c)) and supporting Army medics with minimal telemedicine consult and guidance.

Keywords: amputation; austere; MEDEVAC; special operation; Afghanistan; emergency; telemedicine; combat

PMID: 36951633

DOI: 5HLH-TW89

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.

Keywords:

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.

Keywords:

PMID: 23536454

DOI: 3T4Z-68EP

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Black Hawk Down: A Story of Modern War

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Graverson SP. 23(3). 101 - 101. (Book Review)

Abstract

Mark Bowden. Black Hawk Down: A Story of Modern Warfare. 1999. 400 pp. ISBN: 978-1-5558-4604-6 (EB)

Keywords:

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.

Keywords:

DOI:

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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DOI:

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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Bluetooth Tactical Headsets Improve The Speed of Accurate Patient Handoffs

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Stinner D, McEvoy C, Broussard MA, Nikolaus AD, Parker CH, Santana H, Karnopp JM, Patel JA. 23(4). 75 - 80. (Journal Article)

Abstract

Background: The Committee on En Route Combat Casualty Care recently ranked the patient handoff as their fourth research priority. Bluetooth technology has been introduced to the battlefield and has the potential to improve the tactical patient handoff. The purpose of this study is to compare the traditional methods of communication used in tactical medical evacuation by Special Operations medical personnel (radio push-to-talk [PTT] and Tactical Medic Intercom System [TM-ICS]) to Bluetooth communication. Methods: Twenty-four simulated tactical patient handoffs were performed to compare Bluetooth and traditional methods of communication used in tactical medical evacuation. Patient scenario order and method of communication were randomized. Accuracy and time required to complete the patient handoff were determined. The study took place using a rotary-wing aircraft kept at level 2 to simulate real-world background noise. Preferred method of communication for each study participant was determined. Results: There were no differences in accuracy of the received patient handoffs between groups or patient handoff transmission times at the ramp of the aircraft. However, when comparing patient handoff times to the medical team within the aircraft, Bluetooth communication was significantly faster than both TM-ICS and radio PTT, while Bluetooth PTT and radio PTT were also significantly faster than TM-ICS. Bluetooth communication was ranked as the preferred method of handoff by all study participants. Conclusion: The study demonstrated that utilization of Bluetooth technology for patient handover results in faster handoffs compared with traditional methods without sacrificing any accuracy in a scenario with high levels of noise.

Keywords: Tactical Combat Casualty Care; TCCC; communication; Bluetooth; medical evacuation; handoff

PMID: 38079353

DOI: MAPM-TLNO

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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)

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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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DOI:

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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Cold Weather Injury in a Special Operations Aviation Crew Member: A Case Report

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Clerkin S, Carlson NT, Long B, Taylor DH, Bridwell R. 23(1). 80 - 83. (Case Reports)

Abstract

As arctic warfare becomes a center focus within Special Operations, cold weather injury looms as both a medical and operational threat. While cold weather injury can range from pernio to hemodynamically unstable systemic hypothermia, the more minor injuries are far more common. However, these present a challenge in austere medical care and can drastically impact mission capability. We present a case of a Special Operations crew chief with cold weather digital injury while at the Arctic Isolation Course in Alaska and his subsequent clinical course. Prevention remains the key for mitigating these injuries, while the decision to rewarm must be made with both medical and tactical factors in mind as refreezing incurs significant morbidity. Other components of prehospital treatment include active rewarming, ibuprofen, aloe vera, and pain control.

Keywords: arctic warfare; cold injury; frostbite; rewarm; Alaska; hypothermia; austere

PMID: 36753716

DOI: UTEY-NSCP

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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 Casualties Treated With Intranasal Ketamine for Prehospital Analgesia: A Case Series

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Dubecq C, Montagnon R, Morand G, De Rocquigny G, Petit L, Peyrefitte S, Dubourg O, Pasquier P, Mahe P. 23(1). 84 - 87. (Case Reports)

Abstract

Optimal pain management is challenging in Tactical Combat Casualty Care (TCCC), particularly in remote and austere settings. In these situations, appropriate treatment for prehospital analgesia can be limited or delayed due to the lack of intravenous access. Several guidelines suggest to implement intranasal (IN) analgesia in French Armed Forces for forward combat casualty care (Sauvetage au Combat), similar to the US TCCC. Four medical teams from the French Medical Military Service were deployed to the Middle East and Sahel from August 2017 to March 2019 and used IN ketamine for analgesia in 76 trauma patients, out of a total of 259 treated casualties. IN administration of ketamine 50mg appeared to be safe and effective, alone or in addition to other opioid analgesics. It also had minimal side effects and led to a reduction in the doses of ketamine and morphine used by the intravenous (IV) route. The French Military Medical Service supports current developments for personal devices delivering individual doses of IN ketamine. However, further studies are needed to analyze its efficacy and safety in combat zones.

Keywords: military medicine; casualties; intranasal; ketamine; prehospital analgesia

PMID: 36827683

DOI: OE4C-60HM

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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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Combat Vascular Access: A Scoping Review

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Smith S, White J, McGuire T, Meunier B, Ball I, Hilsden R. 23(3). 32 - 38. (Journal Article)

Abstract

Medical leadership must decide how to obtain vascular access in a combat environment. Adequate combat trauma resuscitation requires efficient vascular access. A search of the Medline and EMBASE databases was conducted to find articles on combat vascular access. The primary dataset of interest was the type of vascular access obtained. Other data reviewed included who performed the intervention and the success rate of the intervention. The search strategy produced 1,339 results, of which 24 were included in the final analysis. Intravenous (IV), intraosseous (IO), and central venous access have all been used in the prehospital combat environment. This review summarizes the available combat literature to help commanders make an evidence-based decision about their prehospital vascular access strategy.

Keywords: intravenous access; vascular access; interosseus access; central venous catheters

PMID: 37490425

DOI: 4WHG-X7ZZ

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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 and Prolonged Casualty Care Working Group Consensus Statement

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Remley MA, Riesberg JC, Drew B, Deaton TG, Montgomery HR, Jensen S, Gurney J. 23(2). 124 - 125. (Classical Conference)

Keywords:

PMID: 37169525

DOI: WOCA-6W0T

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:

Comparing a Novel Hand-Held Device for Chest Tube Insertion to the Traditional Open Tube Thoracostomy for Simple Pneumothorax in a Porcine Model

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Dilday J, Heidenreich B, Spitzer H, Abuhakmeh Y, Ahnfeldt E, Watt J, Mase VJ. 22(4). 41 - 45. (Journal Article)

Abstract

Background: Tube thoracostomy is the most effective treatment for pneumothorax, and on the battlefield, is lifesaving. In combat, far-forward adoption of open thoracostomy has not been successful. Therefore, the ability to safely and reliably perform chest tube insertion in the far-forward combat theatre would be of significant value. The Reactor is a hand-held device for tube thoracostomy that has been validated for tension pneumothorax compared to needle decompression. Here we investigate whether the Reactor has potential for simple pneumothorax compared to open thoracostomy. Treatment of pneumothorax before tension physiology ensues is critical. Methods: Simple pneumothoraces were created in 5 in-vivo swine models and confirmed with x-ray. Interventions were randomized to open technique (OT, n = 25) and Reactor (RT, n = 25). Post-procedure radiography was used to confirm tube placement and pneumothorax resolution. Video Assisted Thoracoscopic Surgery (VATS) was used to evaluate for iatrogenic injuries. 50 chest tubes were placed, with 25 per group. Results: There were no statistical differences between the groups for insertion time, pneumothorax resolution, or estimated blood loss (p = .91 and .83). Injury rates between groups varied, with 28% (n = 7) in the Reactor group and 8% (n = 2) the control group (p = .06). The most common injury was violation of visceral pleura (10%, n = 5, both groups) and violation of the mediastinum (8%, n = 4, both groups). Conclusion: The Reactor device was equal compared to open thoracostomy for insertion time, pneumothorax resolution, and injury rates. The device required smaller incisions compared to tube thoracostomy and may be useful adjunct in simple pneumothorax management.

Keywords: chest tube; thoracostomy; pneumothorax

PMID: 36525010

DOI: SH55-IFP6

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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 DripAssist to Traditional Method for Achieving Rate Infusions by U.S. Army Medics

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Golden DJ, Castaneda P, Carius BM, Simmons CJ. 23(3). 9 - 12. (Journal Article)

Abstract

Literature finds improper intravenous (IV) infusion rates as the most common cause of medication administration errors (MAE). Calculating drip rates and manipulating roller clamps while counting drops within the drip chamber to manage IV infusions - known as the traditional method (TM) - increases the likelihood of IV MAEs compared to electronic infusion pumps. The DripAssist, a novel in-line device, allows users to monitor and adjust infusion rates without calculating rates or counting drops. We conducted a prospective, randomized, crossover study with a convenience sample of U.S. Army medics initiating infusion rates using the DripAssist and the TM. Investigators randomized participants to start with the TM or DripAssist and achieve three specific infusions using an in vitro model. The primary outcome was the time to achieve the desired infusion rate measured in seconds. Secondary outcomes included drip rate accuracy and volume infused over one hour. End user feedback included method confidence on a 100-point Bandura scale and appraisal using a five-point Likert item. Twenty-two medics demonstrated faster time to achieve infusion rates with the DripAssist over TM (median 146.5 seconds vs. 207.5 seconds, p = .003). A sequence effect noted faster time to achieve desired infusion rates with the TM after completing infusions with DripAssist (p = .033). The DripAssist demonstrated significantly improved accuracy for drip rate and volume administered over one hour compared to TM (median rate error: 5% versus 46%, p <.001; median volume percentage error: 26.5% versus 65%, p <.001). The DripAssist had significantly higher user confidence (median 80 vs. 47.5, p <.001) and was perceived as easier to use (median 4 vs. 2, p = <.001) and more likely to be learned, remembered, and performed by a medic (median 5 vs. 3, p <.001). Most participants (90%) preferred the DripAssist for establishing a rate-specific infusion. The DripAssist demonstrated significantly faster time to achieve infusion rates, improved accuracy, and increased user confidence. Sequence effects may confound time data. We recommend further studies of the DripAssist by prehospital medical personnel in more austere environments.

Keywords: medication administration; infusion accuracy; military; performance

PMID: 37616172

DOI: DZ0I-FH6N

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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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Comparison of Warming Capabilities Between Buddy Lite, enFlow, and Thermal Angel for US Army Medical Personnel in Austere Conditions: A Literature Review

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Vallier DJ, Anderson WJ, Snelson JV, Yauger YJ, Felix JR, Alford KI, Bermoy WA. 22(4). 9 - 13. (Journal Article)

Abstract

US Army Forward Surgical Elements (FSEs) are highly mobile teams that provide damage control surgery (DCS) and damage control resuscitation (DCR) in austere locations that often lack standard hospital utilities (electricity, heat, food, and water). FSEs rely on portable battery-operated intravenous (IV) fluid warmers to remain light and mobile. However, their ability to warm blood in a massive resuscitation requires additional analysis. The purpose of this literature review is to examine the three most common battery-operated IV fluid warmers as determined by type and quantity listed on the Mission Table of Organization and Equipment (MTOE) of organic mobile medical units. These include the Buddy Lite, enFlow, and Thermal Angel, which are available to deployed US Army FSEs for blood resuscitation therapy. Based on limited available evidence, the enFlow produced higher outlet temperatures, effectively warmed greater volumes, reached the time to peak temperature faster, and produced greatest flow rates, with cool saline (5-10°C), compared to the Thermal Angel and Buddy Lite. However, recently the US Food and Drug Administration (FDA) issued a Class 1 recall on enFlow cartridges. Testing demonstrated aluminum elution from enFlow cartridges into IV solutions, thereby exposing patients to potentially unsafe aluminum levels. The authors recommend FSE units conduct a 100% enFlow cartridge inventory and seek an alternative IV fluid warming system prior to enFlow cartridge disposal. If an alternative does not exist, or the alternative warming system does not fit mission requirements, then medical personnel must carefully weigh the risks and benefits associated with the enFlow delivery system.

Keywords: Thermal Angel; enFlow; Buddy Lite; fluid warmer; intravenous fluids, IVF; cartridge

PMID: 36525005

DOI: HFTS-LQNF

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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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Conventional Resilience and the Impact of Catastrophic Injury Exposure on Special Operations Surgical Teams

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Jeschke EA, Baker JB, Wyma-Bradley J, Dorsch J, Huffman SL. 23(2). 102 - 106. (Journal Article)

Abstract

This article presents a justification for using an ethnographic approach to research resilience. Our hypothesis is that the conventional resilience construct is ineffective in achieving its stated goal of mitigating diagnosable stress pathologies because it is grounded in a set of assumptions that overlook human experience when examining human performance in combat. To achieve this goal, we (1) describe the evolution of the strategic framework within which the conventional resilience construct is defined; (2) highlight certain limiting assumptions entailed in this framework; (3) explain how bottom-up ethnographic research relates the medic's practical performance to military requirements and mission capabilities; and (4) articulate the unique elements of our study that widen the aperture of the conventional resilience construct. We conclude by gesturing to initial research findings.

Keywords: resilience; SOST; Special Operations Surgical Team; SOF special operations; catastrophic; injury; ethnographic; combat

PMID: 37169528

DOI: FHIP-DWHB

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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 Chairmanship Change and Upcoming Guideline Revision

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Montgomery HR. 23(3). 105 - 107. (Classical Conference)

Keywords:

PMID: 37702603

DOI: UY8Z-KB0M

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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Cric in the Dark: Surgical Cricothyrotomy in Low Light Tactical Environments

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Getz C, Stuart SM, Barbour BM, Verga JM, Roszko PJ, Friedrich EE. 22(4). 50 - 54. (Journal Article)

Abstract

Background: Surgical cricothyrotomy (SC) is a difficult procedure with high failure rates in the battlefield environment. The difficulty of this procedure is compounded in a low-light tactical environment in which white light cannot be used. This study compared the use of red-green (RG) light and red (R) light in the performance of SC in a low-light environment. Materials and Methods: Tactical Combat Casualty Care-certified navy corpsmen (n = 33) were provided 15 minutes of standardized instruction followed by hands-on practice with the Tactical CricKit and the H&H bougie-assisted Emergency Cricothyrotomy Kit. Participants acclimated to a dark environment for 30 minutes before performing SC on a mannequin with both devices using both R and RG light in a randomized order. Application time, success, participant preference, and participant confidence were analyzed. Results: There were similarly high levels of successful placement (>87.5%) in all four cohorts. Light choice did not appear to affect placement time with either of the two kits. On Likert-scale surveys, participants reported that RG decreased difficulty (p < .0001) and increased confidence (p < .0001) in performing the procedure. Conclusion: RG light increased confidence and decreased perceived difficulty when performing SC, though no differences in placement time or success were observed.

Keywords: light source; TCCC; red light; bougie-assisted; green light; white light; cricothyrotomy

PMID: 36525012

DOI: 8DR3-B0RH

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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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Crimean-Congo Hemorrhagic Fever: A Refresher and Update for the SOF Provider

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Klucher J, Gonzalez A, Shishido AA. 23(1). 92 - 95. (Journal Article)

Abstract

Crimean-Congo Hemorrhagic Fever (CCHF) is the most widespread tickborne virus causing human disease. CCHF wields a mortality rate up to 30% and was responsible for the death of a US Soldier in 2009. The virus is spread by the Hyalomma species of hard tick found across Central Europe, the Middle East, Africa, and Asia south of the 50° parallel. Infection typically consists of a 1-7-day non-specific viral prodrome, followed by onset of hemorrhagic disease on days 7-10. Severe disease may cause thrombocytopenia, transaminitis, petechial hemorrhage, hematemesis, and death typically by day 10 of illness. Education and insect control are paramount to disease prevention. Treatment is predominantly supportive care, though evidence suggests a benefit of early ribavirin administration. CCHF has caused multiple nosocomial outbreaks, and therefore consideration should be given to safe transport and evacuation of infected and exposed patients. Given the wide area of distribution, transmissibility, innocuous arthropod vectors, and high mortality rate, it is imperative that Special Operations Forces (SOF) providers be aware of CCHF and the existing countermeasures.

Keywords: military medicine; bioagent; zoonosis; tickborne diseases

PMID: 36753717

DOI: UZTO-DWEP

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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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Critical Hypophosphatemia in a Special Operations Combat Dive Candidate: A Case Report

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Davis G, Czarnik J, Evans J, McGrane OL. 23(2). 107 - 109. (Case Reports)

Abstract

In contrast to shallow water (hypoxic) blackout and swimming-induced pulmonary edema (SIPE), acute electrolyte disturbance secondary to acute respiratory alkalosis is not considered a common Combat Swimmer injury but has the potential to be life-threatening. We present the case of a 28-year-old Special Operations Dive Candidate who presented to the Emergency Department after a near-drowning incident with altered mental status, generalized weakness, respiratory distress, and tetany. He was found to have severe symptomatic hypophosphatemia (1.00mg/dL) and mild hypocalcemia secondary to intentional hyperventilation between subsurface "cross-overs," causing subsequent acute respiratory alkalosis. This is a unique presentation of a common electrolyte abnormality in a highly specialized population that is self-limiting when caused by acute respiratory alkalosis but poses a significant danger to Combat Swimmers if rescue personnel are not able to respond quickly.

Keywords: hypophosphatemia; combat swimmer; acute respiratory alkalosis; hyperventilation

PMID: 37084414

DOI: PMWA-GHDT

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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, Pappamihiel NE. 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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Deployed Combat Use of Methoxyflurane for Analgesia

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Schauer S, Fisher AD, April MD. Ahead of Print. (Journal Article)

Abstract

Background: The U.S. Military needs fast-acting, non-opioid solutions for battlefield pain. The U.S. Military recently used morphine auto-injectors, which are now unavailable. Off-label ketamine and oral transmucosal fentanyl citrate use introduces challenges and is therefore uncommon among conventional forces. Sublingual suftentanil is the only recent pain medication acquired to fill this gap. Conversely, methoxyflurane delivered by a handheld inhaler is promising, fast-acting, and available to some partner forces. We describe methoxyflurane use reported in the Department of Defense Trauma Registry (DODTR). Methods: We requested all available DODTR encounters from 2007 to 2023 with a documented intervention or assessment within the first 72 hours of care. We analyzed casualties who received methoxyflurane in the prehospital setting using descriptive statistics. Results: There were 22 encounters with documented methoxyflurane administration. The median patient age was 23 (range 21-31) years. All were men. The largest proportion was partner force (50%), followed by U.S. Military (27%). Most (64%) sustained battle injuries. Explosives were the most common mechanism of injury (46%), followed by firearms (23%). The median injury severity score was 5 (range 1-17). The most frequent injuries were serious injuries to the extremities (27%), and 23% of patients (5) received a tourniquet. One-half of the casualties received concomitant pain medications. Only three casualties had multiple pain scores measured, with a median pain score change of -3 on a scale of 10. Conclusion: Methoxyflurane use in deployed combat shows both feasibility and usability for analgesia.

Keywords: military; combat; trauma; pain; analgesia; methoxy flurane; penthrox

PMID: 38412526

DOI: X2OD-UYUQ

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Derivation of a Procedural Performance Checklist for Bifemoral Veno-Venous Extracorporeal Membrane Oxygenation Cannula Placement in Operational Environments

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Powell E, Betzold R, Kundi R, Anderson D, Haase D, Keville M, Galvagno S. Ahead of Print. (Journal Article)

Abstract

Background: Veno-venous extracorporeal membrane oxygenation (VV ECMO) is a low-frequency, high-intensity procedure used for severe lung illness or injury to facilitate rapid correction of hypoxemia and respiratory acidosis. This technology is more portable and extracorporeal support is more frequently performed outside of the hospital. Future conflicts may require prolonged causality care and more specialized critical care capabilities including VV ECMO to improve patient outcomes. We used an expert consensus survey based on a developed bifemoral VV ECMO cannulation checklist with an operational focus to establish a standard for training, validation testing, and sustainment. Methods: A 36-item procedural checklist was provided to 14 experts from multiple specialties. Using the modified Delphi method, the checklist was serially modified based on expert feedback. Results: Three rounds of the study were performed, resulting in a final 32-item checklist. Each item on the checklist received at least 70% expert agreement on its inclusion in the final checklist. Conclusion: A procedural performance checklist was created for bifemoral VV ECMO using the modified Delphi method. This is an objective tool to assist procedural training and validation for medical providers performing VV ECMO in austere environments.

Keywords: VVECMO; checklist; prolonged casualty care; ARDS

PMID: 38278770

DOI: Y177-KRQV

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Descriptive Analysis of Combat-Associated Aspiration Pneumonia

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Schauer SG, Damrow T, Martin SM, Hudson IL, De Lorenzo RA, Blackburn MB, Hofmann LJ, April MD. 23(2). 13 - 18. (Journal Article)

Abstract

Background: Airway obstruction is the second leading cause of potentially preventable death on the battlefield. The treatment for airway obstruction is intubation or advanced airway adjunct, which has a known risk of aspiration. We sought to describe the variables associated with aspiration pneumonia after prehospital airway intervention. Methods: This is a sub-analysis of previously described data from the Department of Defense Trauma Registry (DoDTR) from 2007 to 2020. We included casualties that had at least one prehospital airway intervention with documentation of subsequent aspiration pneumonia or pneumonia within three days of the intervention. We used a generalized linear model with Firth bias estimates to test for associations. Results: There were 1,509 casualties that underwent prehospital airway device placement. Of these, 41 (2.7%) met inclusion criteria into the aspiration pneumonia cohort. The demographics had no statistical difference between the groups. The non-aspiration cohort had fewer median ventilator days (2 versus 6, p < 0.001), intensive care unit days (2 versus 7, p < 0.001, and hospital days [3 versus 8, p < 0.001]). Survival was lower in the non-aspiration cohort (74.2% versus 90.2%, p = 0.017). The administration of succinylcholine was higher in the non-aspiration cohort (28.0% versus 12.2%, p = 0.031). In our multivariable model, only the administration of succinylcholine was significant and was associated with lower probability of aspiration pneumonia (odds ratio 0.56). Conclusion: Overall, the incidence of aspiration pneumonia was low in our cohort. The administration of succinylcholine was associated with a lower odds of developing aspiration pneumonia.

Keywords: airway; combat; aspiration; vomit; intubation; prehospital

PMID: 37094291

DOI: QT6H-ECR4

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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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Determining Clinical Priorities Using a Clinical Practice Guideline Deconstruction Tool: COVID-19 in Austere Operational Environments

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Caldwell RM, Dickey W, Sawyer A, Mann-Salinas EA, Crozier L, Montgomery HR, Moody G. 23(2). 55 - 59. (Journal Article)

Abstract

The Joint Trauma System (JTS) publishes Clinical Practice Guidelines (CPGs) used by military and civilian healthcare providers worldwide. With the expansion of CPG development in recent years, there was a need to collate, sort, and deconflict existing and new guidance using systematic methodology both within and across CPGs. This need became readily apparent at the start of the COVID-19 pandemic when guidelines were rapidly developed and fielded in deployed environments. To meet the needs of deploying units requesting immediate and concise guidance for managing COVID-19, JTS developed the CPG entitled Management of Covid-19 in Austere Operational Environments. By applying a deconstruction process to organize clinical recommendations across multiple categories, JTS was able to present clear clinical recommendations across "role of care" and "scope of practice." The use of a deconstruction process supported the rapid socialization of the CPG and may have improved clinical understanding among deployed medical teams.

Keywords: deployed medicine; COVID-19; implementation science; dissemination; clinical practice guidelines; trauma care

PMID: 37094289

DOI: ZSN0-GOK7

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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 and Implementation of a Standard Operating Procedure for Military Working Dog Blood Collection, Storage, and Transport

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Evernham EL, Fedeles BT, Knuf K. Ahead of Print. (Journal Article)

Abstract

Military working canines are critical assets and force multipliers for the Joint Force. Most often deployed forward of Role 2 assets, they are reliant on non-veterinary resources when wounded, ill, or injured in an operational environment. Hemorrhagic shock is the most prevalent form of shock seen in battlefield injuries and is most effectively treated with whole blood transfusion. Dogs cannot be transfused with human blood and there is no formal Department of Defense (DoD) canine blood product distribution system to operational settings. A walking blood bank is helpful when multiple dogs are geographically co-located and the resource can be provided to an injured patient quickly. In areas as widely dispersed as the Horn of Africa, the likelihood of co-location is slim and delaying this vital resource can mean the difference between life and death. Therefore, personnel at the Role 2 facility in Camp Lemonnier, Djibouti, filled a critical capability gap for the operational area by producing a local canine whole blood bank with distribution to multiple countries. This protocol can be replicated by other locations to improve medical readiness for the working canines who serve to maintain DoD Force Protection.

Keywords: military working dogs; whole blood transfusion; transfusion medicine; veterinary medicine

PMID: 38360026

DOI: BLVF-5C1M

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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 Mental and Visual Skills Training Improve High-Value Target Identification and Marksmanship Among Elite Soldiers?

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Dawes JJ, Tramel W, Bartley N, Bricker D, Werth-Bailey K, Brodine L, Clark C, Goldberg P, Pagel K, Federico T, Bullinger D, Canada DM. 22(4). 22 - 25. (Journal Article)

Abstract

Background: The purpose of this preliminary investigation was to determine the impact of a mental and visual skills training (MVST) program on a high-value target identification and marksmanship (HVTM) task among Special Operations Forces (SOF) Soldiers. Methods: Deidentified archival data for 52 male SOF Operators (age: 31.06 ± 4.10 years) were assessed to determine if differences in performance existed between MVST program users (n = 15) and nonusers (n = 37) on a HVTM task performed immediately after a Special Forces Advanced Urban Combat (SFAUC) stress shoot. Independent-samples t-tests were utilized to determine if significant mean score differences existed between groups on specific shooting elements within the HVTM task. Effect size calculations were also performed to assess the magnitude of differences between groups in each measure of performance. Results: Statistically significant differences in performance were not discovered between MVST users and nonusers on overall score (Score) or any individual elements of the HVTM task. However, small to medium effect sizes (d = 0.305-0.493) were observed between groups in Score, Positive Identification Accuracy, Shot Accuracy, and Kill Shot Score. Conclusion: While inconclusive, these findings suggest the use of a MVST program administered by a trained cognitive performance specialist may have the potential to positively influence HVTM performance. More research using larger sample sizes is required to confirm this supposition.

Keywords: shooting; sport psychology; Special Operations Forces; cognition; military

PMID: 36525008

DOI: XSNC-PFJT

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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 and Adherence to Triage Algorithms During Prehospital Response to Mass Casualty Incidents

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Kamler JJ, Taube S, Koch EJ, Lauria MJ, Kue RC, Rush SC. 23(1). 59 - 66. (Journal Article)

Abstract

Mass casualty incidents (MCIs) can rapidly exhaust available resources and demand the prioritization of medical response efforts and materials. Principles of triage (i.e., sorting) from the 18th century have evolved into a number of modern-day triage algorithms designed to systematically train responders managing these chaotic events. We reviewed reports and studies of MCIs to determine the use and efficacy of triage algorithms. Despite efforts to standardize MCI responses and improve the triage process, studies and recent experience demonstrate that these methods have limited accuracy and are infrequently used.

Keywords: mass casualty; trauma

PMID: 36853853

DOI: 73Y0-FSLB

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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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Effectiveness of Sternal Intraosseous Device in Patients Presenting with Circulatory Shock: A Retrospective Observational Study

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Hynes A, Murali S, Bass GA, Kheirbek T, Qasim Z, George N, Yelon JA, Chreiman KC, Martin ND, Cannon JW. 23(4). 81 - 86. (Journal Article)

Abstract

Background: Hemorrhagic shock requires timely administration of blood products and resuscitative adjuncts through multiple access sites. Intraosseous (IO) devices offer an alternative to intravenous (IV) access as recommended by the massive hemorrhage, A-airway, R-respiratory, C-circulation, and H-hypothermia (MARCH) algorithm of Tactical Combat Casualty Care (TCCC). However, venous injuries proximal to the site of IO access may complicate resuscitative attempts. Sternal IO access represents an alternative pioneered by military personnel. However, its effectiveness in patients with shock is supported by limited evidence. We conducted a pilot study of two sternal-IO devices to investigate the efficacy of sternal-IO access in civilian trauma care. Methods: A retrospective review (October 2020 to June 2021) involving injured patients receiving either a TALON® or a FAST1® sternal-IO device was performed at a large urban quaternary academic medical center. Baseline demographics, injury characteristics, vascular access sites, blood products and medications administered, and outcomes were analyzed. The primary outcome was a successful sternal-IO attempt. Results: Nine males with gunshot wounds transported to the hospital by police were included in this study. Eight patients were pulseless on arrival, and one became pulseless shortly thereafter. Seven (78%) sternal-IO placements were successful, including six TALON devices and one of the three FAST1 devices, as FAST1 placement required attention to Operator positioning following resuscitative thoracotomy. Three patients achieved return of spontaneous circulation, two proceeded to the operating room, but none survived to discharge. Conclusions: Sternal-IO access was successful in nearly 80% of attempts. The indications for sternal-IO placement among civilians require further evaluation compared with IV and extremity IO access.

Keywords: intraosseous; resuscitation; sternum; sternal intraosseous; sternal vascular access; vascular access

PMID: 38064650

DOI: AAZW-R052

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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 Airway Localization Device Use During Surgical Cricothyrotomy on Procedural Times and Confidence Levels of Pre-Hospital Personnel

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Schlocker C, Grosser S, Spaulding C, Beltrech B, Brady R. 23(4). 57 - 61. (Journal Article)

Abstract

This study evaluated the effect of an airway localization device (ALD) on surgical cricothyrotomy (SC) success rates and prehospital provider confidence. SC is indicated in 0.62% to 1.8% of all patients with military trauma, especially those presenting with traumatic airway obstruction. The effect of ALD was evaluated in an airway mannequin model during SC with the Committee on Tactical Combat Casualty Care (CoTCCC)-recommended Control-Cric Cricothyrotomy System. Outcomes included procedural time, Likert measures of operator confidence, and qualitative data/feedback for suggested future improvements in device design and training. The average procedural times of the hospital corpsmen (HM) including 20 men and 8 women were 67 seconds (without ALD) and 87 seconds (with ALD) respectively, which were statistically significant. Provider confidence for all SC procedural steps increased significantly after SC with and without ALD. The average procedural times of the Navy Special Operations Forces (SOF) group comprising 8 males were 56 seconds (without ALD) and 64 seconds (with ALD), which was not statistically significant. Provider confidence for two SC procedural steps (adequate hook retraction and first-attempt SC tube insertion) increased significantly after SC with and without ALD. First-attempt SC success rates were 90% in each group. Both groups provided feedback on the Control-Cric and ALD, with qualitative feedback analyzed for further SC training recommendations. Procedural times were increased with ALD when compared to those without ALD, although the increase may not be clinically significant in this classroom setting.

Keywords: airway; trauma; military medicine; surgical cricothyrotomy; procedural time; operator confidence; hospital corpsmen; Special Operations Forces; SOF

PMID: 37976434

DOI: 5TNR-B19B

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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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Effects of Tourniquet Features on Application Processes

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Wall P, Buising CM, Jensen J, White A, Davis J, Renner CH. 23(4). 11 - 30. (Journal Article)

Abstract

Background: We investigated emergency-use limb tourniquet design features effects on application processes (this paper) and times to complete those processes (companion paper). Methods: Sixty-four appliers watched training videos and then each applied all eight tourniquets: Combat Application Tourniquet Generation 7 (CAT7), SOF™ Tactical Tourniquet-Wide Generation 3 (SOFTTW3), SOF™ Tactical Tourniquet-Wide Generation 5 (SOFTTW5), Tactical Mechanical Tourniquet (TMT), OMNA Marine Tourniquet (OMT), X8T tourniquet (X8T), Tactical Ratcheting Medical Tourniquet (Tac RMT), and RapidStop™ Tourniquet (RST). Application processes were scored from videos. Results: Thirty-three appliers had no prior tourniquet experience. All 512 applications were placed proximal to the recipient's simulated distal thigh injury. Thirty-one appliers (13 with no experience) had 66 problem-free applications (18 by no experience appliers). Tightening-system mechanical problems were more frequent with windlass rod systems (26 losing hold of the rod, 27 redoing rod turns, and 58 struggling to secure the rod) versus ratchet systems (3 tooth skips and 16 advance failures). Thirty-five appliers (21 with no experience) had 68 applications (45 by no experience appliers) with an audible Doppler pulse when stating "Done"; causes involved premature stopping (53), inadequate strap pull (1 SOFTTW3, 1 RST), strap/redirect understanding problem (1 SOFTTW5, 1 X8T, 4 Tac RMT, 1 RST), tightening-system understanding problem (2 CAT7, 1 SOFTTW3, 1 TMT, 1 RST), and physical inability to secure (1 SOFTTW3). Fifty-three appliers (32 no experience) had 109 applications (64 by no experience appliers) not correctly secured. Six involved strap/redirect understanding problems: 4 Tac RMT, 1 X8T, 1 SOFTTW5; 103 involved improper securing of non-self-securing design features: 47 CAT7 (8 strap, 45 rod), 31 TMT (17 strap, 19 rod), 22 OMT (strap), and 3 SOFTTW3 (rod). Conclusion: Self-securing systems have process advantages. Because most emergent tourniquet recipients require transport, we believe tourniquet security is a critical design aspect. Decisions regarding tourniquet choices may become very different when both occlusion and tourniquet security are considered.

Keywords: tourniquet; hemorrhage; first aid; emergency treatment

PMID: 38085636

DOI: 8FFG-1Q48

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Effects of Tourniquet Features on Application Processes Times

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Wall P, Buising CM, White A, Jensen J, Davis J, Renner CH. 23(4). 31 - 42. (Journal Article)

Abstract

Background: We investigated emergency-use limb tourniquet design features effects on application processes (companion paper) and times to complete those processes (this paper). Methods: Sixty-four appliers watched training videos then each applied all eight tourniquets: Combat Application Tour- niquet Generation 7 (CAT7), SOF™ Tactical Tourniquet-Wide Generation 3 (SOFTTW3), SOF™ Tactical Tourniquet-Wide Generation 5 (SOFTTW5), Tactical Mechanical Tourniquet (TMT), OMNA Marine Tourniquet (OMT), X8T-Tourniquet (X8T), Tactical Ratcheting Medical Tourniquet (Tac RMT), and RapidStop Tourniquet (RST). Application processes times were captured from videos. Results: From "Go" to "touch tightening system" was fastest with clips and self-securing redirect buckles and without strap/redirect application process problems (n, median seconds: CAT7 n=23, 26.89; SOFTTW3 n=11, 20.95; SOFTTW5 n=16, 20.53; TMT n=5, 26.61; OMT n=12, 25.94; X8T n=3, 18.44; Tac RMT n=15, 30.59; RST n=7, 22.80). From "touch tightening system" to "last occlusion" was fastest with windlass rod systems when there were no tightening system understanding or mechanical problems (seconds: CAT7 n=48, 4.21; SOFTTW3 n=47, 5.99; SOFTTW5 n=44, 4.65; TMT n=38, 6.21; OMT n=51, 6.22; X8T n=48, 7.59; Tac RMT n=52, 8.44; RST n=40, 8.02). For occluded, tightening system secure applications, from "touch tightening system" to "Done" was fastest with self-securing tightening systems tightening from a tight strap (occluded, secure time in seconds from a tight strap: CAT7 n=17, 14.47; SOFTTW3 n=22, 10.91; SOFTTW5 n=38, 9.19; TMT n=14, 11.42; OMT n=44, 7.01; X8T n=12 9.82; Tac RMT n=20, 6.45; RST n=23, 8.64). Conclusions: Suboptimal processes in- crease application times. Optimal design features for fast, occlusive, secure tourniquet applications are self-securing strap/ redirect systems with an easily identified and easily used clip and self-securing tightening systems.

Keywords: tourniquet; hemorrhage; first aid; emergency treatment

PMID: 38112184

DOI: RPO1-CB79

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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 Military Tactical Emergency Tourniquet for Lower Extremity Arterial Occlusion Compared with the Combat Application Tourniquet: A Randomized Crossover Study

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Samutsakorn DK, Carius BM. 23(2). 36 - 39. (Journal Article)

Abstract

Introduction: Extremity bleeding and subsequent hemorrhagic shock is one of the main causes of preventable battlefield death, leading to mass-fielding of modern tourniquets, such as the Combat Application Tourniquet (CAT; Composite Resources). Numerous look-alike tourniquets, such as the Military Tactical Emergency Tourniquet (MTET; SZCTKlink), flood commercial markets, offering visually near-identical tourniquets for drastically reduced prices. We examined the performance of the MTET compared with that of the CAT. Methods: We undertook a randomized crossover trial to observe self-applied tourniquets to the lower extremity by combat medics, comparing the CAT to the MTET in application time and success rates, proven by loss of distal pulse assessed by Doppler ultrasound in <1 minute. Results: All 50 participants (100%) successfully applied the CAT versus 40 participants (80%) using the MTET (p = .0001). Median application time for the CAT (29.03 seconds; range, 18.63 to 59.50 seconds) was significantly less than those of successful MTET applications (35.27 seconds; range, 17.00 to 58.90 seconds) or failed MTET applications (72.26 seconds; range, 62.84 to 83.96 seconds) (p = .0012). Of 10 MTET failures, three (30%) were from application time >1 minute and seven (70%) from tourniquet mechanical failure. Conclusion: The MTET performed worse than the CAT did in all observed areas. Despite identical appearance, look-alike tourniquets should not be assumed to be equivalent in quality or functionality to robustly tested tourniquets.

Keywords: education; hemorrhage; bleeding control

PMID: 37094290

DOI: 4SEI-O7LO

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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 Fresh Whole Blood Transfusion Training for Ukrainian Health Professionals in Austere Environments

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Brown ZL, Cuestas JP, Matthews KJ, Shumaker JT, Moore DW, Cole R. Ahead of Print. (Journal Article)

Abstract

Background: Blood is a highly valuable medical resource that necessitates strict guidelines to ensure the safety and well-being of the recipient. Since the onset of the war in Ukraine there has been an increased demand for training in emergency fresh whole blood transfusion (EFWBT) to improve damage control resuscitation capabilities. To meet this demand, we developed, implemented, and evaluated a training program aimed at enhancing Ukrainian EFWBT proficiency. Methods: Eight Ukrainian healthcare professionals (UHPs), including six physicians and two medics, completed our training, derived from the Joint Trauma System Clinical Practice Guidelines, Tactical Combat Casualty Care (TCCC) Guidelines, 75th Ranger Regiment Ranger O-Low Titer (ROLO) program, and Marine Corps Valkyrie program. Participants were assessed on their confidence in the practical application and administrative oversight requirements of an EFWBT program. A cross-comparison was conducted between a larger data set of third-year medical students from the Uniformed Services University and the UHPs to determine the statistical significance of the program. Results: The difference in mean scores of UHPs during preand post-training was statistically significant (p<0.001). Additionally, the average rate of improvement was greater for the UHPs compared with the third-year medical students (p=0.000065). Conclusion: Our study revealed that the application of an EFWBT training program for UHPs can significantly increase confidence in their ability to conduct EFWBTs on the battlefield. Further larger-scale research is needed to determine the impact of this training on performance outcomes.

Keywords: Ukraine; fresh whole blood; transfusion medicine; emergency medical services; Russian-Ukrainian War

PMID: 38408046

DOI: ZEDS-YB8N

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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 Reflex Action Drills and the Problem with Stress

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Zink N, Merelman A, Fisher AD, Lauria MJ. 23(1). 54 - 58. (Journal Article)

Abstract

Clinicians involved in the care of critically ill patients are often exposed to demanding and stressful situations that require immediate action. Evidence suggests that human performance can be significantly diminished when multiple stressors and stimuli are present. Humans have developed conscious and unconscious methods of dealing with this type of cognitive overload in various high-risk occupations, but these coping methods have not necessarily been structured and adapted to the provision of emergency medical care. Emergency reflex action drills (ERADs) are derived from available evidence in specific domains (e.g., airway management) and develop automaticity of critical skills which engender quick, effective, and reproducible performance with minimal cognitive load. These are pre-planned, practiced responses to specific, high-demand and time-sensitive situations. This article outlines the psychological, cognitive, and behavioral effects of stress that affect performance and necessitate development of ERADs. It also reviews the scientific underpinnings behind how humans have adapted cognitive behavioral techniques to manage under high-stress situations. Finally, this article recommends the adoption of these cognitive tactics via ERADs to enhance clinical practice and provides an example in the context of airway management.

Keywords: adaption; error; performance; stress; training

PMID: 36764288

DOI: RCF2-CXS9

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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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Epidemiology of Musculoskeletal Injuries Among Naval Special Warfare Personnel

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Lovalekar M, Keenan KA, Bird M, Cruz DE, Beals K, Nindl BC. 23(1). 38 - 44. (Journal Article)

Abstract

Background: Musculoskeletal injuries (MSIs) are an important cause of morbidity in the military, especially among Special Forces. The aim of this analysis was to describe MSIs among two groups of Naval Special Warfare (NSW) personnel-Special Warfare Combatant-Craft Crewman (SWCC) Operators and Crewman Qualification Training (CQT) students. Methods: In this cross-sectional study, we describe self-reported MSIs that occurred during a one-year period and the calculated financial costs of MSIs. Group comparisons were conducted using Fisher's exact tests and independent samples t tests. Results: Data were available for 142 SWCC Operators (26.9 ± 5.9 years, 1.8 ± 0.1 meters, 85.4 ± 10.4 kilograms) and 187 CQT students (22.8 ± 3.2 years, 1.8 ± 0.2 meters, 81.4 ± 8.9 kilograms). The one-year cumulative MSI incidence was significantly lower among SWCC Operators (21.1%) compared to CQT students (37.4%, p = 0.002). The most common anatomic location for MSIs was the lower extremity (SWCC: 50.0% of MSIs, CQT: 66.3%). Physical training was the predominant activity when MSIs occurred (SWCC: 31.6%, CQT: 77.6%). The lifetime cost of all the MSIs included in the analysis was approximately $580,000 among 142 SWCC Operators and $1.2 million among 187 CQT students. Conclusion: MSIs, especially those affecting the lower extremity and occurring during physical training, cause considerable morbidity and financial burden among NSW personnel. Many of the musculoskeletal injuries are to musculotendinous tissue, which typically results from tissue overload or inadequate recovery. Further investigation of the preventable causes of these MSIs and development of a customized, evidence-based MSI prevention program is required to reduce the burden of these MSIs.

Keywords: military personnel; incidence; cross-sectional studies; self-report; sprains and strains

PMID: 36827682

DOI: RIJY-4EK5

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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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Evacuation of Non-ST Elevation Myocardial Infarction in West Africa: 19 Hours of Lessons Learned in Prolonged Casualty Care and En Route Care

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Speicher MV, McGowan J, Pruett S, Shurden J, Bianchi WD, Kibler A. 23(1). 114 - 116. (Journal Article)

Abstract

Trauma casualty care has historically been the cornerstone of special operations military medical training. A recent case of myocardial infarction at a remote base of operations in Africa highlights the importance of foundational medical knowledge and training. A 54-year-old government contractor supporting operations in the AFRICOM area of responsibility (AOR) presented to the Role 1 medic with substernal chest pain with onset during exercise. Abnormal rhythm strips concerning for ischemia were obtained from his monitors. A MEDEVAC to a Role 2 facility was arranged and executed. At the Role 2 a non-ST-elevation myocardial infarction (NSTEMI) was diagnosed. The patient was emergently evacuated on a lengthy flight to a civilian Role 4 treatment facility for definitive care. He was found to have a 99% occlusion of the left anterior descending (LAD) coronary artery, as well as a 75% occlusion of the posterior coronary artery and a chronic 100% occlusion of the circumflex artery. The LAD and posterior arteries were stented, and the patient made a favorable recovery. This case highlights the importance of preparedness for medical emergencies and care of medically critical patients in remote and austere locations.

Keywords:

PMID: 36878851

DOI: JIDF-CWE7

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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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Experience With Trauma-Induced ARDS: A Retrospective Study of US Wartime Casualties 2003-2015

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Nam JJ, McCravy MS, Haines KL, Thomas SB, Aden JK, Johnston LR, Mason PE, Gurney J, Sams VG. 22(4). 111 - 116. (Journal Article)

Abstract

Background: The purpose of our study was to assess risks/ outcomes of acute respiratory distress syndrome (ARDS) in US combat casualties. We hypothesized that combat trauma patients with ARDS would have worse outcomes based on mechanism of injury (MOI) and labs/vital signs aberrancies. Materials and Methods: We reviewed data on military Servicemembers serving in Iraq and Afghanistan from 1 January 2003 to 31 December 2015 diagnosed with ARDS by ICD-9 code. We extracted patient demographics, injury specifics, and mortality from the Department of Defense Trauma Registry (DoDTR). Results: The most common MOI was an explosion, accounting for 67.6% of all injuries. Nonsurvivors were more likely to have explosion-related injuries, have higher injury severity score (ISS), higher international normalized ratio (INR), lower platelet count, greater base deficit, lower temperature, lower Glasgow Coma Scale (GCS) score, and lower pH. There was no significant difference in deaths across time. Conclusion: By identifying characteristics of patients with higher mortality in trauma ARDS, we can develop treatment guidelines to improve outcomes. Given the high mortality associated with trauma ARDS and relative paucity of clinical data available, we need to improve battlefield data capture to better guide practice and ultimately improve care. The management of ARDS will be increasingly relevant in prolonged casualty care (PCC; formerly prolonged field care) on the modern battlefield.

Keywords: PCC; PFC; prolonged casualty care; prolonged field care; ARDS; acute respiratory distress syndrome; combat casualties; combat trauma; mechanism of injury

PMID: 36525023

DOI: MTVH-ONCM

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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 286–294

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.

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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.

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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.

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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.

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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.

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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)

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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)

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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)

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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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Flotation-Restricted Environmental Stimulation Technique: A Proposed Therapy for Improving Performance and Recovery in Special Forces Operators - A Narrative Review

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O'Hara R, Sussman LR, Sheehan R, Keizer B, Tiede JM. 22(4). 65 - 69. (Journal Article)

Abstract

The flotation-restriction environmental stimulation technique (FR) may have utility as a recovery tool for improving performance in elite competitive athletes and Special Operations Forces Operators (SOs). Studies suggest that FR may ameliorate various neurophysiological disorders and improve performance in recreational and elite athletic populations. We sought to understand whether there is evidence to support the use of FR to enhance physiological and psychological performance parameters in the SO population and to provide postulations as to the mechanisms of action of FR therapy. We performed an online literary search of publications dating from 1982 to 2021 and identified 34 sources addressing the aims, depending on population and condition or conditions, being treated. The reported physiological and psychological benefits of FR range from immediate to lasting 4 months. Overall, eight to twelve FR treatment sessions of from 40 to 90 minutes each may provide variable long-term benefits. The associated synergistic benefits of FR may be attributed to its thermal, chemical, and mechanical effects but deserve further exploration. Based on the current evidence, FR may serve as an effective performance-recovery therapy for improving pain, sleep, and performance measures (e.g., marksmanship and physical performance) in trained, untrained, and healthy adults. Future research focusing on FR as a unimodal recovery intervention is warranted in a specialized group of SOs.

Keywords: adult; humans; pain; sleep; exercise; athletes; physical functional performance

PMID: 36525015

DOI: 98PG-19VH

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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.

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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 the complexities associated with defense support to civil authorities and provides excellent teaching points that may enhance units' expeditionary posture, regardless of mission.

Keywords: force health protection support; natural disaster; Superstorm Sandy

PMID: 25399378

DOI: LTRU-9D2L

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Force Protection Medical Support at National Special Security Events: Experience From the 2016 Republican and Democratic National Conventions

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Tang N, Margolis AM, Woltman N, Levy MJ. 16(3). 72 - 75. (Journal Article)

Keywords:

PMID: 27734447

DOI: PPTP-HTEB

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Foreign Language Short Course: Special Operations Clinical Research Fundamentals

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Rocklein Kemplin K, Bowling F. 17(2). 12 - 17. (Journal Article)

Abstract

When we do not know a language, we are at the mercy of an interpreter. The same is true for research: Special Operations Forces (SOF) clinicians not actively involved in research initiatives may rely on scientific interpreters, so it is important to speak some of the language personally. For any clinician, using evidence in practice requires a working knowledge of how that evidence was generated from research, which requires an understanding of research science language. Here we review common basics of research science to reinforce concepts and elements of experimental and nonexperimental research.

Keywords: research; statistics; statistical analysis

PMID: 28599031

DOI: 3UCQ-5RH2

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Forward Assessment of 79 Prehospital Battlefield Tourniquets Used in the Current War

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King DR, van der Wilden GM, Kragh JF, Blackbourne LH. 12(4). 33 - 38. (Journal Article)

Abstract

Introduction: Battlefield tourniquet use can be lifesaving, but most reports are from hospitals with knowledge gaps remaining at the forward surgical team (FST). The quality of tourniquet applications in forward settings remain unknown. The purpose of this case series is to describe observations of tourniquet use at an FST in order to improve clinical performance. Methods: War casualties with tourniquet use presenting to an FST in Afghanistan in 2011 were observed. We identified appliers by training, device effectiveness, injury pattern, and clinical opportunities for improvement. Feedback was given to treating medics. Results: Tourniquet applications (79) were performed by special operations combat medics (47, 59%), flight medics (17, 22%), combat medics (12, 15%), and general surgeons (3, 4%). Most tourniquets were Combat Application Tourniquets (71/79, 90%). With tourniquets in place upon arrival at the FST, most limbs (83%, 54/65) had palpable distal pulses present; 17% were pulseless (11/65). Of all tourniquets, the use was venous in 83% and arterial in 17%. In total, there were 14 arterial injuries, but only 5 had effective arterial tourniquets applied. Discussion: Tourniquets are liberally applied to extremity injuries on the battlefield. 17% were arterial and 83% were venous tourniquets. When ongoing bleeding or distal pulses were appreciated, medics tightened tourniquets under surgeon supervision until distal pulses stopped. Medics were generally surprised at how tight a tourniquet must be to stop arterial flow - convert a venous tourniquet into an arterial tourniquet. Implications for sustainment training should be considered with regard to this life-saving skill.

Keywords: first aid; hemorrhage; extremity; damage control; resuscitation

PMID: 23536455

DOI: BV5C-T9IG

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Fraction of Inspired Oxygen Delivered by Elisée™ 350 Turbine Transport Ventilator With a Portable Oxygen Concentrator in an Austere Environment

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d'Aranda E, Bordes J, Bourgeois B, Clay J, Esnault P, Cungi P, Goutorbe P, Kaiser E, Meaudre E. 16(3). 30 - 35. (Journal Article)

Abstract

Background: Management of critically ill patients in austere environments is a logistic challenge. Availability of oxygen cylinders for the mechanically ventilated patient may be difficult in such a context. One solution is to use a ventilator able to function with an oxygen concentrator (OC). Methods: We tested two Elisée™ 350 ventilators paired with SeQual Integra 10-OM oxygen concentrators (OC) (Chart Industries, http://www .chartindustries.com) and evaluated the delivered fraction of inspired oxygen (Fio2). Ventilators were connected to a test lung and Fio2 was measured and indicated by the ventilator. Continuous oxygen was generated by the OC from 0.5L/min to 10L/min, and administered by the specific inlet port of the ventilator. Several combinations of ventilator settings were evaluated to determine the factors affecting the delivered Fio2. Results: The Elisée 350 turbine ventilator is able to deliver a high Fio2 when functioning with an OC. However, modifications of the ventilator settings such as an increase in minute ventilation, inspiratory-to-expiratory ratio, and positive end-expiratory pressure affect delivered Fio2 despite steady-state oxygen flow from the concentrator. Conclusion: OCs provide an alternative to oxygen cylinders for delivering high Fio2 with a turbine ventilator. Nevertheless, Fio2 must be monitored continuously, since it decreases when minute ventilation is increased.

Keywords: Mechanical Ventilation; oxygen delivery; oxygen, low-flow; oxygen concentrator; Elisée&tm; 350

PMID: 27734439

DOI: CD5C-3NPJ

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Fracture Detection In A Combat Theater: Four Cases Comparing Ultrasound To Conventional Radiography

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Hubler DA, Lopez RA, Morgan AR, Vasios WN. 10(2). 11 - 15. (Journal Article)

Abstract

Ultrasound (US) is rapid, non-invasive, simple, effective, and presents a viable and practical alternative to conventional radiography (CR) for the Special Forces Medical Sergeant (18D), particularly in the deployed setting. The authors present four cases that illustrate the ability of US used by the 18D to detect fractures in a combat theater. This success invites a debate as to what extent the Special Operations Forces (SOF) community should field US as it demonstrates a number of distinct advantages over the existing gold standard of portable conventional radiography.

Keywords:

PMID: 20936598

DOI: 0AEV-MECT

Freeze Dried Plasma Administration Within the Department of Defense Trauma Registry

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Cuenca CM, Chamy G, Schauer SG. 20(1). 43 - 45. (Journal Article)

Abstract

Hemorrhage is common among the combat injured, and plasma plays a vital role in blood product resuscitation. Regarding freeze dried plasma (FDP), US forces have had limited access to this product compared with other countries. In 2018, the US Food and Drug Administration provided emergency authorization for Department of Defense (DoD) use through the newly congressionally directed military use pathway. We describe the documented uses of FDP by US forces by performing a secondary analysis of two previously described datasets from the DoD Trauma Registry. In 11 identified cases, the median age was 28; cases were most frequently male, part of Operation Enduring Freedom, with US military affiliation, and injured by explosive or gunshot wound. The median injury severity score was 21; most did not receive a massive transfusion. Most survived to hospital discharge. Ongoing surveillance is warranted to optimize the implementation of FDP into military prehospital guidelines, training, and doctrine.

Keywords: freeze dried; plasma; combat; military

PMID: 32203605

DOI: N7HJ-PSME

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Fresh Whole Blood Collection and Transfusion at Point of Injury, Prolonged Permissive Hypotension, and Intermittent REBOA: Extreme Measures Led to Survival in a Severely Injured Soldier-A Case Report

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Lewis C, Nilan M, Srivilasa C, Knight RM, Shevchik J, Bowen B, Able T, Kreishman P. 20(2). 123 - 126. (Journal Article)

Abstract

We present the case of a severely injured Special Operations Servicemember whose care was remarkable for three unique interventions: the first use of a walking blood bank performed at the point of injury, prolonged permissive hypotension, and intermittent resuscitative endovascular balloon occlusion of the aorta (REBOA).

Keywords: resuscitative endovascular balloon occlusion of the aorta; intermittent REBOA; permissive hypotension; walking blood bank; buddy transfusion

PMID: 32573748

DOI: 03EF-6LU6

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Fresh Whole Blood Transfusion for a Combat Casualty in Austere Combat Environment

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Cordova CB, Cap AP, Spinella PC. 14(1). 9 - 12. (Case Reports)

Abstract

There are many challenges to treating life-threatening injuries for a healthcare provider deployed to a remote location in a combat setting. Once conventional treatment protocols for exsanguinating hemorrhage have been exhausted and no medical evacuation platform is available, a nonconventional method of treatment to consider is a fresh whole blood (FWB) transfusion. A FWB transfusion can be a life-saving or life-prolonging intervention in the appropriate setting. The authors present the case of a combat casualty in hypovolemic shock and coagulopathy with delayed medical evacuation to a surgical team. While the ultimate outcome was death in this case report, the patient arrived to a surgical team 15 hours after his injury, alert and oriented. In this scenario, FWB transfusion gave this patient the best chance of survival.

Keywords:

PMID: 24604433

DOI: 6WR8-NER8

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Fresh Whole Blood Transfusion: Perspectives From a Federal Law Enforcement Agency Tactical Program

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Kemp SJ, Levy MJ, Knapp JG, Steiner LA, Tang N. 21(2). 108 - 111. (Journal Article)

Keywords:

PMID: 34105133

DOI: TI5X-7GO1

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Fresh Whole Blood Transfusions In The Austere Environment

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Bowling F, Kerr W. 11(4). 3 - 37. (Journal Article)

Abstract

The use of Fresh Whole Blood (FWB) transfusions can be a powerful tool for the Special Operations Forces (SOF) medic to treat uncontrolled hemorrhage. In fact, it may be the only tool currently available for hemostatic resuscitation, which along with hypotensive resuscitation, forms the basis for Damage Control Resuscitation (DCR). Until now, no comprehensive protocol has existed for conducting FWB transfusions in austere environments. The United States Special Operations Command (USSOCOM) sponsored Curriculum Evaluation Board (CEB), which is responsible for authoring the Tactical Emergency Medical Protocols (TMEPs) has produced a protocol. This article serves as its introduction.

Keywords:

PMID: 22173594

DOI: 023P-R0T2

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From the Trails of Afghanistan to the Streets of America: COL (Ret) Andy Pennardt on Frontline Medical Care

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Godbee DC. 16(4). 118 - 120. (Interview)

Keywords:

PMID: 28088832

DOI: XFBG-7MFK

Front Line Surgery A Practical Approach

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Farr WD. 17(3). 151 - 151. (Book Review)

Abstract

Martin MJ, Beekley AC, editors. Front Line Surgery: A Practical Approach. New York, NY: Springer Science+Business Media; 2011. Paperback, 554 pages. ISBN: 978-1-4419-6078-8.

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Frostbite: A Novel Presentation of Glucose-6-Phosphate Dehydrogenase Deficiency?

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Bowles JM, Joas C, Head S. 15(3). 1 - 3. (Journal Article)

Abstract

Acute hemolytic anemia (AHA) due to glucose 6-phosphate dehydrogenase (G6PD) deficiency has rarely been recognized as a contributor to the development of frostbite. We discuss a case of frostbite in a 32-year-old male Marine with G6PD deficiency during military training on Mount Mckinley in Alaska, which eventually led to a permanent disability. In this report, the pathophysiology of G6PD deficiency, the effects of hemolytic anemia, and factors that contribute to frostbite will be discussed, as well as the clinical findings, treatment course, and the outcome of this case. The patient was evacuated and admitted to Alaska Regional Hospital. He was treated for fourth-degree frostbite, ultimately resulting in the complete or partial amputation of all toes. Although it cannot be proved that AHA occurred in this patient, this case potentially adds frostbite to the list of rare but possible clinical presentations of G6PD deficiency.

Keywords: G6PD Deficiency; frostbite; acetazolamide; acute hemolytic anemia; oxidative stress; reactive oxygen species

PMID: 26360347

DOI: NI1V-GV2Q

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Frostbite: Pathophysiology, Epidemiology, Diagnosis, Treatment, and Prevention

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Knapik JJ, Reynolds KL, Castellani JW. 20(4). 123 - 135. (Journal Article)

Abstract

Frostbite can occur during cold-weather operations when the temperature is <0°C (<32°F). When skin temperature is ≤-4°C (≤25°F), ice crystals form in the blood, causing mechanical damage, inflammation, thrombosis, and cellular death. Lower temperatures, higher wind speeds, and moisture exacerbate the process. The frozen part or area should not be rewarmed unless the patient can remain in a warm environment; repeated freeze/thaw cycles cause further injury. Treatment involves rapid rewarming in a warm, circulating water bath 37°C to 39°C (99°F-102°F) or, if this is not possible, then contact with another human body. Thrombolytics show promise in the early treatment of frostbite. In the field, the depth and severity of the injury can be determined with laser Doppler ultrasound devices or thermography. In hospital settings, bone scintigraphy with single-photon emission computed tomography (SPECT) 2 to 4 days postinjury provides detailed information on the depth of the injury. Prevention is focused primarily on covering exposed skin with proper clothing and minimizing exposure to wind and moisture. The Generation III Extended Cold Weather Clothing System is an interchangeable 12-piece clothing ensemble designed for low temperatures and is compatible with other military systems. The Extreme Cold Vapor Barrier Boot has outer and inner layers composed of seamless rubber with wool insulation between, rated for low temperatures. The Generation 3 Modular Glove System consists of 11 different gloves and mitts with design features that assist in enhancing grip, aid in the use of mobile devices, and allow shooting firearms. Besides clothing, physical activity also increases body heat, reducing the risk of frostbite.

Keywords: temperature; wind; moisture; thrombolytics; laser Doppler ultrasound; bone scintigraphy; computed tolography; Extended Cold Weather Clothing System; Extreme Cold Vapor Barrier Boot; Generation 3 Modular Glove System; physical activity

PMID: 33320326

DOI: PDX9-BG8G

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Functional Screening for Vestibular and Balance Problems Soon After head Injury: Options in Development for the Field or Aid Station

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Lawson BD, Rupert AH, Cho TH. 13(1). 42 - 48. (Journal Article)

Abstract

Vestibular balance dysfunction has been documented as a military problem after duty-related barotrauma and/ or traumatic head acceleration. We are fostering the development of rapid, portable, fieldable tests of balance function after such vestibular insults. We consulted on military-relevant tests with more than 50 vestibular researchers, scientific advisors, clinicians, and biomedical engineers working for government agencies, universities, clinics, hospitals, or businesses. Screening tests and devices appropriate for early (post-injury) military functional assessment were considered. Based on these consultations, we recommend that military field tests emphasize dynamic, functional, and duty-relevant aspects of standing balance, gait, visual acuity, perception of visual vertical, and vertigo. While many current tests are useful for the clinic, they often require modification before they are suitable for military field and aid station settings. This report summarizes likely future military testing needs, giving priority to testing approaches in development that promise to be rapid, portable, field-ready, semiautomated, usable by a nonspecialist, and suitable during testing and rehabilitation.

Keywords:

PMID: 23526321

DOI: ZW27-XMRS

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Functional Training Program Bridges Rehabilitation And Return To Duty

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Gross DL, Christopher GE, Faulk RT. 09(2). 29 - 48. (Journal Article)

Abstract

Traditional clinic-based rehabilitation programs often fall short of returning Soldiers to peak condition prior to releasing them for duty. With the higher physical demands placed on the Special Operations Soldier, a bridge program offers rehabilitation professionals a way to maximize recovery, enhance performance, and hopefully prevent injuries (or re-injury). A six week functional training program is outlined and data collection from over two years is presented. Statistically and operationally significant differences were noted in nearly every category tested. Functional Movement Screen™ scores improved an average of 2.5 points. T-test improvement was 0.5 seconds. Single leg hop time improved 10%. Hop for distance improved approximately 10%. Body fat improvement was statistically significant. Kip-ups improved 32%. Vertical jump height improvement was statistically significant. All subjective fitness category self-evaluations demonstrated statistically significant improvements, except for pain. Data suggests that a program like this may be beneficial to patients and non-patients seeking a safe, effective alternative training regimen.

Keywords:

PMID: 19813517

DOI: L1C4-YR13

Fuzileiros Portugueses (Portuguese Marines)

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Ferreira B. 15(2). 144 - 146. (Journal Article)

Keywords:

PMID: 26125180

DOI: 5FHB-02ZO

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Garlic Burn to the Face

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Oberle M, Wachs T, Brisson P. 16(4). 80 - 81. (Journal Article)

Abstract

Topical burns from the use of garlic have been reported rarely in the medical literature. Most cases have resulted from the use of naturopathic or home remedy treatments. A 20-year-old male military Servicemember presented to a military wound care clinic 7 days after applying a homemade topical preparation of garlic to the zygomatic region of the right side of his face. The patient had consulted the Internet for treatment of a minor skin lesion in that area. He created a garlic paste, applied it to the affected area, and covered it with a dressing. Twelve hours later, he noted an intense burning sensation where he had applied the garlic paste. After the initial blistering, the patient recovered without any additional treatment. Second-degree burns were an unintended consequence of the use of garlic as a home remedy.

Keywords: burns, chemical; garlic; military personnel

PMID: 28088823

DOI: J149-W2LL

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Garrison Clinical Setting Inadequate for Maintenance of Procedural Skills for Emergency Medicine Physicians: A Cross-Sectional Study

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Schauer SG, Varney SM, Cox KL. 15(4). 67 - 70. (Journal Article)

Abstract

Background: Emergency medicine physicians (EPs) are often placed in far-forward, isolated areas in theater. Maintenance of their emergency intervention skills is vital to keep the medical forces deployment ready. The US Army suggests that working at a Military Treatment Facility (MTF) is sufficient to keep emergency procedural skills at a deployment-ready level. We sought to compare the volume of emergency procedures that providers reported necessary to maintain their skills with the number available in the MTF setting. Methods: EPs were surveyed to quantify the number of procedures they reported they would need to perform yearly to stay deployment-ready. We obtained procedure data for their duty stations and compared the procedure volume with the survey responses to determine if working at an MTF is sufficient to keep providers' skills deployment ready. Results: The reported necessary average numbers per year were as follows: tube thoracostomy (5.9), intubation (11.4), cricothyrotomy (4.2), lumbar puncture (5.2), central line (10.0), focused assessment with sonography for trauma (FAST) (21.3), reductions (10.6), splints (10.5), and sedations (11.7). None of the procedure volumes at MTFs met provider requirements with the exception of FAST examinations at the only trauma center. Conclusions: This suggests the garrison clinical environment is inadequate for maintaining procedure skills. Further research is needed to determine modalities that will provide adequate training volume.

Keywords: procedure; skills, procedural; competency, procedural; physicians, emergency medicine; skills; maintenance; deployment; volume

PMID: 26630097

DOI: IJD9-CZNL

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Generating Competent Special Operations Clinicians From Military Graduate Medical Education

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Hiller HM, Hill GJ, Shea S, Fernandes J, Earl K, Knight J, Schaffrinna A, Donham B, Allen PB. 22(3). 37 - 41. (Journal Article)

Abstract

Units within the Special Operations Forces (SOF) community require medically competent and operationally proficient medical providers (physicians, physician assistants, and nurse practitioners, among others) to support complex mission sets. The expectations placed on providers who successfully assess for and are selected into these units are high. These providers are not only expected to be experts in their respective subspecialities, but also to serve as staff officers, provide medical direction for SOF medics, serve as medical advisors to the command team, and provide direct medical support for kinetic operations. They are expected to perform these functions with little oversight and guidance and when geographically separated from higher units. Graduates from military Graduate Medical Education (GME) programs are extremely well-educated and can provide high quality medical care. However, they often find themselves ill-prepared for the extra demands placed upon them by the Special Operations community due to a lack of operational exposure. The authors of this paper recognized this gap and propose that the Joint Emergency Medicine Exercise (JEMX) model can help augment the body of knowledge required to perform well as a provider in a Special Operations unit.

Keywords: military graduate medical education; Special Operations; joint emergency medicine exercise

PMID: 35862844

DOI: H073-BKVG

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Getting "SMART" on Shock Treatment: An Evidence-Based Mnemonic Acronym for the Initial Management of Hemorrhage in Trauma

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Thompson P, Hudson AJ. 19(4). 62 - 65. (Journal Article)

Abstract

Treating hemorrhagic shock is challenging, the pathology is complex, and time is critical. Treatment requires resources in mental bandwidth (i.e., focused attention), drugs and blood products, equipment, and personnel. Providers must focus on treatment options in order of priority while also maintaining a dynamic assessment of the patient's response to treatment and considering potential differential diagnoses. In this process, the cognitive load is substantial. To avoid errors of clinical reasoning and practical errors of commission, omission, or becoming fixated, it is necessary to use evidence-based treatment recommendations that are concise, in priority order, and easily recalled. This is particularly the case in the austere, remote, or tactical environment. A simple mnemonic acronym, SMART, is presented in this article. It is a clinical heuristic that can be used as an aide-mémoire during the initial phases of resuscitation of the trauma patient with hemorrhagic shock: Start the clock and Stop the bleeding; Maintain perfusion; Administer antifibrinolytics; Retain heat; Titrate blood products and calcium; Think of alternative causes of shock.

Keywords: hemorrhage; shock; treatment; mnemonic; acronym; heuristic

PMID: 31910473

DOI: K2ZQ-YDKM

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Giant Basal Cell Carcinoma

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Rivard SS, Crandall ML, Gibbs NF. 14(1). 99 - 102. (Journal Article)

Abstract

Servicemembers are often exposed to extreme environments with sun exposure, often laying the foundation for future skin cancer. Basal cell carcinoma (BCC) is the most common of skin cancers. We present the case of a 36-year-old male active duty Seabee who presents with a left shoulder plaque that initially started as an erythematous papule but has now increased to greater than 6cm in the past 10 years and is diagnosed as giant basal cell carcinoma (GBCC). Although only 0.5% to 1% of BCCs develop into GBCCs, there is the potential for metastasis and even death. This article addresses the concerning and potentially fatal diagnosis of GBCC, including your initial impressions and differential diagnoses, available treatment options, and ways to prevent it from ever occurring in our military population.

Keywords: basal cell carcinoma; giant basal cell carcinoma; enlarging plaque; electrodessication and curettage; UV damage; sun exposure; Seabee; military provider

PMID: 24604447

DOI: XVGN-UHTJ

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Giardiasis

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Burnett MW. 18(1). 106 - 107. (Journal Article)

Keywords: infectious disease; Giardiasis; intestinal parasite; gastroenteritis

PMID: 29533443

DOI: X429-AKS5

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Global Health Language and Culture Competency

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Beadling C, Maza J, Nakano G, Mahmood M, Jawad S, Al-Ameri A, Zuerlein S, Anderson W. 12(4). 10 - 16. (Journal Article)

Abstract

This article presents findings from a survey conducted to examine the availability of foreign language and culture training to Civil Affairs health personnel and the relevance of that training to the tasks they perform. Civil Affairs forces recognize the value of cross-cultural communication competence because their missions involve a significant level of interaction with foreign governments' officials, military, and civilians. Members of the 95th Civil Affairs Brigade (Airborne) who had a health-related military occupational specialty code were invited to participate in the survey. More than 45% of those surveyed were foreign language qualified. Many also received predeployment language and culture training specific to the area of deployment. Significantly more respondents reported receiving cultural training and training on how to work effectively with interpreters than having received foreign language training. Respondents perceived interpreters as important assets and were generally satisfied with their performance. Findings from the survey highlight a need to identify standard requirements for predeployment language training that focuses on medical and health terminology and to determine the best delivery platform(s). Civil Affairs health personnel would benefit from additional cultural training that focuses on health and healthcare in the country or region of deployment. Investing in the development of distance learning capabilities as a platform for delivering health-specific language and culture training may help ease the time and resources constraints that limit the ability of Civil Affairs health personnel to access the training they need.

Keywords:

PMID: 23536451

DOI: 7QKZ-GLC1

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Global Health Language and Culture Competency

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Beadling C, Maza J, Nakano G, Mahmood M, Jawad S, Al-Ameri A, Zuerlein S, Anderson W. 12(3). 10 - 16. (Journal Article)

Abstract

This article presents findings from a survey conducted to examine the availability of foreign language and culture training to Civil Affairs health personnel and the relevance of that training to the tasks they perform. Civil Affairs forces recognize the value of cross-cultural communication competence because their missions involve a significant level of interaction with foreign governments' officials, military, and civilians. Members of the 95th Civil Affairs Brigade (Airborne) who had a health-related military occupational specialty code were invited to participate in the survey. More than 45% of those surveyed were foreign language qualified. Many also received predeployment language and culture training specific to the area of deployment. Significantly more respondents reported receiving cultural training and training on how to work effectively with interpreters than having received foreign language training. Respondents perceived interpreters as important assets and were generally satisfied with their performance. Findings from the survey highlight a need to identify standard requirements for predeployment language training that focuses on medical and health terminology and to determine the best delivery platform(s). Civil Affairs health personnel would benefit from additional cultural training that focuses on health and healthcare in the country or region of deployment. Investing in the development of distance learning capabilities as a platform for delivering health-specific language and culture training may help ease the time and resources constraints that limit the ability of Civil Affairs health personnel to access the training they need.

Keywords:

PMID: 23536451

DOI: PQJU-V81B

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Global Medical Mission Training: The Department of Defense is Making Headway in Training for Global Medical Missions

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Pueschel M. 11(1). 15 - 20. (Journal Article)

Keywords:

PMID: 22113721

DOI: U0WR-0J5E

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Graduate Medical Education in Tactical Medicine and the Impact of ACGME Accreditation of EMS Fellowships

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Tang N, Levy MJ, Margolis AM, Woltman N. 17(1). 101 - 104. (Journal Article)

Abstract

Physician interest in tactical medicine as an area of professional practice has grown significantly over the past decade. The prevalence of physician involvement in terms of medical oversight and operational support of civilian tactical medicine has experienced tremendous growth during this timeframe. Factors contributing to this trend are multifactorial and include enhanced law enforcement agency understanding of the role of the tactical physician, support for the engagement of qualified medical oversight, increasing numbers of physicians formally trained in tactical medicine, and the ongoing escalation of intentional mass-casualty incidents worldwide. Continued vigilance for the sustenance of adequate and appropriate graduate medical education resources for physicians seeking training in the comprehensive aspects of tactical medicine is essential to ensure continued advancement of the quality of casualty care in the civilian high-threat environment.

Keywords: tactical medicine; emergency medicine; law enforcement

PMID: 28285488

DOI: 41BH-E3TT

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Green Ghosts

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Hester RA. 12(2). 103 - 103. (Book Review)

Abstract

Lt Col W.C. Floyd USMC (Ret)
iUniverse, 2004, 2006

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Guardian Angel: Life and Death Adventures with Pararescue, the World's Most Powerful Commando Rescue Force

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Hester RA. 13(1). 72 - 72. (Book Review)

Abstract

William F. Sine
Casemate Publishers. 9/19/2012. ISBN-13: 9781612001227

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Guerrilla Hospital Design and Lessons Learned

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Farr WD. 18(4). 30 - 33. (Journal Article)

Abstract

The author discusses the lessons that can be learned from older sources when engaging in guerilla warfare medicine and surgery.

Keywords: guerilla warfare medicine; guerilla warfare surgery

PMID: 30566721

DOI: OUJ1-91FO

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Guerrilla Surgeon: A Thing of the Past or Warning to the Future?

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Lyon RF. 21(1). 125 - 125. (Book Review)

Abstract

Rogers L. Guerilla Surgeon: A New Zealand surgeon's wartime experiences with the Yugoslav Partisans. Collins: January 1, 1958. ASIN: B000S5M92O. Hardcover.

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Guerrilla Warfare on the Amber Coast

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Farr WD. 17(2). 164 - 164. (Book Review)

Abstract

Tauras KV, Cherne L. Guerrilla Warfare on the Amber Coast. New York, NY: Lithuanian Research Institute, Voyages Press; 1962. Hardback, 121 pages. ASIN: B06XGNDM5K (ISBN-10: 1258496593 / ISBN-13: 978-1258496593 for newer reprints). Review by COL (Ret) Warner "Rocky" D. Farr, MD, MPH

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Guidelines For Implementing Medical Operations In The Counterinsurgency (COIN) Fight: A Framework For Engagement

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Hamid S. 11(3). 7 - 11. (Journal Article)

Abstract

Several articles have been published over the last decade that describe the current role of medical operations (variously known as MEDCAPS- Medical Civic Action Programs, CMEs- Co-Operative Medical Engagements, etc.) in COIN and stability operations. Many of these articles focus on the experiences of healthcare and support personnel and their observations of inappropriately used U.S. Military healthcare resources. These medical assets were often used to provide fragmented and direct patient care to local populations. These operations were conducted in a non-sustainable fashion. Most importantly, poorly organized efforts damage COIN efforts and alienate local populations. Effective medical operations must be nested within the larger realm of overall COIN actions. In this paper, a fundamental framework is presented to align medical operations within COIN missions.

Keywords:

PMID: 21706455

DOI: 3YB3-Y8TZ

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Gunshot Wound to the Distal Phalanx: A Case Review

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Hoy RD, Paul J. 13(1). 58 - 60. (Journal Article)

Abstract

Background: This report describes the case of a Soldier who sustained a gunshot wound from a 9mm to the distal phalanx and presented to the authors while they were deployed on a recent joint training mission to Southwest Asia.

Keywords:

PMID: 23526324

DOI: T3FS-GI2Y

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Gunshotwounds In Militaryworking Dogs

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Baker JL, Truesdale CA. 08(1). 120 - 121. (Journal Article)

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Hand Injuries

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Banting J, Meriano T. 17(4). 93 - 96. (Journal Article)

Keywords:

PMID: 29256203

DOI: G5MX-DCAW

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Hazards Of Dietary Supplement Use

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Johnson AE, Haley CA, Ward JA. 07(1). 30 - 38. (Journal Article)

Abstract

Introduction: An ergogenic aid is any agent used to enhance energy production and/or utilization with the intent to improve performance in a particular sport or activity. Dietary supplements are consumed for their potential ergogenic effects by Soldiers seeking to improve physical performance. However, these agents are not regulated by the United States Food and DrugAdministration (FDA). The long-term health effects of these unregulated dietary supplements are unknown. The purpose of this study is to establish the incidence of dietary supplement use in a U.S. Army combat unit and to present a brief review of the literature on the documented adverse reactions related to dietary supplements use. Methods: 750 Rangers from the U.S. Army 1st Ranger Battalion were administered an anonymous, self-reported, survey concerning recreational and competitive athletic participation, participation in weight training, ergogenic supplement use, and sources of nutritional information. All surveys were administered by the battalion surgeon. The data was analyzed using the Pearson's Chi-square with continuity correction method of analysis. Results: 294 Rangers (39.5%) completed the questionnaire. One hundred and nine (37%) of the responders admitted to using at least one dietary supplement. The average age of the respondent was 23 years. Dietary supplement use was associated with participation in recreational athletics and weight training. Protein supplements were the most common supplement, followed by creatine and thermogenics respectively. Less than 1% used anabolic steroids. The most commonly cited source for nutritional information concerning ergogenic supplements is another Soldier, followed closely by fitness magazines. Less than 10% cited the unit surgeon or local nutritionist. Conclusions: Dietary supplement use in the surveyed unit is similar to rates reported for other athletic organizations. As the long-term health effects are unknown, the decision to consume dietary supplements should be carefully deliberated. Unit surgeons are uniquely situated to advise these Soldiers.

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Headache

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Banting J, Meriano T. 17(2). 108 - 111. (Journal Article)

Keywords:

PMID: 28599042

DOI: WYDV-Z6ZF

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Heat Tolerance Testing and the Return to Duty Decision: A Two-Year Case Cohort Analysis

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Kester R, Abraham PA, Leggit JC, Harp JB, Kazman JB, Deuster PA, O'Connor FG. Ahead of Print. (Journal Article)

Abstract

Background: Among individuals with prior exertional heat illness (EHI), heat tolerance testing (HTT) may inform risk and return to duty/activity. However, little is known about HTT's predictive validity, particularly for EHI recurrence. Our project sought to demonstrate the predictive validity of HTT in EHI recurrence and HTT's utility as a diagnostic tool in exertional heat stroke (EHS). Methods: Participants with prior EHS were recruited for the study by a physician's referral and were classified as heat tolerant or intolerant after completing demographics and an HTT. Participants were further categorized as single/simple (SS) EHI or recurrent/complex (RC) EHI by conducting a retrospective record review of the following two years. We calculated the positive (PPV) and negative predictive values (NPV) of HTT. Results: The retrospective review of HTT records was used to categorize 44% of Servicemembers as RC, with 77% classified as heat tolerant, 14% as heat intolerant, and 9% as borderline. When borderline cases were classified as heat intolerant, HTT had a high NPV, indicating a high probability that heat-tolerant individuals did not have recurrent EHI. When borderline cases were classified as heat tolerant, NPV and sensitivity decreased while specificity increased. Conclusion: We demonstrated that the HTT had a 100% NPV for future EHI over two years of follow-up for Servicemembers with a history of recurrent heat injury and negative HTT results. An HTT can provide critical data points to inform return to duty decisions and timelines by predicting the risk of EHI recurrence.

Keywords: exertional heat stroke; heat stroke; heat tolerance testing; return to duty; heat tolerance; exertional heat illness; recurrent heat injury

PMID: 38360027

DOI: W7TV-MBRZ

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Helicopter Crashes in the Deployed Combat Setting: The Department of Defense Trauma Registry Experience

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Jude JW, Spanier AM, Hiller HM, Weymouth WL, Cunningham CW, Hill GJ, Schauer SG. 22(3). 57 - 61. (Journal Article)

Abstract

Background: Military helicopter mishaps frequently lead to multiple casualty events with complex injury patterns. Data specific to this mechanism of injury in the deployed setting are limited. We describe injury patterns associated with helicopter crashes. Materials and Methods: This is a secondary analysis of a Department of Defense Trauma Registry (DODTR) dataset from 2007 to 2020 seeking to describe prehospital care within all theaters in the registry. We searched within the dataset for casualties injured by helicopter crash. A serious injury was defined by an abbreviated injury scale of =3 by body region. Results: We identified 120 casualties injured by helicopter crash within the dataset. Most were Army (64%), the median age was 30 (interquartile range [IQR] 26-35), and most were male (98%), enlisted service members made up the largest cohort (47%), with most injuries occurring during Operation Enduring Freedom (69%). Only 2 were classified as battle injuries. The median injury severity score was 9 (IQR 4-22). Serious injuries by body region are the following: thorax (27%), head/neck (17%), extremities (17%), abdomen (11%), facial (3%), and skin/superficial (1%). The most common prehospital interventions focused on hypothermia prevention/management (62%) and cervical spine stabilization (32%). Most patients survived to hospital discharge (98%). Conclusions: Serious injuries to the thorax were most common. Survival was high, although better data capture systems are needed to study deaths that occur prehospital that do not reach military treatment facilities with surgical care to optimize planning and outcomes. The high proportion of nonbattle injuries highlights the risks associated with helicopters in general.

Keywords: helicopter crash; rotary wing mishap; mass casualty; traumatic resuscitation; military medicine

PMID: 35877978

DOI: AVOQ-PATS

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Hemoglobin-Based Oxygen Carrier for the Reconstitution of Canine Freeze-Dried Plasma in an In Vitro Model of Resuscitation

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Edwards TH, Meledeo MA, Peltier GC, Henderson AF, Hammill RM, McIntosh CS, Bynum JA. 22(1). 111 - 114. (Journal Article)

Abstract

Military working dogs (MWDs) are force multipliers that are at risk for severe trauma when employed on the battlefield. When in severe hemorrhagic shock, MWDs require both oxygen- carrying capacity and replacement of vascular volume and coagulation factors. The objective of this study was to evaluate the hemostatic capacity of canine freeze-dried plasma (cFDP) with a Food and Drug Administration (FDA)-approved hemoglobin- based oxygen carrier (HBOC) in an in vitro model of resuscitation. Whole blood (WB) was collected from 10 MWDs, and these samples were diluted by 10%, 25%, or 40% with either cFDP (reconstituted with water), HBOC, cFDP (reconstituted with HBOC), or an equal volume of a 1:1 ratio of cFDP (reconstituted with water) and HBOC. Hemostatic parameters were minimally changed based on evaluation of prothrombin time, activated partial thromboplastin time, fibrinogen and thromboelastography at the 10% and 25% dilutions, and parameters consistent with a hypocoagulability were seen at dilutions of 40%. Based on the results of this study, additional research is warranted to determine if cFDP reconstituted with HBOC is a viable resuscitation product in canine trauma.

Keywords: canine; hemoglobin-based oxygen carrier; freezedried plasma; oxyglobin; thromboelastography; dogs

PMID: 35278326

DOI: YEYM-XU23

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Hemorrhage Control Devices: Tourniquets and Hemostatic Dressings

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Holcomb JB, Butler FK, Rhee P. 15(4). 153 - 156. (Journal Article)

Keywords:

PMID: 26630111

DOI: N26T-EG95

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Hepatitis E

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Burnett MW. 17(3). 114 - 115. (Journal Article)

Keywords: infectious disease; hepatitis E virus; acute icteric hepatitis

PMID: 28910479

DOI: PDPW-9ZPJ

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High Intensity Scenario Training of Military Medical Students to Increase Learning Capacity and Management of Stress Response

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Mueller G, Moloff A, Wedmore I, Schoeff J, LaPorta AJ. 12(2). 71 - 76. (Journal Article)

Abstract

A delicate balance exists between a beneficial stress response that enhances memory and recall performance and a detrimental high stress response that impairs memory and learning. Repetitive training in stressful situations enables people to lower their stress levels from the detrimental range to a more beneficial one.1 This is particularly true for physicians in training as they seek to achieve advanced skills and knowledge in the fields of triage, emergency medicine, and surgery prior to graduation. This need is significant for medical students entering military service after graduation. We theorize that military medical students can advance their proficiencies through an Intensive Skills Week (ISW) prior to entering their third and forth year rotations. To test this theory, Rocky Vista University will hold a week long high-intensity first-responder, emergency medicine and surgical training course, facilitated by military medical physicians, to further students' skills and maximize training using the Human Worn Partial Surgical Task Simulator (Cut Suit). We also see the possible benefit to physician and non-physician military personnel, especially Special Operations Forces (SOF) medical personnel, from developing and implementing similar training programs when live tissue or cadaver models are unavailable or not feasible.

Keywords: stress; cortisol; medical student; enhanced learning scenario; high intensisty

PMID: 22707028

DOI: RLC0-OPXD

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Hiv Postexposure Prophylaxis For Special Forces Soldiers

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Lutz RH, Carlton D, Taylor SF. 09(1). 10 - 15. (Journal Article)

Abstract

Exposure to human immunodeficiency virus (HIV) is a recognized occupational hazard to healthcare personnel. The virus also presents an operational hazard to deployed Special Operations Forces (SOF) personnel. Management guidelines for work related exposure to HIV mainly deal with healthcare workers in a first world hospital environment. Formal guidelines for postexposure prophylaxis (PEP) regarding potential HIV exposure in third world environments have not been established. SOF personnel deploy to regions such as sub-Saharan Africa with a reported HIV prevalence of 35% or higher. This article examines the case of a SOF servicemember exposed to HIV in a confrontation with host nation personnel, the problems with trying to utilize current CDC guidelines and host-nation healthcare capabilities, and a proposed solution devised to ensure appropriate PEP in future cases.

Keywords:

PMID: 19813343

DOI: PFA1-5G64

Hot Dogs: Not Just Backyard Fun A K-9 Heat Injury Case Study

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LeClair TG. 11(4). 66 - 68. (Journal Article)

Keywords:

PMID: 22173600

DOI: 3XDM-Y064

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Hot, Warm, and Cold Zones: Applying Existing National Incident Management System Terminology to Enhance Tactical Emergency Medical Support Interoperability

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Pennardt A, Schwartz RB. 14(3). 78 - 79. (Editorial)

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PMID: 25344711

DOI: ONF2-WPXE

How the Five Principles of High Reliability Organizations Align with the Five Truths of Special Operations

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Biggs A, Jewell J, Littlejohn LF. 23(2). 94 - 98. (Journal Article)

Abstract

Special Operations medicine must provide highly reliable healthcare under intense and sometimes dangerous circumstances. In turn, it is important to understand the principles inherent to building a High Reliability Organization (HRO). These principles include (1) sensitivity to operations; (2) preoccupation with failure; (3) reluctance to simplify; (4) resilience; and (5) deference to expertise. Understanding them is crucial to turning good ideas into sound practical benefit in operational medicine. A prime teaching opportunity involves an interesting coincidence that occurred during the emergence of HROs. Specifically, United States Special Operations Command (USSOCOM) adopted five Special Operations Forces (SOF) Truths that contribute to success in Special Operations, including (1) humans are more important than hardware; (2) quality is better than quantity; (3) SOF cannot be mass produced; (4) competent SOF cannot be created after emergencies occur; and (5) most Special Operations require non-SOF support. These five Truths have more in common with the five HRO principles than merely quantity. They describe the same underlying ideas with a key focus on human performance in high-risk activities. As such, when presented alongside the five HRO principles, there is an opportunity to improve the overall health and performance of SOF personnel by integrating these principles across the range of Special Operations medicine from point of injury care to garrison human performance initiatives. The following discussion describes in greater detail the five HRO principles, the five SOF Truths, and how these similar ideas emerged as more than just a useful coincidence in illustrating the key concepts to produce high performance.

Keywords: Special Operations; high reliability organization; HRO; resilience

PMID: 37126777

DOI: HOBU-RZGM

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How the International Special Training Centre Is Training World-Class Medics: An Outline of the NATO Special Operations Combat Medic Course

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Christensen JB. 18(3). 103 - 108. (Journal Article)

Abstract

The North Atlantic Treaty Organization (NATO) Special Operations Combat Medic (NSOCM) course is specifically designed to train 24 highly selected Special Operations Forces (SOF) members to treat trauma and nontrauma patients who have life-threatening diseases and/or injuries. The NSOCM course is held at the International Special Training Centre (ISTC) in Pfullendorf, Germany, and exemplifies ISTC's mission to build interoperability and strengthening alliances between multinational partners. The 24-week NSOCM course is taught by subject matter experts and SOF members from around the globe. Building interoperability and capacity with common NATO standards is crucial to medical support of all future SOF missions where military units and other small elements will be vitally dependent on each other for combined missions at the regional, national, or NATO level. A better understanding and knowledge of the current SOF medic role and the capabilities they need to bring to the battlefield will help advance their scope from the "classic" trauma scenarios to the more advanced clinical medicine and prolonged field care situations. The NSOCM must become a critical-thinker and be able to recognize and treat these health risks and conditions in remote, austere environments, finding the right solution with a limited arsenal at their disposal. The ISTC-NSOCM course is designed to help bridge this gap and raise situational awareness for the NATO on-the-ground medical professionals to ensure "the more they know the more apt they are to save a life." In essence, it is ISTC's goal to meet these challenges by training NSOCMs to meet these multidimensional demands. This article outlines ISTC's development and design of the NSOCM course and new adaptations as we move forward into our third year of training world-class medics.

Keywords: NATO; International Special Training Centre; Special Operations Combat Medic; training

PMID: 30222847

DOI: KQ3U-OYBO

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Human Bocavirus as a Possible Contributor to Respiratory Disease in the Georgian Military Population

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Akhvlediani N, Walls S, Latif NH, Markhvashvili N, Javakhishvili N, Mitaishvili N, Marliani D, Hering K, Washington MA. 20(4). 100 - 103. (Journal Article)

Abstract

The coronavirus disease 2019 (COVID-19) pandemic has demonstrated that new and devastating respiratory pathogens can emerge without warning. It is therefore imperative that Special Operations medical personnel be aware of the presence of emerging pathogens within their area of operation. Human bocavirus (HBoV) is a newly described member of a family of viruses known as the Parvovirinae that are often associated with acute respiratory illness. The presence of HBoV in the country of Georgia has not been previously reported. Nasal and throat swabs were collected from 95 symptomatic members of the Georgian military. HBoV was detected in 11 of them (12%). To our knowledge, this is the first report of HBoV infection in the country of Georgia. This finding may have a significant impact on members of the Special Operations community who train in Georgia as more data concerning the transmission, pathogenesis, and treatment of HBoV are accumulated and the role of HBoV in human disease is more clearly defined.

Keywords: coronavirus disease 2019; COVID-19; respiratory pathogens; bocavirus; human bocavirus

PMID: 33320321

DOI: FPTJ-23I7

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Human Performance Optimization and Precision Performance: The Future of Special Operations Human Performance Efforts

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Russell A, Deuster PA. 17(1). 80 - 89. (Journal Article)

Abstract

The Precision Medicine Initiative (PMI) was launched by the White House to promote individualized medicine. Although the focus of the PMI is on curing disease, we introduce the concept of Precision Performance (P2)- advances that might "enable a new era of human performance optimization through research, technology, and policies that empower warfighters and those who support them to work together toward development of individually optimized performance" (The White House, 2015). We provide a limited review of the current state of the science in human performance optimization (HPO) and show that averages among individuals can be both misleading and potentially counterproductive. Several examples where individual differences have historically presented challenges to HPO research and application are provided, as are ideas on how such differences might be leveraged to enable new opportunities to approach the goal of individually optimized human performance. We end with a few questions likely to be of increasing importance if the notion of P2 continues to evolve and mature; we also provide limited recommendations, given this is a nascent concept. The Special Operations Forces human performance programs can move the science forward by considering and then implementing the infrastructures, processes, and approaches to best identify and exploit emerging tools for ever greater and faster P2 data collection, analyses, sharing, and applications.

Keywords: human performance optimization; precision performance; human performance programs; Precision Medicine Initiative; individualized care

PMID: 28285485

DOI: XFYJ-EQUN

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Human Performance Optimization: An Operational and Operator-Centric Approach

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Lunasco T, Chamberlin RA, Deuster PA. 19(3). 101 - 106. (Journal Article)

Abstract

USSOCOM invests millions of dollars in the assessment, selection, and training of its Operators. Handpicked and forged to defend their nation, each Operator emerges from initial and career field training with unique skills and honed talents integral to their unit's effectiveness, sustainability, and mission success. The need for SOF unit commanders to optimize and preserve the talents of their Operators was highlighted as a top priority in the 2018 National Defense Strategy. Human performance optimization (HPO) offers a paradigm shift to support that priority by grounding health and performance services in the unique needs, cultures, skills, and missions of SOF Operators at the career field and unit level. Currently, HPO efforts continue to inform Military Health System (MHS) realignment efforts towards this paradigm shift; however, significant gaps still exist due to a lack of definitional clarity around HPO as a conceptual framework and to the unequal operationalization of HPO across the Department of Defense (DoD). To synergize health and performance efforts through HPO and provide SOF unit commanders with the tools they need to sustain the optimal performance of their operational forces over a career lifespan, this review builds upon previous work in HPO and highlights the operationalization of HPO on a tactical level to support units' Mission Essential Task List (METL) and Operator's Core Tasks (CT). Through returning to HPO's tenets, this review discusses how performance and health priorities of an Operational community can be identified in order to enhance the targeting of performance and health efforts. Last, we present a community-based model for mapping these priorities.

Keywords:

PMID: 31539442

DOI: SN5G-CMOA

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Humanitarian Struggle in Burma's Conflict Zones

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Gyo M. 17(3). 95 - 99. (Journal Article)

Abstract

The Back Pack Health Worker Team (BPHWT), a community- based health organization, provides primary health care to ethnic people in conflict, remote, and internally displaced areas, in Burma (aka Myanmar), controlled by ethnic armed organizations fighting against the Burma government. Its services include both curative and preventative health care through a network of 1,425 health personnel including community health workers and village-embedded traditional birth attendants and village health workers. The BPHWT organizational and program model may prove useful to Special Operations medical actions in support of insurgent movements and conversely with a host nation's counterinsurgency strategies, which include the extension of its health services into areas that may be remote and/or inhabited by indigenous people and have insurgency potential. In the former respect, special attention is directed toward "humanitarian struggle" that uses health care as a weapon against the counterinsurgency strategies of a country's oppressive military.

Keywords: Back Pack Health Worker Team; Burma; health care; humanitarianism

PMID: 28910477

DOI: Y95F-ASKN

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Humanitarian Surgical Missions: Guidelines for Successful Anesthesia Support

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Fitzgerald BM, Nagy CJ, Goosman EF, Gummerson MC, Wilson JE. 17(4). 56 - 62. (Journal Article)

Abstract

Many anesthesiologists and CRNAs are provided little training in preparing for a humanitarian surgical mission. Furthermore, there is very little published literature that outlines how to plan and prepare for anesthesia support of a humanitarian surgical mission. This article attempts to serve as an in-depth planning guide for anesthesia support of humanitarian surgical missions. Recommendations are provided on planning requirements that most anesthesiologists and CRNAs do not have to consider on routinely, such as key questions to be answered before agreeing to support a mission, ordering and shipping supplies and medications, travel and lodging arrangements, and coordinating translators in a host nation. Detailed considerations are included for all the phases of mission planning: advanced, mission-specific, final, mission-execution, and postmission follow-up planning, as well as a timeline in which to complete each phase. With the proper planning and execution, the anesthetic support of humanitarian surgical missions is a very manageable task that can result in an extremely satisfying sense of accomplishment and a rewarding experience. The authors suggest this article should be used as a reference document by any anesthesia professional tasked with planning and supporting a humanitarian surgical mission.

Keywords: humanitarian surgical mission; anesthesia; planning

PMID: 29256196

DOI: 4E3X-VT6H

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Hydration: Tactical and Practical Strategies

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Scott J, Linderman JR, Deuster PA. 23(1). 88 - 91. (Journal Article)

Abstract

Full-spectrum Human Performance Optimization (HPO) is essential for Special Operations Forces (SOF). Adequate hydration is essential to all aspects of performance (physical and cognitive) and recovery. Water losses occur as a result of physical activity and can increase further depending on clothing and environmental conditions. Without intentional and appropriate strategic hydration planning, Operators are at increased risk for degradation in performance and exertional heat illness. The purpose of this article is to highlight current best practices for maintaining hydration before, during, and after activity, while considering various environmental conditions. Effective leadership and planning are necessary for preparing Operators for successful military operations.

Keywords: hydration; Special Operations Forces; SOF; human performance optimization; HPO; nutrition

PMID: 36827684

DOI: QOBG-HTOX

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Hypertension And The SOF Warrior

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Horsley GW. 07(1). 44 - 47. (Journal Article)

Abstract

Many Soldiers regard hypertension is an innocuous disease. It is something that happens to civilians and older people; something that can be taken care of at home station. These are dangerous assumptions. There are Special Operations Forces Soldiers whose hypertension is not adequately controlled resulting in permanent end organ damage. This refresher on hypertension is integrated into a case study of one such Soldier.

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Hypertonic Saline for Severe Traumatic Brain Injury With Herniation: A Military Prehospital Case Report

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Michael R, Gaddy M, Antonino N, Payne R, DeSoucy ES, Rush JT. 22(3). 98 - 100. (Journal Article)

Abstract

Severe traumatic brain injury (sTBI) is a devastating injury with limited prehospital therapies available. The Joint Trauma System (JTS) Clinical Practice Guidelines recommend hypertonic saline (HTS) for casualties with sTBI and signs of impending or ongoing herniation (IOH), but its use by combat medics has never been reported in the literature. This report details the management of a pregnant patient with sTBI and signs of IOH, including the use of HTS, by US Air Force pararescumen in an austere prehospital setting. Treatment with HTS was followed by improvement in the patient's neurologic exam and successful evacuation to definitive care where her child was delivered alive. Additionally, we review the pathophysiology and signs of herniation, the mechanism of action of hyperosmotic therapies, and the rationale behind the use of HTS in the combat setting.

Keywords: impending ongoing herniation; IOH; hypertonic saline; hypertonic sodium chloride; military medicine; brain herniation; TBI; traumatic brain injury

PMID: 35862837

DOI: VB07-GJN5

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Hypolipidemia in a Special Operations Candidate: Case Report and Review of the Literature

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Strain JE, Vigilante JA, DiGeorge NW. 15(4). 1 - 5. (Journal Article)

Abstract

Background: A 19-year-old male military recruit who presented for a screening physical for US Naval Special Warfare Duty was found to have hypolipidemia. Medical history revealed mildly increased frequency of bowel movements, but was otherwise unremarkable. His presentation was most consistent with heterozygous familial hypobetalipoproteinemia (FHBL), and the patient was cleared for Special Operations duty. Methods: A literature search was conducted using PubMed/MEDLINE. Keywords included familial hypobetalipoproteinemia, heterozygous familial hypobetalipoproteinemia, abetalipoproteinemia, hypolipidemia, diving, special operations, and military. Results that included cases of familial hypobetalipoproteinemia were included. Results: Review of the literature reveals that FHBL is a genetic disorder frequently, but not always, due to a mutation in the apolipoprotein B (apoB) gene. Those with the condition should be screened for ophthalmologic, neurologic, and gastrointestinal complications. Analysis of the disease, as well as the absence of reported cases of FHBL in diving and Special Operations, suggest there is minimal increased risk in diving and Special Operations for patients who are likely heterozygous, are asymptomatic, and have a negative workup for potential complications from the disease. Conclusion: Individuals with presumed or proven heterozygous FHBL seeking clearance for Special Operations duty should be given precautions, undergo careful questioning for history of disease-specific complications, and should have a baseline evaluation. If negative, it seems reasonable to clear the patient for Special Operations and diving.

Keywords: hypobetalipoprotteinemia, familial; hypobetalipoprotteinemia, heterozygous familial; abetalipoproteinemia; hypolipidemia; diving; Special Operations; military

PMID: 26630090

DOI: 8AF7-1QDL

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I Can't Breathe-A SIPe of Water

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Urbaniak MK, Hampton K. 18(1). 145 - 145. (Journal Article)

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PMID: 29533451

DOI: AZJ0-L6JS

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I Remember Nothing More: A Doctor's Powerfully Moving Memoir of Her Struggle to Save the Children of the Warsaw Ghetto

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Farr WD. 13(3). 109 - 109. (Book Review)

Abstract

Adina Blady Szwajger. I Remember Nothing More. New York, NY: Simon and Schuster; 1988.
205 pages. ISBN 0-671-76038-6.

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PMID: 24049002

DOI: IXGL-QAOZ

I See Red! Red Light Illumination in Helicopter Air Ambulance Services

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Schober P, Schwarte LA. 19(3). 22 - 23. (Journal Article)

Abstract

Helicopter air ambulance services (HAA) increasingly operate during darkness, and the cockpit crew prefers a dimmed light to be used in the cabin. Our HAA team is currently researching the use of dimmed red light. We encountered a downside to the use of red light-some texts and symbols became virtually invisible.

Keywords: helicopter; air ambulance; red light

PMID: 31539429

DOI: R6AI-02MV

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I Was a Stranger

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Farr WD. 20(4). 141 - 141. (Book Review)

Abstract

Hackett JW. I Was a Stranger. Boston, MA: Houghton Mifflin Company; 1978. ISBN: 0-395-27087-1 and ISBN-13: 978-0395270875. 220 pages, hardback.

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Identification and Management of Bed Bug Infestations in Austere Environments

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Amodt ZT. 13(4). 6 - 11. (Journal Article)

Abstract

Military forces have missions that send them all over the globe. With the reemergence of bed bugs worldwide, the possibility of Servicemembers encountering them has increased. Special Operations Forces are often sent to locations that may not have integrated pest management support. Knowing how to identify and manage a bed bug infestation, with and without proper equipment and supplies, may become necessary in the very near future. It is also important that Servicemembers are aware of how bed bugs travel, to prevent their dispersal back to the United States and into their barracks and homes.

Keywords: bed bugs; bat bugs; infestations; austere environments; pest management

PMID: 24227555

DOI: ARIY-E41N

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Identification of Potentially Preventable Traumatic Injury Among Military Working Dogs Deployed During the Global War on Terror

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Cwikla J, Edwards TH, Giles JT, Kennedy S, Smith B, Gimeno Ruiz de Porras D, Scott LL. 22(4). 122 - 129. (Journal Article)

Abstract

Background: Prevention of deployment-related injury is critical for readiness of US military working dogs (MWDs). This study evaluated deployment-related injuries to determine if they were potentially preventable and identify possible abatement strategies. Methods: Data were collected on 195 MWD injury events that occurred between 11 September 2001 and 31 December 2018. Injuries were reviewed by a panel of veterinarians and categorized into groups based on panel consensus. The panel also established which interventions could have been effective for mitigating injuries. Multipurpose canine (MPC) and conventional MWD injury event characteristics were compared to identify meaningful differences. Results: Of the 195 injuries, 101 (52%) were classified as preventable or potentially preventable. Most (72%) of the potentially preventable injuries occurred in conventional MWDs, with penetrating injuries (64%) being the most common type of trauma. For the preventable/potentially preventable injuries, the most common preventative intervention identified was handler training (53%) followed by protective equipment (46%). There were differences between MPCs and conventional MWDs for injury prevention category, type of trauma, mechanism of injury, and preventative intervention (all p < .001). Conclusion: The application of a preventable review process to MWD populations may be beneficial in identifying potentially preventable injuries and preventative intervention strategies.

Keywords: military working dogs; traumatic injury; injury prevention, canine

PMID: 36525025

DOI: TH1B-VL8O

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Imaging Comparison of Pelvic Ring Disruption and Injury Reduction With Use of the Junctional Emergency Treatment Tool for Preinjury and Postinjury Pelvic Dimensions: A Cadaveric Study With Computed Tomography

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Gary JL, Kumaravel M, Gates K, Burgess AR, Routt ML, Welch T, Podbielski JM, Beeler AM, Holcomb JB. 14(4). 30 - 34. (Journal Article)

Abstract

Objective: Complex dismounted blast injuries from (improvised) explosive devices have caused amputations of the lower extremities associated with open injuries to the pelvic ring, resulting in life-threatening hemorrhage from disruption of blood vessels near the pelvic ring. Provisional stabilization of the skeletal pelvis by circumferential pelvic compression provides stability for intrapelvic clots and reduces the volume of the pelvis, thereby limiting the amount of hemorrhage. The Junctional Emergency Treatment Tool™ (JETT™; North American Rescue Products, http://www.narescue .com) is a junctional hemorrhage control device developed to treat pelvic and lower extremity injuries sustained in high-energy trauma on the battlefield and in the civilian environment. Our purpose was to evaluate the compressive function of the JETT in the reduction of pelvic ring injuries in a cadaveric model. Methods: Radiographic comparison of pre (intact) and post pelvic ring disruption and injury was compared with radiographic measurements post reduction with the JETT device in two cadavers. The device's ability to reduce pelvic disruption and injury in a human cadaver model was assessed through measurements of the anteroposterior (AP) and transverse diameters obtained at the inlet and outlet of the pelvis. Results: Computed tomography (CT) scans demonstrated that JETT application effectively induced circumferential soft tissue compression that was evoked near anatomic reduction of the sacroiliac joint and symphysis pubis. Conclusions: The JETT is capable of effectively reducing an AP compression type III injury (APC III) pelvic ring disruption and injury by approximating the inlet and outlet dimensions toward predisruption measurements. Such a degree of reduction suggests that the JETT device may be suitable in the acute setting for provisional pelvic stabilization.

Keywords: open book pelvis; pelvic binder; wounds and injuries; hemorrhage, junctional; combat casualty care; pelvic ring disruption and injury; APC III injuries

PMID: 25399365

DOI: WDI0-7Q18

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Immediate Paramedic Tactical Response Unit in a Civilian Emergency Medical Service: The First Year Experience

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Kamarainen A, Virtanen J, Lintunen J, Kolkkinen J, Nykopp I, Isotalo M, Valimaa J, Uotila T. 21(1). 90 - 93. (Journal Article)

Abstract

Purpose: An immediate paramedic tactical response unit was implemented into a civilian emergency medical services (EMS) system. This was compared with the preexisting traditional tactical EMS support (TEMS). The primary aim of the study was to evaluate the effect on tasking frequencies. The secondary aims of the study were to assess mission timings and the effect on patient encounters. Methods: Paramedics with tactical emergency medical training provided immediate response on a 24/7 basis. They responded to support police in high-risk TEMS scenarios and incidents in a Tactical Emergency Casualty Care (TECC) role. Tasking frequencies, timings, and clinical input were compared between the first year of immediate response and 3 preceding years of TEMS. Results: The number of TEMS dispatches increased from an average of 5 to 54 annually. The median time from dispatch to scene arrival decreased from a median of 54 minutes (interquartile range [IQR] 39-65) to 17 minutes (IQR 11-26) (p < .0001). The overall mission duration decreased from a median of 3 hr 13 min (IQR 2 h 29 min to 4 h 40 min) to 1 h 12 min (IQR 34 min-1 h 18 min) (p < .0001). The number of treated patients increased from one minor injury annually to 13 severe and six minor injuries annually. Conclusions: Implementing immediate tactical paramedic response significantly decreases response time and mission duration and increases the number of activations and resultant number of treated patients.

Keywords: paramedics; tactical response unit; emergency medical services; Tactical Emergency Casualty Care (TECC); Finland

PMID: 33721313

DOI: N8EW-ME22

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Immunoglobulin M and Immunoglobulin G Seronegative Q Fever: A Hypothesis for Veterans' Medically Unexplained Chronic Multi-symptom Illnesses

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Chagaris MJ, Smith RC, Goldstein AL. 12(1). 37 - 48. (Journal Article)

Abstract

We present Q fever as a credible hypothesis for Gulf War Veterans' Illnesses (GWVIs) and as a possible etiology for prevalent symptomologies affecting currently serving servicemembers. Q fever is caused by the bacteria Coxiella burnetii, which is endemic throughout the Middle East. Q fever may manifest in many forms of widely varying and often inconstant symptoms. Due to false-negative interpretations in current and past diagnostic testing, Q fever has not received appropriate consideration as a possible causative agent for medically unexplained veterans' illnesses. Review of current literature invites us to consider that a form of Q fever involving an incomplete immune response is a potential cause of these debilitating illnesses. We hypothesize C. burnetii infection coincidental to exposures suppressing antibody-specific immune response results in infection mediated by immunoglobulin D (IgD). Literature indicates that successful treatment for this form of Q fever requires the concurrent administration of doxycycline and hydroxychloroquine.

Keywords:

PMID: 22427048

DOI: ORKO-HS6U

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Impact of a 10,000-m Cold-Water Swim on Norwegian Naval Special Forces Recruits

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Melau J, Hisdal J, Solberg PA. 21(3). 55 - 59. (Journal Article)

Abstract

Background: Special Operation Forces (SOF) operate regularly in extreme environmental conditions that may affect tactical and physical performance. The main aims of the present study were to elucidate the impact of a long cold-water swim on SOF recruits' dexterity, performance, and reaction time. Material and Methods: Eleven recruits from Norwegian Naval Special Operation Command (NORNAVSOC) that were participating in a 10,000-m open water swim with a dry suit in 5°C cold water volunteered to participate in this study. The exercise was part of their training. Grip strength, lower body power, and dexterity were measured before, immediately after, and 24 hours after the swim. In addition, core and skin temperatures were measured continuously during the swim and until 45 minutes after the swim. Results: After the swim, moderate to large reductions in core temperature, lower body power, and reaction time were observed. Moreover, very large to extremely large reductions in skin temperature, grip strength, and dexterity were also observed. Conclusion: These results demonstrate that exposure to a 10,000-m swim in 5°C water using standard equipment led to a significant drop in the recruits' temperature and performance. These findings could have a meaningful impact on the planning of training, operations, and gear used for SOF.

Keywords: stress hormones; body temperature; skin temperature; military medicine; swimming; physical fitness; combat swimmer; combat diver

PMID: 34529806

DOI: QE23-511P

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Impact of Continuous Ketamine Infusion Versus Alternative Regimens on Mortality Among Burn Intensive Care Unit Patients: Implications for Prolonged Field Care

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Schauer SG, April MD, Aden JK, Rowan M, Chung KK. 19(2). 77 - 80. (Journal Article)

Abstract

Background: The military is rapidly moving into a battlespace in which prolonged holding times in the field are probable. Ketamine provides hemodynamic support and has analgesic properties, but the safety of prolonged infusions is unclear. We compare in-hospital mortality between intubated burn intensive care unit (ICU) patients receiving prolonged ketamine infusion lasting =7 days or until death versus controls. Methods: We conducted a before/after cohort study of patients undergoing admission to a burn ICU with intubation within the first 24 hours as part of treatment for thermal burns. In January 2012, this ICU implemented a novel continuous ketamine infusions protocol. We performed a preintervention and postintervention cohort analysis. Results: We identified 2394 patients meeting our inclusion criteria-475 in the ketamine group and 1919 in the control group. Regarding burn total body surface area (TBSA) involvement, there were 1533 in the <10% group, 586 in the 11-30% group, and 281 in the >31% group. The median number of ventilator-free days within the first 30 days did not vary significantly between the ketamine group and the control group: 8.5 days (interquartile range [IQR] 1-16 days) versus 8 days (IQR 3-13 days, p = .442). Subjects receiving ketamine had higher mortality rates: 59.4% (n = 117) versus 40.6% (n = 80, p < .001), with an odds ratio for in-hospital mortality of 7.51 (95% CI 5.53-10.20, p < .001). When controlling for TBSA category, ventilator days and vasopressor administration, there was no association between ketamine and in-hospital mortality (0.66, 0.41-1.05, p = .08). Conclusions: When controlling for confounders, we found no difference in in-hospital mortality between the prolonged ketamine infusion recipients versus non-recipients.

Keywords: ketamine; prolonged; military; trauma; analgesia

PMID: 31201755

DOI: L391-IUA4

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Impact of Marine Exposure on Hemostatic Gauzes Using Thromboelastography

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George T, Jordan M, Bianchi W, Boboc M, Zarow GJ, Natarajan R, Walchak AC, Roszko PJ. 19(1). 89 - 94. (Journal Article)

Abstract

Background: Military forces render emergency care in marine environments, where care for exsanguination is challenging. However, the effect of saltwater on the functionality of hemostatic agents is unknown. In this study, we used thromboelastography (TEG) to quantify the effect of saltwater on the efficacy of five gauze products. Methods: Blood from 24 healthy adult men was diluted by 30% with hetastarch to mimic hemodilution. Dry and saltwater-soaked Kerlix™, ChitoGauze®, Combat Gauze®, NuStat™, and WoundClot™ were contrasted in terms of the TEG parameters of speed of clot initiation (R), clot amplification (K), α angle (i.e., clot formation rate), and maximum amplitude of clot (MA), using repeated-measures analysis of variance at the p < .05 statistical significance threshold. Results: Compared with untreated dilute blood, R was significantly faster when any dry or wet gauze was added, with the fastest R values recorded for Combat Gauze. K and α angle findings were mixed. MA was greater than diluted blood for dry hemostatic gauze, but in the wet condition, only the MA for Combat Gauze was significantly greater than that of diluted blood. Conclusion: Gauze products, wet or dry, improved clotting compared to diluted blood without gauze. Saltwater exposure did not significantly detract from this benefit. Our findings suggest that Combat Gauze may be the choice hemostatic gauze for maritime environments.

Keywords: thromboelastography; hemostatic agents; gauze; kaolin; chitosan; trauma; exsanguination; cellulose; hemodilution; military; hemostatics; bandages; hemorrhage; marine; seawater; coagulation; TEG

PMID: 30859534

DOI: BZOZ-DNNM

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Implementation and Evaluation of a First-Responder Bleeding-Control Training Program in a Rural Police Department

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Reed JR, Carman MJ, Titch FJ, Kotwal RS. 18(3). 57 - 61. (Journal Article)

Abstract

Background: In the prehospital environment, nonmedical first responders are often the first to arrive on the scene of a traumatic event and must be prepared to provide initial care at the point of injury. In civilian communities, these nonmedical first responders often include law enforcement officers. Hemorrhage is a major cause of death in trauma, and many of these deaths occur in the prehospital environment; therefore, prehospital training efforts should be directed accordingly toward bleeding control. Methods: A bleeding control training program was implemented and evaluated in a rural police department in Pinehurst, North Carolina, from February to April 2017. A repeated measures observational study was conducted to evaluate the training program. Measured were self-efficacy (pre- and post-test), knowledge (pretest, post-test 1 [immediate], post-test 2 [at 4 weeks]), and limb-tourniquet application time (classroom, simulation exercise). Results: The study population was composed of 28 police officers (92.9% male) whose median age was 37 (interquartile range, 22-55) years. Mean self-efficacy scores, equating to user confidence and the decision to intervene, increased from pre- to post-training (34.54 [standard deviation (SD) 4.16] versus 35.62 [SD 4.17]; p = .042). In addition, mean knowledge test scores increased from pre- to immediately post-training (75.00 [SD 16.94] versus 85.83 [SD 11.00]; p = .006), as well as from preto 4 weeks post-training (75.00 [SD 16.94] versus 84.17 [SD 11.77]; p = .018). Lower limb-tourniquet application times were more rapid in the classroom than during the simulation exercise (23.06 seconds [SD 7.68] versus 31.91 seconds [SD 9.81]; p = .005). Conclusion: First-responder bleeding-control programs should be initiated and integrated at the local level throughout the Nation. Implementation and sustainment of such programs in police departments can save lives and enhance existing law enforcement efforts to protect and serve communities.

Keywords: bleeding control; first responder; hemorrhage; limb tourniquet; prehospital; trauma

PMID: 30222838

DOI: DN8P-L4EL

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Implications of Neurological Directed-Energy Weapons for Military Medicine

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Lyon RF, Gramm J, Branagan B, Houck SC. 22(3). 104 - 107. (Journal Article)

Abstract

Since 2016, there has been an increase in reported cases of intelligence officers and diplomats hearing pulsing sounds and experiencing neurophysiologic and cognitive symptoms. These varied and often intense symptoms manifest in ways similar to a traumatic brain injury (TBI) but without inciting trauma. Known formerly as "unconventionally acquired brain injury" (UBI), these events are now labeled "anomalous health incidents" (AHIs). Investigations of these incidents suggest reasons to be concerned that a specific type of neuroweapon may be the cause-a directed energy weapon (DEW). Neuroweapons that target the brain to influence cognition and behavior are leading to a new domain of warfare-neurowarfare. The implications and resultant stakes, especially for the Special Operations community, are significant. This article focuses specifically on the implications of DEWs as a neuroweapon causing UBIs/AHIs for military medical practitioners and suggests using a comprehensive strategy, analogous to that of chemical warfare or other weapons of mass destruction (WMD), to improve our preparedness for the medical repercussions of neurowarfare.

Keywords: unconventionally acquired brain injury; directed energy weapon; neurowarfare

PMID: 35877979

DOI: 0JAL-JIJT

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Improving Concussion Education: Consensus From the NCAA-Department of Defense Mind Matters Research & Education Grand Challenge

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Kroshus E, Cameron KL, Coatsworth JD, D'Lauro C, Kim NJ, Lee KM, Register-Mihalik J, Milroy JJ, Roetert EP, Schmidt JD, Silverman RD, Warmath D, Wayment HA, Hainline B. 20(3). 88 - 95. (Journal Article)

Abstract

Early disclosure of possible concussive symptoms has the potential to improve concussion-related clinical outcomes. The objective of the present consensus process was to provide useful and feasible recommendations for collegiate athletic departments and military service academy leaders about how to increase concussion symptom disclosure in their setting. Consensus was obtained using a modified Delphi process. Participants in the consensus process were grant awardees from the National Collegiate Athletic Association and Department of Defense Mind Matters Research & Education Grand Challenge and a multidisciplinary group of stakeholders from collegiate athletics and military service academies. The process included a combination of in-person meetings and anonymous online voting on iteratively modified recommendations for approaches to improve concussion symptom disclosure. Recommendations were rated in terms of their utility and feasibility in collegiate athletic and MSA settings with a priori thresholds for retaining, discarding, and revising statements. A total of 17 recommendations met thresholds for utility and feasibility and are grouped for discussion in five domains: (1) content of concussion education for athletes and MSA cadets, (2) dissemination and implementation of concussion education for athletes and military service academy cadets, (3) other stakeholder concussion education, (4) team and unit-level processes, and (5) organizational processes. Collectively, these recommendations provide a path forward for athletics departments and military service academies in terms of the behavioral health supports and institutional processes that are needed to increase early and honest disclosure of concussion symptoms and ultimately to improve clinical care outcomes.

Keywords: concussion; athletics departments; military service academies; clinical care outcomes

PMID: 32969010

DOI: 6UWZ-D7UU

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Improving Outcomes Associated with Prehospital Combat Airway Interventions: An Unrealized Opportunity

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Schauer SG, Hudson IL, Fisher AD, Dion G, Long B, Blackburn MB, De Lorenzo RA, Shaw TA, April MD. 23(1). 23 - 29. (Journal Article)

Abstract

Background: Airway obstruction is the second leading cause of potentially survivable death on the battlefield. Assessing outcomes associated with airway interventions is important, and temporal trends can reflect the influence of training, technology, the system of care, and other factors. We assessed mortality among casualties undergoing prehospital airway intervention occurring over the course of combat operations during 2007-2019. Methods: This is a retrospective analysis of a previously described dataset from the Department of Defense Trauma Registry (DODTR). We included only casualties with documented placement of an endotracheal tube, cricothyrotomy, or supraglottic airway (SGA) in the prehospital setting. Results: Within the DODTR from January 2007 to December 2019, there were 25,849 adult encounters with documentation of any prehospital activity. Within that group, there were 251 documented cricothyrotomies, 1,147 documented intubations, and 35 documented supraglottic airways placed. Cricothyrotomy recipients had a median age of 25. Within this group, the largest proportion were non-North Atlantic Treaty Organization (NATO) military personnel (35%), were injured by explosives (54%), had a median injury severity score (ISS) of 24, and 60% survived to hospital discharge. Intubation recipients had a median age of 24. Within this group, the largest proportion were non-NATO military personnel (37%), were injured by explosives (57%), had a median ISS of 18, and 76% survived to hospital discharge. SGA recipients had a median age of 28. Within this group, the largest proportion were non-NATO military (37%), were injured by firearms (48%), had a median ISS of 25, and 54% survived to hospital discharge. A downward trend existed in the quantity of all procedures performed during the study period. In both unadjusted and adjusted regression models, we identified no year-to-year differences in survival after prehospital cricothyrotomy or SGA placement. In the unadjusted and adjusted models, we noted a decrease in mortality during the 2007-2008 (odds ratio [OR] for death 0.47, 95% CI 0.26-0.86) and an increase from 2012-2013 (OR 2.10, 95% CI 1.09-4.05) for prehospital intubation. Conclusion: Mortality among combat casualties undergoing prehospital or emergency department airway interventions showed no sustained change during the study period. These findings suggest that advances in airway resuscitation are necessary to achieve mortality improvements in potentially survivable airway injuries in the prehospital setting.

Keywords: prehospital; trend; airway; combat; outcome; survival; military

PMID: 36853854

DOI: SJI5-VWJH

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Improvised Ground Evacuation Platforms for Austere Special Operations Casualty Transport

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Antosh IJ, McGrane OL, Capan EJ, Dominguez JD, Hofmann LJ. 19(1). 48 - 51. (Journal Article)

Abstract

There are no established ground medical-evacuation systems within Special Operations Command Africa (SOCAFRICA), given the austere and varied environments. Transporting the injured casualty requires ingenuity and modification of existing vehicles. The Expeditionary Resuscitative Surgical Team (ERST) assigned to SOCAFRICA used four unconventional means for ground evacuation. This is a retrospective review of the various modes of ground transportation used by the ERST-3 during deployment with SOCAFRICA. All handcarried litter and air evacuation platforms were excluded. Over 9 months, four different ground casualty platforms were used after they were modified: (1) Mine-Resistant Ambush-Protected All-Terrain Vehicle (MAT-V; Oshkosh Defense); (2) MRZR-4 ("Razor"; Polaris Industries); (3) nonstandard tactical vehicles, (NSTVs; Toyota HiLux); and (4) John Deere TH 6x4 ("Gator"). Use of all vehicle platforms was initially rehearsed and then they were used on missions for transport of casualties. Each of the four methods of ground evacuation includes a description of the talon litter setup, the necessary modifications, the litter capacity, the strengths and weaknesses, and any summary recommendations for that platform. Understanding and planning for ground casualty evacuation is necessary in the austere environment. Although each modified vehicle was used successfully to transfer the combat casualty with an ERST team member, consideration should be given to acquisition of the MAT-V medical-specific vehicle. Understanding the currently available modes of ground casualty evacuation transport promotes successful transfer of the battlefield casualty to the next echelon of care.

Keywords: patient transport; ground evacuation; Special Operations; austere; prolonged field care

PMID: 30859526

DOI: FE6F-LOEW

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Improvised Inguinal Junctional Tourniquets: Recommendations From the Special Operations Combat Medical Skills Sustainment Course

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Kerr W, Hubbard B, Anderson B, Montgomery HR, Glassberg E, King DR, Hardin RD, Knight RM, Cunningham CW. 19(2). 128 - 133. (Journal Article)

Abstract

Effectively and rapidly controlling significant junctional hemorrhage is an important effort of Tactical Combat Casualty Care (TCCC) and can potentially contribute to greater survival on the battlefield. Although the US Food and Drug Administration (FDA) has approved labeling of four devices for use as junctional tourniquets, many Special Operations Forces (SOF) medics do not carry commercially marketed junctional tourniquets. As part of ongoing educational improvement during Special Operations Combat Medical Skills Sustainment Courses (SOCMSSC), the authors surveyed medics to determine why they do not carry commercial tourniquets and present principles and methods of improvised junctional tourniquet (IJT) application. The authors describe the construction and application of IJTs, including the use of available pressure delivery devices and emphasizing that successful application requires sufficient and repetitive training.

Keywords: tourniquets; tourniquets, improvised; hemorrhage, junctional; training; austere

PMID: 31201768

DOI: 4QM4-J8MG

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Improvised Management of Polycythemia Vera Using Whole Blood Transfusion Kits

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Carius BM, Dodge PM, Bates JA, Castaneda P. 22(4). 15 - 17. (Journal Article)

Abstract

Polycythemia vera (PV) is a frequent myeloproliferative disease resulting in excessive red blood cells, white blood cells, and platelets rarely identified in military populations. Increased blood viscosity and platelets can lead to fatal myocardial infarction and stroke. Historically, regimented phlebotomy managed this condition, but modern medicinal advances now are utilized. These immunosuppressive medications are generally incompatible with active-duty service and can lead to medical discharge. Phlebotomy therefore is critical for readiness and health; however, this can be challenging in resource-limited environments, necessitating effective improvisation. We describe an active-duty Soldier with PV symptoms consisting of substernal chest pressure, bilateral lower extremity paresthesias, and persistent pruritic neck rash. He had an elevated hematocrit (Hct) of 47%, necessitating phlebotomy and posing a challenge to his primary care team. The local emergency medicine team employed blood collection bags from whole blood (WB) transfusion kits, including proven volume estimation methods, to routinely draw one unit of blood and effectively manage this condition. This is the first reported case in military literature of PV managed with improvised field resources and techniques.

Keywords: phlebotomy; hematology; blood disorder; case report

PMID: 36525006

DOI: 17K4-F6CV

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In Search of the Warrior Spirit: Teaching Awareness Disciplines to the Green Berets

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Myatt CA. 12(3). 78 - 79. (Book Review)

Abstract

Richard Strozzi Heckler
Berkeley, California: North Atlantic Books. 1992. ISBN 1-55643-116-3. Review by LTC Craig A. Myatt

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In the Neck and Not Out of the Woods

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Dare C, Hampton K. 19(1). 130 - 130. (Journal Article)

Keywords:

PMID: 30859541

DOI: WBQN-0YWP

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In Vitro Compatibility of Canine and Human Blood: A Pilot Study

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Edwards TH, Wienandt NA, Baxter RL, Mays EL, Gay SD, Cap AP. 19(2). 95 - 99. (Journal Article)

Abstract

Military working dogs (MWDs) are force multipliers that are exposed to the same risks as their human counterparts on the battlefield. Hemostatic resuscitation using blood products is a cornerstone of damage control resuscitation protocols for both humans and dogs. Canine-specific blood products are in short supply in mature theaters due to logistic and regulatory concerns and are almost nonexistent in austere environments, whereas human blood products are readily available at most surgical facilities. The objective of this study was to evaluate the in vitro compatibility of human and canine blood by using standard crossmatching techniques with the canine blood acting as the recipient and the human blood acting as the donor. Blood samples were collected from 20 government-owned canines (GOCs) and 7 healthy human volunteers in addition to washed red blood cells (RBCs) from a commercial blood typing kit. Major and minor crossmatches were conducted as well as a protein denatured crossmatch. All samples in this study showed strong cross-reactivity, with the majority demonstrating profound hemolysis and a minority showing substantial agglutination. Based on the results of this study, transfusion of human blood to an MWD cannot be recommended at this time.

Keywords: xenotransfusion; crossmatch; canines

PMID: 31201759

DOI: 6EAP-6E9G

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Incidence of Airway Interventions in the Setting of Serious Facial Trauma

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Schauer S, Naylor JF, Fisher AD, Becker TE, April MD. 22(4). 18 - 21. (Journal Article)

Abstract

Background: Airway obstruction is the second leading cause of preventable death on the battlefield. Most airway obstruction occurs secondary to traumatic disruptions of the airway anatomical structures. Facial trauma is frequently cited as rationale for maintaining cricothyrotomy in the medics' skill set over the supraglottic airways more commonly used in the civilian setting. Methods: We used a series of emergency department procedure codes to identify patients within the Department of Defense Trauma Registry (DoDTR) from January 2007 to August 2016. This is a sub-group analysis of casualties with documented serious facial trauma based on an abbreviated injury scale of 3 or greater for the facial body region. Results: Our predefined search codes captured 28,222 DoDTR casualties, of which we identified 136 (0.5%) casualties with serious facial trauma, of which 19 of the 136 had documentation of an airway intervention (13.9%). No casualties with serious facial trauma underwent nasopharyngeal airway (NPA) placement, 0.04% underwent cricothyrotomy (n = 10), 0.03% underwent intubation (n = 9), and a single subject underwent supraglottic airway (SGA) placement (<0.01%). We only identified four casualties (0.01% of total dataset) with an isolated injury to the face. Conclusions: Serious injury to the face rarely occurred among trauma casualties within the DoDTR. In this subgroup analysis of casualties with serious facial trauma, the incidence of airway interventions to include cricothyrotomy was exceedingly low. However, within this small subset the mortality rate is high and thus better methods for airway management need to be developed.

Keywords: prehospital; airway; facial; trauma; military

PMID: 36525007

DOI: MCUP-FEIC

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Increasing Security through Public Health: A Practical Model

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Parker RD. 11(1). 4 - 8. (Journal Article)

Abstract

As political and social changes swee p the globe, there are opportunities to increase national security through innovative approaches. While traditional security methods such as defense forces and homeland security provide both pre-emptive and defensive protection, new methods could meet emerging challenges by responding to the political, financial, and social trends. One method is the integration of defense, medicine and public health. By assisting a nation by providing basic services, such as healthcare, collaborative efforts can increase stabilization in areas of unrest. Improved health outcomes leads to increased domestic security, which can create a ripple effect across a region. Assessment, uptake and sustainability by the host nation are critical for program success. The proposed methodology focuses on the use of primarily extant resources, such as programs used by Special Operations Forces and other health and defense programs. Additional components include evaluation, set objectives and mission collaborations. As the nexus between foreign affairs, security, and public heal th is in crea s ing ly valida ted thr ough research and prac tice, stand ard ized i nt erv entions should b e developed to minimize overlapping expenditures, promote security and strengthen international relations.

Keywords:

PMID: 22113719

DOI: 96MZ-KV4F

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Infectious Diseases: Cholera

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Burnett MW. 14(2). 91 - 94. (Journal Article)

Abstract

Vibrio cholerae is a comma-shaped, gram-negative rod that produces an enterotoxin, which causes an acute-onset diarrheal disease ranging in severity from mild to life threatening. Worldwide, there are an estimated 3-5 million cases per year, with more than 100,000 deaths. The disease remains a significant cause of death and illness in sub-Saharan Africa, southeast Asia (especially Bangladesh and India), and Haiti, and the infection should be recognized by the Special Operations Forces (SOF) medical provider.

Keywords: Vibrio cholerae; enterotoxin; diarrheal disease

PMID: 24952048

DOI: 71HS-0RDO

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Influence of a Multitask Paradigm on Motor and Cognitive Performance of Military and Law Enforcement Personnel: A Systematic Review

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Talarico M, Brancaleone MP, Onate JA. 20(1). 72 - 80. (Journal Article)

Abstract

Purpose: To review the current literature investigating if performance of tactical athletes under multitask paradigms is different than performance under single-task paradigms. Methods: The authors completed a search of the literature published from January 01, 2000, to June 01, 2018, using key search terms in PubMed, Web of Science, SPORTDiscus, and Defense Technical Information Center (DTIC) databases. Studies that met inclusion and exclusion criteria were assessed for quality. Results: Fourteen articles were identified as eligible to be included in the review. Compared with single-task, two studies reported better motor performance, six reported poorer motor performance, and three reported no difference in motor performance under multitask. Compared with single- task, two studies reported better cognitive performance, seven studies reported poorer cognitive performance, and three studies reported no difference in cognitive performance under multitask. Conclusion: As occupational duties become increasingly demanding, it is crucial to modify and adapt performance assessments to meet the needs required of tactical athletes to guide training and injury management programs. Motor and cognitive assessments are an integral part of performance evaluations to train, prepare, and rehabilitate tactical athletes. To meet the modern demands of tactical athletes, varying levels of difficulty in multitask paradigms that include both motor and cognitive tasks should be investigated to understand fundamental performance under operational settings to better translate across training paradigms and rehabilitation programs.

Keywords: military; law enforcement; dual-task; multitasking; cognition; psychomotor performance

PMID: 32203610

DOI: II7L-NFHC

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Influence of Celox Rapid's Mode of Action Under Normal and Compromised Blood Conditions

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Hoggarth A, Grist M, Murch T. 20(2). 154 - 155. (Journal Article)

Keywords:

PMID: 32573757

DOI: 4YLL-M365

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Initial Tourniquet Pressure Does Not Affect Tourniquet Arterial Occlusion Pressure

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Slaven SE, Wall PL, Rinker JH, Halub ME, Hopkins JW, Sahr SM, Buising CM. 15(1). 39 - 49. (Journal Article)

Abstract

Background: Effective nonelastic strap-based tourniquets are typically pulled tight and friction or hook-and-loop secured before engaging a mechanical advantage system to reach arterial occlusion pressure. This study examined the effects of skin surface initial secured pressure (Friction Pressure) on the skin surface pressure applied at arterial occlusion (Occlusion Pressure) and on the use of the mechanical advantage system. Methods: Combat Application Tourniquets® (CATs; combattourniquet.com) and Tactical Ratcheting Medical Tourniquets (RMTs; www .ratchetingbuckles.com) were applied to 12 recipient thighs with starting Friction Pressures of 25 (RMT only), 50, 75, 100, 125, 150, 175 (CAT only), and 200mmHg (CAT only). The CAT strap was single threaded. Pressure was measured with an air-filled, size #1, neonatal blood pressure cuff under the Base (CAT), Ladder (RMT), and Strap (CAT and RMT) of each 3.8cm-wide tourniquet. Results: Base or Ladder pressure and Strap pressure were related but increasingly different at increasing pressures, with Strap pressures being lower (Friction Pressure, r > 0.91; Occlusion Pressure, r > 0.60). Friction Pressure did not affect Occlusion Pressure for either design. Across the 12 thighs, the correlation coefficient for Strap Friction Pressure versus CAT windlass turns was r = -0.91 ± 0.04, and versus RMT ladder distance traveled was r = -0.94 ± 0.06. Friction Pressures of 150mmHg or greater were required to achieve CAT Occlusion with two or fewer windlass turns. CAT and RMT Strap Occlusion Pressures were similar on each recipient (median, minimum - maximum; CAT: 318mmHg, 260-536mmHg; RMT: 328mmHg, 160-472mmHg). Conclusions: Achieving high initial strap tension is desirable to minimize windlass turns or ratcheting buckle travel distance required to reach arterial occlusion, but does not affect tourniquet surface-applied pressure needed for arterial occlusion. For same-width, nonelastic strap-based tourniquets, differences in the mechanical advantage system may be unimportant to final tourniquet-applied pressure needed for arterial occlusion.

Keywords: tourniquet; hemorrhage control; first aid; emergency treatment

PMID: 25770797

DOI: 4G5T-09T4

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Injuries and Footwear (Part 1): Athletic Shoe History and Injuries in Relation to Foot Arch Height and Training in Boots

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Knapik JJ, Pope R, Orr R, Grier T. 15(4). 102 - 108. (Journal Article)

Abstract

This article traces the history of the athletic shoe, examines whether selecting running shoes based on foot arch height influences injuries, and examines historical data on injury rates when physical training (PT) is performed in boots versus running shoes. In the 1980s and into the 2000s, running shoe companies were advertising specialized shoes with "motion control," "stability," and "cushioning," designed for individuals with low, normal, and high arches, respectively. Despite marketing claims that these shoes would reduce injury rates, coordinated studies in Army, Air Force, and Marine Corps basic training showed that assigning or selecting shoes on this basis had no effect on injury rates. Consistent with this finding, biomechanical studies have shown that the relationships between arch height, foot joint mobility, and rear-foot motion are complex, variable, and frequently not as strong as often assumed. In 1982, the US Army switched from PT in boots to PT in running shoes because of the belief that boots were causing injuries and that running shoes would reduce injury rates. However, a historical comparison of injury rates before and after the switch to running shoes showed virtually no difference in injury risk between the two periods. It is not clear at this point if the type of footwear effects injury incidence.

Keywords: injury, foot; shoe, athletic; physical training

PMID: 26630104

DOI: KTP0-XU4Q

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Injuries And Footwear (Part 2): Minimalist Running Shoes

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Knapik JJ, Orr R, Pope R, Grier T. 16(1). 89 - 96. (Journal Article)

Abstract

This article defines minimalist running shoes and examines physiological, biomechanical, and injury rate differences when running in conventional versus minimalist running shoes. A minimalist shoe is one that provides "minimal interference with the natural movement of the foot, because of its high flexibility, low heel to toe drop, weight and stack height, and the absence of motion control and stability devices." Most studies indicate that running in minimalist shoes results in a lower physiological energy cost than running in conventional shoes, likely because of the lower weight of the minimalist shoe. Most individuals running in conventional shoes impact the ground heel first (rearfoot strike pattern), whereas most people running in minimalist shoes tend to strike with the front of the foot (forefoot strike pattern). The rate at which force is developed on ground impact (i.e., the loading rate) is generally higher when running in conventional versus minimalist shoes. Findings from studies that have looked at associations between injuries and foot strike patterns or injuries and loading rates are conflicting, so it is not clear if these factors influence injury rates; more research is needed. Better-designed prospective studies indicate that bone stress injuries and the overall injury incidence are higher in minimalist shoes during the early weeks (10-12 weeks) of transition to this type of footwear. Longer-term studies are needed to define injury rates once runners are fully transitioned to minimalist shoes. At least one longer-term minimalist-shoe investigation is ongoing and, hopefully, will be published soon.

Keywords: injuries, foot; footwear; shoes, minimalist; shoes, conventional; shoes, running

PMID: 27045504

DOI: R4MX-MTDK

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Injuries and Injury Prevention During Foot Marching

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Knapik JJ. 14(4). 131 - 135. (Journal Article)

Abstract

Since the beginning of recorded history, Soldiers have carried arms and equipment on their bodies. More recently, loads have substantially increased, driven by improvements in weapons technology and personal protection. As Soldier loads increase, there are increases in energy cost, altered gait mechanics, increased stress on the musculoskeletal system, and more rapid fatigue, factors that may increase the risk of injury. Common injuries and symptoms experienced by Soldiers on load-carriage missions include foot blisters, metatarsalgia, knee problems, and back problems. This article discusses these problems, providing diagnoses, injury mechanisms, and preventive measures. In general, lighter loads, improving load distribution, using appropriate physical training, selecting proper equipment, and using specific prevention techniques will facilitate load carriage and provide Special Operations Forces with a higher probability of mission success.

Keywords: load-carriage; foot blisters; knee injury

PMID: 25399383

DOI: 38TR-TEUP

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Injuries and Interventions on Transported Military Working Dogs Within the US Central Command

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Johnson SA, Carr C, Reeves LK, Bean K, Schauer S. 22(1). 97 - 101. (Journal Article)

Abstract

Background: Limited veterinary care is available in the far forward environment, leading to human medical personnel being responsible, in part, for treatment of military working dogs (MWD). Though guidelines for MWD care exist, there is little research on the care and treatment of MWDs by human medical personnel. There is a lot of research on the care and treatment of MWDs. Methods: This is a secondary analysis of a dataset from the Transportation Command (TRANSCOM) Regulating Command & Control and Evacuation System (TRAC2ES) database within the US Central Command (CENTCOM) from 2008 to 2018. Within this dataset specific to regulated transport from locations within CENTCOM, we abstracted all entries involving MWDs and analyzed causes of injury, type of injury, and interventions performed on traumatically and non-traumatically injured MWDs. Results: Within our dataset, there were 84 MWD cases for analysis. Of those, 36 (43%) were transported for traumatic injuries, and the remaining 48 (57%) were transported for other medical ailments. The most common cause of trauma was gunshot wound (31%), followed by explosion (22%). The majority of trauma MWDs had injuries to the extremities (67%), and hemorrhage requiring intervention occurred in 25%. The most common interventions performed on traumas were analgesia (67%), antibiotics (31%), IV fluids (28%), and surgery (31%). The most common indications that occurred in MWDs treated for nontraumatic medical indications were gastrointestinal diseases (33%), followed by nontraumatic orthopedic injuries (21%). Conclusions: Of the MWDs in our dataset, most were transported for nontraumatic medical events. The most frequent intervention performed was medication administration for both traumatic and medical ailments. Our dataset adds to the limited body of MWD data from theater.

Keywords: military working dogs; surveillance; security

PMID: 35278322

DOI: VTBK-XU21

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Injuries During High-Intensity Functional Training

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Knapik JJ. 21(4). 112 - 115. (Journal Article)

Abstract

High-intensity functional training (HIFT) involves high-volume and high-intensity physical activities with short rest periods between movements and the use of multiple-joint exercises. This paper analyzes narrative and systematic reviews covering studies of injuries sustained during HIFT. Two narrative and six systematic reviews on injuries during HIFT were identified. Seven reviews concluded that the injury incidences or injury rates during HIFT were similar to those of comparable sports and exercise programs. The most often injured anatomic locations were shoulders, backs, and knees. The most comprehensive and recent review involved 21 retrospective and three prospective studies. In this review, mean ± standard deviation (SD) injury prevalence was 35% ± 15%, the injury rate was approximately 3 ± 5 injuries/1,000 hours of training, and the prevalence of injuries requiring surgery was 6% ± 5%. Most injuries were associated with weightlifting exercises, especially deadlifts, snatches, clean and jerks, and overhead presses. Other risk factors included participation time in HIFT, participation in competition, prior injuries, weekly training frequency, male sex, older age, and alternating training loads. Although most studies included in these reviews were of lower methodologic quality, current evidence suggests that injury rates in HIFT are similar to those of other exercise activities. More high-quality prospective studies are needed to fully evaluate HIFT safety.

Keywords: CrossFit; weightlifting; exercise; systematic review; narrative reviews

PMID: 34969140

DOI: K817-9GWY

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Injuries During High-Intensity Functional Training: Systematic Review and Meta-Analysis

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Knapik JJ. 22(1). 121 - 129. (Journal Article)

Abstract

High-intensity functional training (HIFT) involves high-volume and high-intensity physical activities with short rest periods between movements and use of multiple joint exercises. This article reports the results of a systematic review and meta- analysis of studies involving injuries during HIFT. Individual studies were selected for review if they involved individuals =18 years of age and provided quantitative data on injury prevalence and/or injury rates during HIFT. Twenty-eight studies involving 11,089 participants met the inclusion criteria. There was considerable variability in individual studies with injury prevalences ranging from 12% to 74% and injury rates from 0.04 to 18.90 injuries/1000 h of training. Meta-analyses indicated that the overall injury prevalence was 36% (95% confidence interval [95% CI] = 32-41%) and overall injury rate 4.3 injuries/1000 h (95% CI = 3.35-5.23). Injury rates among the five available prospective cohort studies was considerably higher, 9.9 injuries/1000 h (95% CI = 3.3-16.4). The most commonly injured anatomical locations (with % of total injuries) were the shoulder (26%), back/spine (26%), knee (14%), wrist/hands/fingers (12%), arm/elbow (10%), and ankle/foot (6%). Given the higher injury rates among prospective studies that likely more effectively tracked injuries over time, more prospectively designed studies are required before the injury rate during HIFT can be appropriately quantified.

Keywords: high-intensity functional training; training; injury prevalence; injury rates; movements; physical training

PMID: 35278328

DOI: G29P-I0AU

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Injuries, Medical Conditions, and Changes in Blood Levels in German Special Operations Forces Selection

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Lechner R, Tausch B, Unkelbach U, Tannheimer M, Neitzel C. 15(2). 64 - 70. (Journal Article)

Abstract

Background: Medical conditions often develop during military training. The aim of this study was to compile medical conditions and injuries sustained during a 5-day military exercise, compare them with incidences at similar civilian events, and subsequently identify differences between those who finished the exercise (Finishers) and those who did not (Nonfinishers) to identify preventable causes for not finishing and to reduce unnecessary health risks. Methods: Fifty-one soldiers had their blood parameters (creatine kinase [CK], aspartate transaminase [AST], alanine transaminase [ALT], gamma-glutamyl transferase [GGT], C-reactive protein [CRP], leukocytes, sodium), weight loss, and body temperature determined after the exercise. Additionally, the injuries and conditions that led the Nonfinishers to drop out were recorded. Results: The main reasons why Nonfinishers did not complete the exercise were physical exhaustion and minor injuries. After exercise, the Finishers showed only slightly increased incidence of hyponatremia, higher levels of CK, and significantly higher levels of AST, ALT, and CRP, and body weight loss. The Nonfinishers' results were significant for an elevated leukocyte count and lower mean temperatures. Conclusion: The specifics of military training did not influence the kind or the number of exertion-related medical conditions compared to similar civilian events. Both Finishers and Nonfinishers are at risk of developing exertion-related medical conditions such as rhabdomyolysis and hyponatremia. However, plain water did not increase the risk of exertional hyponatremia. Leukocytosis found in the Nonfinisher group could have been due to acute excessive exertion and, therefore, may be an indicator of general systemic fatigue. This could be used to differ between physical and psychological reasons for not finishing.

Keywords:

PMID: 26125166

DOI: RRPW-RTLN

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Injury Profile For Airborne Operations Untilizing The Sf-10a Maneuverable Parachute

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Deaton TG, Roby JL. 10(2). 22 - 25. (Journal Article)

Abstract

Purpose: The purpose of this investigation was to determine the injury profile of the steerable, SF-10A, static-line parachute. Methods: The investigation evaluated prospectively 972 low-level static-line training jumps for major injuries that required CASEVAC from the drop zone and for minor injuries that allowed the jumpers to continue with their training mission. Results: The investigation found overall injury rates to be 8.23 per 1000 jumps, with 2.03 per 1000 jumps requiring CASEVAC. Conclusions: Overall attrition rates of the steerable SF-10A parachute were below those of previously reported non-steerable parachutes, suggesting further evaluation is warranted of maneuverable parachutes in all military services.

Keywords:

PMID: 20936600

DOI: X8HZ-XUWO

Inner Ear Barotrauma After Underwater Pool Competency Training Without the Use of Compressed Air Case and Review

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McIntire S, Boujie L. 16(2). 52 - 56. (Journal Article)

Abstract

Inner ear barotrauma can occur when the gas-filled chambers of the ear have difficulty equalizing pressure with the outside environment after changes in ambient pressure. This can transpire even with small pressure changes. Hypobaric or hyperbaric environments can place significant stress on the structures of the middle and inner ear. If methods to equalize pressure between the middle ear and other connected gas-filled spaces (i.e., Valsalva maneuver) are unsuccessful, middle ear overpressurization can occur. This force can be transmitted to the fluid-filled inner ear, making it susceptible to injury. Damage specifically to the structures of the vestibulocochlear system can lead to symptoms of vertigo, hearing loss, and tinnitus. This article discusses the case of a 23-year-old male Marine who presented with symptoms of nausea and gait instability after performing underwater pool competency exercises to a maximum depth of 13 feet, without breathing compressed air. Diagnosis and management of inner ear barotrauma are reviewed, as is differentiation from inner ear decompression sickness.

Keywords: inner ear; barotrauma, inner ear; decompression sickness; inner ear; vertigo; tinnitus; hearing loss

PMID: 27450603

DOI: JBEE-27IF

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Insurgent Women: Female Combatants in Civil Wars

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Farr WD. 19(4). 127 - 127. (Book Review)

Abstract

Darden JT, Henshaw A, Szekely O. Insurgent Women: Female Combatants in Civil Wars. Washington, DC: Georgetown University Press; 2019. ISBN 978-1-62616-666-0. 112 pages.

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DOI:

Insurgents, Raiders, and Bandits: How Masters of Irregular Warfare Have Shaped Our World

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Farr WD. 15(1). 130 - 130. (Book Review)

Abstract

Arquilla, John. Insurgents, Raiders, and Bandits: How Masters of Irregular Warfare Have Shaped Our World. Chicago, IL: Ivan R. Dee, Publisher: 2011. Hardcover: 336 pages.
ISBN-10: 1566638321/ISBN-13: 978-1566638326.

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DOI:

Integrated Education of All Responders

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McSwain NE. 15(4). 160 - 162. (Journal Article)

Keywords:

PMID: 26630113

DOI: 7A81-M84F

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Integrating Chemical Biological, Radiologic, and Nuclear (CBRN) Protocols Into TCCC Introduction of a Conceptual Model - TCCC + CBRN = (MARCHE)2

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DeFeo DR, Givens ML. 18(1). 118 - 123. (Journal Article)

Abstract

The authors would like to introduce TCCC [Tactical Combat Casualty Care] + CBRN [chemical, biological, radiological, and nuclear] = (MARCHE)2 as a conceptual model to frame the response to CBRN events. This model is not intended to replace existing and well-established literature on CBRNE events but rather to serve as a response tool that is an adjunct to agent specific resources.

Keywords: MARCHE; (MARCHE)2; CBRN; CBRNE; triage; casualties

PMID: 29533446

DOI: ZK2U-M1DZ

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Integrating Prolonged Field Care Into Rough Terrain and Mountain Warfare Training: The Mountain Critical Care Course

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Nicholson B, Neskey J, Stanfield R, Fetterolf B, Ersando J, Cohen J, Kue R. 19(1). 66 - 69. (Journal Article)

Abstract

Current prolonged field care (PFC) training routinely occurs in simulated physical locations that force providers to continue care until evacuation to definitive care, as based on the staged Ruck-Truck-House-Plane model. As PFC-capable teams move further forward into austere environments in support of the fight, they are in physical locations that do not fit this staged model and may require teams to execute their own casualty evacuation through rough terrain. The physical constraints that come specifically with austere, mountainous terrain can challenge PFC providers to initiate resuscitative interventions and challenge their ability to sustain these interventions during lengthy, dismounted movement over unimproved terrain. In this brief report, we describe our experience with a novel training course designed for PFC-capable medical teams to integrate their level of advanced resuscitative care within a mountainous, rough terrain evacuation-training program. Our goals were to identify training gaps for Special Operations Forces medical units tasked to operate in a cold-weather, mountain environment with limited evacuation resources and the challenges related to maintaining PFC interventions during dismounted casualty movement.

Keywords: prolonged field care; evacuation; rough terrain; austere; mountain warfare

PMID: 30859530

DOI: ZS6D-CXNH

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Integration of Tactical Emergency Casualty Care Into the National Tactical Emergency Medical Support Competency Domains

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Pennardt A, Callaway DW, Kamin R, Llewellyn C, Shapiro G, Carmona PA, Schwartz RB. 16(2). 62 - 66. (Journal Article)

Abstract

Tactical emergency medical support (TEMS) is a critical component of the out-of-hospital response to domestic high-threat incidents such as hostage scenarios, warrant service, active shooter or violent incidents, terrorist attacks, and other intentional mass casualty-producing acts. From its grass-roots inception in the form of medical support of select law enforcement special weapons and tactics (SWAT) units in the 1980s, the TEMS subspecialty of prehospital care has rapidly grown and evolved over the past 40 years. The National TEMS Initiative and Council (NTIC) competencies and training objectives are the only published recommendations of their kind and offer the opportunity for national standardization of TEMS training programs and a future accreditation process. Building on the previous work of the NTIC and the creation of acknowledged competency domains for TEMS and the acknowledged civilian translation of TCCC by the Committee for Tactical Emergency Casualty Care (C-TECC), the Joint Review Committee (JRC) has created an opportunity to bring forward the work in a form that could be operationally useful in an all-hazards and whole of community format.

Keywords: National TEMS Initiative and Council; tactical emergency medical support; Committee on Tactical Combat Casualty Care; incidents, domestic high-threat

PMID: 27450605

DOI: V4VZ-V5M3

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Intelligent Exam for Crucial Intelligence. . .

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Dare C, Hampton K. 18(2). 141 - 141. (Journal Article)

Keywords:

PMID: 29889972

DOI: LK16-HZV4

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Intensive Skills Week for Military Medical Students Increases Technical Proficiency, Confidence, and Skills to Minimize Negative Stress

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Mueller G, Hunt B, Wall V, Rush RM, Moloff A, Schoeff J, Wedmore I, Schmid J, LaPorta AJ. 12(4). 45 - 53. (Journal Article)

Abstract

The effects of stress induced cortisol on learning and memory is well documented in the literature.1-3 Memory and learning are enhanced at low levels while high levels are detrimental. Repetitive training in stressful situations enables management of the stress response4 as demonstrated by the high intensity training military members undergo to prepare for tactical situations. Appropriate management of one's stress response is critical in the medical field, as the negative effects of stress can potentially hinder life-saving procedures and treatments. This also applies to physicians-in-training as they learn and practice triage, emergency medicine, and surgical skills prior to graduation. Rocky Vista University's Military Medicine Honor's Track (MMHT) held a week long high-intensity emergency medicine and surgical Intensive Skills Week (ISW), facilitated by military and university physicians, to advance students' skills and maximize training using the Human Worn Partial Surgical Task Simulator (Cut Suit). The short-term goal of the ISW was to overcome negative stress responses to increase confidence, technical and non-technical knowledge, and skill in surgery and emergency medicine in an effort to improve performance as third-year medical students. The long-term goal was to enhance performance and proficiency in residency and future medical practice. The metrics for the short-term goals were the focus of this pilot study. Results show an increase in confidence and decrease in perceived stress as well as statistically significant improvements in technical and non-technical skills and surgical instrumentation knowledge throughout the week. There is a correlative benefit to physician and non-physician military personnel, especially Special Operations Forces (SOF) medical personnel, from developing and implementing similar training programs when live tissue or cadaver models are unavailable or unfeasible.

Keywords: stress control; medical student; enhanced learning scenario; high intensisty; military medicine

PMID: 23536457

DOI: S1Y1-SBU9

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Intentional Mass Casualty Events: Implications for Prehospital Emergency Medical Services Systems

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Levy MJ. 15(4). 157 - 159. (Journal Article)

Keywords:

PMID: 26630112

DOI: K4BK-WQNR

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Interest Survey And Guide To Medical Schooladmissions For SOF Medics

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True NA, Conway AC, Landis TM, Cairns CB, Cairns BA. 11(3). 30 - 34. (Journal Article)

Abstract

The University of North Carolina at Chapel Hill and the Special Warfare Training Group, Airborne (SWTG)(A) at Fort Bragg, NC began a bilateral partnership in 2009 to enhance medical training, care and innovation in austere environments. As a result of this partnership, instructors from the Joint Special Operations Training Center have been completing month-long rotations in the North Carolina Jaycee Burn Center and University of North Carolina Hospitals. This rotation has been successful and prompted us to assess the interest of Special Operation Forces (SOF) medics is in pursuing careers in healthcare, especially medical school. We surveyed the Special Forces Medical Sergeant (SFMS) listserve on Army Knowledge Online (AKO) to collect these data. This article will review SFMS survey responses and offer information on how to negotiate medical school admissions.

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PMID: 21706459

DOI: S66D-U9HC

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Intermittent Fasting: Can It Help Optimize Human Performance?

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Deuster PA, Scott JM. 21(2). 92 - 97. (Journal Article)

Abstract

Nutritional fitness is a key goal of every Special Operations Forces (SOF) Operator, and nutrition is one way of potentially gaining a necessary edge. Although fad diets are popular among SOF Operators, many have no evidence with regard to military-specific tasks. One fad diet-intermittent fasting (IF)-is clearly the rage across the United States (US) and popular as a dietary pattern. Most fad diets are studied in the context of various chronic diseases, in particular, cardiovascular disease, diabetes, and obesity, and there are no data on the benefits among SOF or any military population. Thus, evidence demonstrating improvements in performance is typically lacking. Despite no clear evidence, many still devote their lives to popular fad diets. We address whether IF confers performance improvements in SOF by first discussing the concepts of metabolic flexibility and metabolic shifting, then describing IF and its subtypes, after which we summarize the literature with regard to cardiovascular disease and obesity. We close with how IF impacts performance and discuss who should use consider using IF as a dietary pattern.

Keywords: nutrition; fitness; fad diets; intermittent fasting; cardiovascular disease; diabetes; obesity

PMID: 34105130

DOI: LR58-MQKN

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Intermittent Hypoxic Exposure Protocols To Rapidly Induce Altitude Acclimatization In The Sof Operator

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Delmonaco BL, Andrews J, May A. 08(3). 61 - 64. (Journal Article)

Abstract

In August 2007 a three-man Special Operations Forces (SOF) Team attempted a rapid ascent of Mt Rainier after a five-day intermittent hypoxic exposure (IHE) protocol in a Colorado Exercise Room. The following article discusses the process used by the team to select the five-day IHE protocol as well as the science upon which IHE protocols for altitude acclimatization is based. The experiences of the team as they attempted to summit Mt Rainier at greater than 14,000 feet are summarized with a focus on acute mountain sickness (AMS) and its possible prevention with IHE. The subject of rapid acclimatization to prevent AMS is important to the SOF community in order to quickly operate at high altitudes without succumbing to AMS or being forced to a lower altitude. Although medical literature is thinly populated with rigorous studies of IHE to prevent AMS, recent good studies, especially from Dr. Stephen Muza at the U.S. Army Research Institute of Environmental Medicine (USARIEM), validate some IHE protocols. This research is reviewed in the following article to help determine an appropriate IHE protocol for the SOF community.

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Internal Decapitation - High Ligamentus Cervical Injury

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Ben-Galim P. 10(2). 31 - 34. (Previously Published)

Permission to publish this presentation in the JSOM was granted by author

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PMID: 21259210

DOI: KKNZ-L8DL

Internal Decapitation: Survival After Head To Neck Dissociation Injuries

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Ben-Galim P, Sibai TA, Hipp JA, Heggeness MH, Reitman CA. 10(2). 35 - 39. (Previously Published)

Previously published in Spine, Volume 33, Number 16, pp 1744–1749. Permission to republish granted by Lippincott Williams & Wilkins

Abstract

Study Design: Case series. Objective: To describe survival and outcomes after occipitocervical dissociation injuries. Summary of Background Data: Historically, occipitocervical dissociation injuries have a high rate of associated neurologic deficit with a relatively high incidence of mortality. Methods: Six patients with occipitocervical dissociation injuries are reported and their management and imaging findings reviewed. Possible contributory factors for survival are discussed. Results: All patients had upper neck and head dissociation injuries. The pattern of injury in all of these cases included a distraction type mechanism. All cases demonstrated soft tissue disruption in the zone of injury, which was consistent and apparent on all imaging studies. In these patients, the extent and severity of injury was more apparent on magnetic resonance imaging (MRI) than on radiograph or computed tomography scan. Management of these injuries included immobilization followed by surgery with particular care taken to avoid application of distraction forces to the neck. Conclusion: Patients with occipitocervical dissociation injuries may survive their injury and even retain neurologic integrity. Initial in-line head stabilization is emphasized to prevent catastrophic neurologic injury. The resting osseous relationships and vertebral alignment at the time of imaging evaluation may be deceivingly normal, and the damage often primarily or exclusively involves disruption of the perivertebral soft tissue structures. Prevertebral soft tissue swelling was apparent in all cases. For these injuries that involve primarily damage to the ligamentous structures, MRI seems to be the optimal test for revealing the magnitude of the injury.

Keywords: soft tissue spinal injury; MRI; head to neck dissociation; occipitocervical dissociation; upper neck injury

PMID: 21259211

DOI: M96Y-789Z

Interobserver Variability in Injury Severity Scoring After Combat Trauma: Different Perspectives, Different Values?

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Smith IM, Naumann DN, Guyver P, Bishop J, Davies S, Lundy JB, Bowley DM. 15(2). 86 - 93. (Journal Article)

Abstract

Background: Anatomic measures of injury burden provide key information for studies of prehospital and in-hospital trauma care. The military version of the Abbreviated Injury Scale [AIS(M)] is used to score injuries in deployed military hospitals. Estimates of total trauma burden are derived from this. These scores are used for categorization of patients, assessment of care quality, and research studies. Scoring is normally performed retrospectively from chart review. We compared data recorded in the UK Joint Theatre Trauma Registry (JTTR) and scores calculated independently at the time of surgery by the operating surgeons to assess the concordance between surgeons and trauma nurse coordinators in assigning injury severity scores. Methods: Trauma casualties treated at a deployed Role 3 hospital were assigned AIS(M) scores by surgeons between 24 September 2012 and 16 October 2012. JTTR records from the same period were retrieved. The AIS(M), Injury Severity Score (ISS), and New Injury Severity Score (NISS) were compared between datasets. Results: Among 32 matched casualties, 214 injuries were recorded in the JTTR, whereas surgeons noted 212. Percentage agreement for number of injuries was 19%. Surgeons scored 75 injuries as "serious" or greater compared with 68 in the JTTR. Percentage agreement for the maximum AIS(M), ISS, and NISS assigned to cases was 66%, 34%, and 28%, respectively, although the distributions of scores were not statistically different (median ISS: surgeons: 20 [interquartile range (IQR), 9-28] versus JTTR: 17.5 [IQR, 9-31.5], ρ = .7; median NISS: surgeons: 27 [IQR, 12-42] versus JTTR: 25.5 [IQR, 11.5-41], ρ = .7). Conclusion: There are discrepancies in the recording of AIS(M) between surgeons directly involved in the care of trauma casualties and trauma nurse coordinators working by retrospective chart review. Increased accuracy might be achieved by actively collaborating in this process.

Keywords: Injury Severity Score; Abbreviated Injury Scale; trauma; surgeon; trauma nurse coordinator

PMID: 26125170

DOI: PBK8-WHR1

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Interoperable Readiness to Use Tourniquets by One's Familiarity With Different Models

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Kragh JF, Aden JK, Dubick MA. 19(4). 51 - 57. (Journal Article)

Abstract

Background: We investigated interoperability for a first aid provider to perform simulated use of three tourniquet models of maximal, moderate, and minimal familiarity. Methods: The experiment was focused on the tourniquets used by an expert who rendered aid on a manikin by using three models of tourniquet with different extents of familiarity: The familiarity with Combat Application Tourniquet (C-A-T) was maximal; that for Special Operations Forces Tactical Tourniquet (SOFTT) was moderate, and that for Military Emergency Tourniquet (MET) was minimal. Each model had a band-and-rod design. Interoperability changes as intermodel differences were beneficial or costly in that performances were improved or impaired in units of time, ease, blood, and pressure. Each model had 10 tests, and test order was randomized by model. The HapMed Leg Tourniquet Trainer simulated a limb amputation. Results: In comparison of interoperability burdens, sums of 10 test durations by model for C-A-T, SOFTT, and MET were 38, 77, and 64 minutes, respectively; C-A-T was fastest (p ≤ .002, both). The sums of times to stop bleeding for C-A-T, SOFTT, and MET were 334, 953, and 826 seconds, respectively; C-A-T was fastest (p ≤ .0013, both). The sums of blood losses for C-A-T, SOFTT, and MET were 2105, 3287, and 4256mL, respectively; that for C-A-T was least (p ≤ .0005, both). The mean ease of use differed, with C-A-T being easiest (p ≤ .0046, both). The mean pressure differed, with C-A-T being higher than SOFTT (p = .0073). Conclusions: Timesaving strongly favored the model with which the user had maximal familiarity. In theory and simulation, interoperability bears costs in successfully attaining it, in maintaining it, and in failing either. The user's familiarity with tourniquet model was associated with improved interoperability as seen by improved performances. If multiple models are fielded, then organizations may plan on extra spending, supplying, training, and managing.

Keywords: tourniquet model; Combat Application Tourniquet (C-A-T); Special Forces Tactical Tourniquet (SOFTT); Military Emergency Tourniquet (MET); interoperability; manikin; emergency; first aid

PMID: 31910471

DOI: 5UQT-PYYT

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Interventions Performed on Multipurpose Military Working Dogs in the Prehospital Combat Setting: A Comprehensive Case Series Report

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Reeves LK, Mora AG, Field A, Redman TT. 19(3). 90 - 93. (Journal Article)

Abstract

Introduction: The military working dog (MWD) has been essential in military operations such as Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF). MWDs sustain traumatic injuries that require point of injury and en route clinical interventions. The objective of this study was to describe the injuries and treatment military working dogs received on the battlefield and report their final disposition. Methods: This was a convenience sample of 11 injury and treatment reports of US MWDs from February 2008 to December 2014. We obtained clinical data regarding battlefield treatment from the 160th Special Operations Aviation Regiment (SOAR) database and supplemental operational sources. A single individual collected the data and maintained the dataset. The data collected included mechanism of injury, clinical interventions, and outcomes. We reported findings as frequencies. Results: Of the 11 MWD casualties identified in this dataset, 10 reports had documented injuries secondary to trauma. Eighty percent of the cases sustained gunshot wounds. The hindlegs were the most common site of injury (50%); however, 80% sustained injuries at more than one anatomical location. Seventy percent of cases received at least one clinical intervention before arrival at their first treatment facility. The most common interventions included trauma dressing (30%), gauze (30%), chest seal (30%), and pain medication (30%). The survival rate was 50%. Conclusion: The majority of the MWD cases in this dataset sustained traumatic injuries, with gunshot being the most common mechanism of injury. Most MWDs received at least one clinical intervention. Fifty percent did not survive their traumatic injuries.

Keywords: military working dog; Operation Iraqi Freedom; Operation Enduring Freedom; combat training; combat veterinary care

PMID: 31539440

DOI: LE5D-P32Y

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Interviews With MSG (Ret) Rick Hines, Capt Kyle S. Stigall, MD, and COL (Ret) Russ Kotwal, MD, MPH

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Randles J, Merkle A. 21(1). 124 - 124. (Interview)

Keywords:

PMID: 33721321

DOI: SC2L-RYFL

Intra-articular Morphine versus Lidocaine for Acute Knee Pain

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Graham RF, Hughes JR, Johnson AE, Cuenca PJ, Mosely T. 14(2). 74 - 79. (Journal Article)

Abstract

Objective: The authors conducted an unfunded randomized controlled trial approved by the Brooke Army Medical Center (BAMC) Institutional Review Board (IRB) to determine the possible efficacy of intra-articular morphine for pain in acute knee injuries. Methods: Patients presenting to the emergency department at San Antonio Military Medical Center (SAMMC) from May 2012 to August 2013 with knee pain due to an acute injury were consented and then enrolled based on a convenience sample. Patients were randomized to one of three intervention arms (morphine, lidocaine, or morphine and lidocaine) and were blinded to the intervention. The respective solution was injected into the knee joint using standard techniques. The patients self-reported their levels of knee pain via a standard 100mm visual analogue scale (VAS) at the time of injection and 30 minutes, 60 minutes, 90 minutes, 2 hours, 6 hours, and 24 hours postinjection. At 24 hours, the patients also reported the estimated amount of time they applied ice to the knee and the amount of oral analgesia consumed in the previous 24 hours. Results: The primary outcome was relative pain reduction as measured by the VAS. Secondary outcomes were the total cumulative use of ice and analgesics during the first 24 hours. Although this was a small study, the results showed a possible trend toward better pain control at all time intervals with injections containing morphine compared with lidocaine-only injections. Ice and oral analgesia usage was equivalent between the three intervention arms. Conclusion: Further investigation with a larger sample is required to explore whether these results are statistically significant and the possible superiority of intra-articular morphine to lidocaine for acute knee pain.

Keywords: knee pain, acute; intra-articular morphine; intra-articular lidocaine

PMID: 24952044

DOI: 4324-0IWL

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Intramuscular Tranexamic Acid in Tactical and Combat Settings

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Vu EN, Wan WC, Yeung TC, Callaway DW. 18(1). 62 - 68. (Journal Article)

Abstract

Background: Uncontrolled hemorrhage remains a leading cause of preventable death in tactical and combat settings. Alternate routes of delivery of tranexamic acid (TXA), an adjunct in the management of hemorrhagic shock, are being studied. A working group for the Committee for Tactical Emergency Casualty Care reviewed the available evidence on the potential role for intramuscular (IM) administration of TXA in nonhospital settings as soon as possible from the point of injury. Methods: EMBASE and MEDLINE/PubMed databases were sequentially searched by medical librarians for evidence of TXA use in the following contexts and/or using the following keywords: prehospital, trauma, hemorrhagic shock, optimal timing, optimal dose, safe volume, incidence of venous thromboembolism (VTE), IM bioavailability. Results: A total of 183 studies were reviewed. The strength of the available data was variable, generally weak in quality, and included laboratory research, case reports, retrospective observational reviews, and few prospective studies. Current volume and concentrations of available formulations of TXA make it, in theory, amenable to IM injection. Current bestpractice guidelines for large-volume injection (i.e., 5mL) support IM administration in four locations in the adult human body. One case series suggests complete bioavailability of IM TXA in healthy patients. Data are lacking on the efficacy and safety of IM TXA in hemorrhagic shock. Conclusion: There is currently insufficient evidence to support a strong recommendation for or against IM administration of TXA in the combat setting; however, there is an abundance of literature demonstrating efficacy and safety of TXA use in a broad range of patient populations. Balancing the available data and risk- benefit ratio, IM TXA should be considered a viable treatment option for tactical and combat applications. Additional studies should focus on the optimal dose and bioavailability of IM dosing of patients in hemorrhagic shock, with assessment of potential downstream sequelae.

Keywords: intramuscular; tranexamic acid; hemorrhagic shock; Tactical Combat Casualty Care; Tactical Emergency Casualty Care

PMID: 29533435

DOI: PLW2-KN9Z

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Intraorbital Training Munition

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Davies BW, Hink EM, Enzenauer RW. 13(2). 8 - 11. (Case Reports)

Abstract

Objectives: To present a case report of an intraorbital training munition during combat simulation. Methods: A 36-year-old National Guardsman presented to our hospital after being struck in the right orbit with a training munition during combat exercises at Fort Carson, Colorado. The clinical findings, treatment course, and outcome of the case are discussed with review of the literature. Results: An anterior orbitotomy and retinal detachment repair was performed on the patient. The training munition was recovered through the entrance wound in the upper eyelid. At 1 month postoperative, the patient's vision was 20/20 with correction. No complications were noted. Conclusions: This case report is serves as an example of the ocular morbidity associated with training munitions as well as a reminder of the importance of compliance with protective eyewear during training exercises. While surgical excision is this case was straightforward, intraorbital foreign bodies can pose a significant surgical challenge.

Keywords: orbit; trauma; training; munition

PMID: 24419828

DOI: 0F6E-68NK

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Introduction to TCCC Changes Summary 6 May 2021

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Butler FK. 21(2). 120 - 120. (Letter)

Keywords:

PMID: 34105137

DOI: V1N3-PEDL

Introduction to the NATO Special Operations Combat Medic Research Ongoing Series

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Murphy A. 19(2). 117 - 117. (Journal Article)

Keywords:

PMID: 31201763

DOI: QPWF-WSF3

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Introduction to the NATO Special Operations Combat Medic Research Ongoing Series

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Sardianos D, Boland J. 19(2). 118 - 121. (Journal Article)

Abstract

Technology has become a necessity in modern society, providing capabilities that have never been experienced before. The integration of such capabilities arms today's Special Operations medic with abilities that can make a vast difference to the survivability rate of an ill or injured patient. Taking advantage of new technological capabilities such as advanced monitoring and diagnostics and portable ultrasound also plays a key role; together with the evolution in modern communication.

Keywords: technology; awareness; ultrasound; telemedicine; NATO; Special Operations Combat Medic; NSOCM

PMID: 31201764

DOI: GI02-NSJA

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Introduction to the Unconventional Medicine Series

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Hetzler MR. 17(2). 153 - 153. (Journal Article)

Keywords:

PMID: 28599050

DOI: 6057-7VDI

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Intubation of the Right Atrium During an Attempted Modified Surgical Airway in a Pig

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Melanie J, Juergens A, McClure M, Spear D. 17(2). 96 - 100. (Journal Article)

Abstract

In modern medicine, the surgical cricothyrotomy is an airway procedure of last resort. In austere environments, however, its simplicity may make it a more feasible option than carrying a full complement of laryngoscopes. To create a Transportation Security Agency-compliant compact first-response bag, we attempted to establish a surgical cricothyrotomy in a pig, using trauma shears, basic medical scissors, a pocket bougie, and an endotracheal tube. Bougies can provide tactile feedback via the "tracheal ring sign" and "stop sign" to indicate positive tracheal placement during orotracheal intubation. We report on a previously unknown serious potential complication that questions the use of scissors to establish a surgical airway and the reliability of tactile bougie signs when translated into certain surgical airways.

Keywords: emergency cricothyrotomy; cannot intubate-cannot ventilate; prehospital airway management

PMID: 28599040

DOI: YUHE-AD1C

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Invasive Reduction of Paraphimosis in an Adolescent Male While in a Deployed Austere Environment

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Pham C, Zehring J, Berry-Caban CS. 17(1). 9 - 13. (Case Reports)

Abstract

Paraphimosis is a urologic emergency resulting in tissue necrosis and partial amputation, if not reduced. Paraphimosis occurs when the foreskin of the uncircumcised or partially circumcised male is retracted behind the glans penis, develops venous and lymphatic congestion, and cannot be returned to its normal position. Invasive reduction of paraphimosis requires minimal instruments and can be accomplished by experienced providers. This case describes a 10-year-old local national with paraphimosis over 10 days that required invasive reduction in a deployed austere environment in Africa.

Keywords: paraphimosis; penile diseases; penis; foreskin; treatment

PMID: 28285474

DOI: 5NB6-A30E

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Invisible Armies: An Epic History of Guerrilla Warfare from Ancient Times to the Present

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Farr WD. 13(2). 75 - 75. (Book Review)

Abstract

Max Boot. Invisible Armies: An Epic History of Guerrilla Warfare From Ancient Times to the Present.
New York: Liveright Publishing Company; 2013. 784 pages. ISBN-10: 0-87140-4249/
ISBN-13: 978-0-87140-424-4.

Keywords:

DOI:

Isolating Populations to Control Pandemic Spread in an Austere Military Environment

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Hall AB, Dixon M, Dennis AJ, Wilson RL. 20(4). 92 - 94. (Journal Article)

Abstract

Background: The COVID-19 pandemic has been a struggle for medical systems throughout the world. In austere locations in which testing, resupply, and evacuation have been limited or impossible, unique challenges exist. This case series demonstrates the importance of population isolation in preventing disease from overwhelming medical assets. Methods: This is a case series describing the outbreak of COVID-19 in an isolated population in Africa. The population consists of a main population with a Role 2 capability, with several supported satellite populations with a Role 1 capability. Outbreaks in five satellite population centers occurred over the course of the COVID-19 pandemic from its start on approximately 1 March 2020 until 28 April 2020, when a more robust medical asset became available at the central evacuation hub within the main population. Results: Population movement controls and the use of telehealth prevented the spread within the main population at risk and enabled the setup of medical assets to prepare for anticipated widespread disease. Conclusion: Isolation of disease in the satellite populations and treating in place, rather than immediately moving to the larger population center's medical facilities, prevented widespread exposure. Isolation also protected critical patient transport capabilities for use for high-risk patients. In addition, this strategy provided time and resources to develop infrastructure to handle anticipated larger outbreaks.

Keywords: COVID-19; Coronavirus; austere; military

PMID: 33320319

DOI: IZLM-CQ5D

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iTClamp-Mediated Wound Closure Speeds Control of Arterial Hemorrhage With or Without Additional Hemostatic Agents

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Stuart SM, Bohan ML, Mclean JB, Walchak AC, Friedrich EE. 22(4). 87 - 92. (Journal Article)

Abstract

Background: Exsanguination is the leading cause of preventable posttraumatic death, especially in the prehospital arena. Traditional hemorrhage control methods involve packing the wound with hemostatic agents, providing manual pressure, and then applying a pressure dressing to stabilize the treatment. This is a lengthy process that frequently destabilizes upon patient transport. Conversely, the iTClamp, a compact wound closure device, is designed to rapidly seal wound edges mechanically, expediting clot formation at the site of injury. Objectives: To determine the efficacy of the iTClamp with and without wound packing in the control of a lethal junction hemorrhage. Methods: Given the limited available information regarding the efficacy of the iTClamp in conjunction with traditional hemostatic agents, this study used a swine model of severe junctional hemorrhage. The goal was to compare a multiagent strategy using the iTClamp in conjunction with XSTAT to the traditional method of Combat Gauze packing with pressure dressing application. Readouts include application time, blood loss, and rebleed occurrence. Results: Mean application times of the iTClamp treatment alone or in conjunction with other hemostatic agents were at least 75% faster than the application time of Combat Gauze with pressure dressing. Percent blood loss was not significantly different between groups but trended the highest for Combat Gauze treated swine, followed by iTClamp plus XSTAT, iTClamp alone and finally iTClamp plus Combat Gauze. Conclusion: The results from this study demonstrate that the iTClamp can be effectively utilized in conjunction with hemostatic packing to control junctional hemorrhages.

Keywords: TClamp; hemorrhage; trauma; junctional wounds; hemostatic agent

PMID: 36525019

DOI: TPMG-0MQU

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Japanese Encephalitis

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Burnett MW. 16(2). 89 - 90. (Journal Article)

Keywords:

PMID: 27450609

DOI: 0GIV-PERT

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Joint Special Operations Task Force - Phillipines (jsotf-p) Joint Medcap Planning

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Fletcher J, Dominguez J, Walker T, Gallaher P. 07(4). 43 - 49. (Journal Article)

Abstract

Over the last several years civil military operations (CMO) have increasingly become a vital part of a commander's overall mission strategy. Special Operations Forces Medics help support a commander's CMO plan by planning, coordinating, and executing medical civil action programs (MEDCAPs). SOF Medics face unique challenges in planning and successfully executingMEDCAPs at the operational and tactical level of war. However, because of shared experiences in different combatant commands, civil affairs teams (CAT-As), and operational detachments alpha (ODAs) are developing successful tactics, techniques, and procedures (TTPs) for conductingMEDCAPs through a professional peer exchange within the JSOTF-P. The TTPs developed enable the CAT-A or ODA to immediately establish credibility, foster rapport, and improve contacts with local government units, local government organizations, non-government organizations, and host nation counterparts. The professional peer exchange provides the CAT-A or ODA team with the opportunity to learn the planning and logistical requirements of conducting a MEDCAP in the Joint Special Operations Task Force - Philippines AOR.

Keywords:

DOI:

Joint Trauma System Clinical Practice Guideline (JTS CPG): Prehospital Blood Transfusion. 30 October 2020

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Voller J, Tobin JM, Cap AP, Cunningham CW, Denoyer M, Drew B, Johannigman J, Mann-Salinas EA, Walrath B, Gurney JM, Shackelford SA. 21(4). 11 - 21. (Journal Article)

Abstract

This Clinical Practice Guideline (CPG) provides a brief summary of the scientific literature for prehospital blood use, with an emphasis on the en route care environment. Updates include the importance of calcium administration to counteract the deleterious effects of hypocalcemia, minimal to no use of crystalloid, and stresses the importance of involved and educated en route care medical directors alongside at a competent prehospital and en route care providers (see Table 1). With the paradigm shift to use FDA-approved cold stored low titer group O whole blood (CS-LTOWB) along with the operational need for continued use of walking blood banks (WBB) and point of injury (POI) transfusion, there must be focused, deliberate training incorporating the different whole blood options. Appropriate supervision of autologous blood transfusion training is important for execution of this task in support of deployed combat operations as well as other operations in which traumatic injuries will occur. Command emphasis on the importance of this effort as well as appropriate logistical support are essential elements of a prehospital blood program as part of a prehospital/en route combat casualty care system.

Keywords: prehospital; blood transfusion; plood precautions; JTS CPG

PMID: 34969121

DOI: P685-L7R7

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Joint Trauma System Clinical Practice Guideline: Acute Coronary Syndrome (ACS). 14 May 2021

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Sarkisian S, Sletten ZJ, Clark RA, Soh EK, Appel DA, Bellin DA, Nayak KR, Kaviratne S, Strilka R, Schimke A, Nasir J, Mone D, Keenan S, Shackelford SA. 21(3). 11 - 20. (Journal Article)

Abstract

Deployed medical providers at all roles of care must be prepared to recognize and manage acute coronary syndrome (ACS). Under optimal conditions, treatment is initiated with medical therapy and may be followed by prompt coronary angiography and revascularization. Emergent percutaneous coronary intervention (PCI) is not available in most deployed locations, however, and the time for such intervention is often dependent on long-range evacuation. This CPG provides guidance on best management for ACS patients in the deployed and resource-constrained environment.

Keywords:

PMID: 34529799

DOI: LH2D-LM4R

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Joint Trauma System Clinical Practice Guideline: Austere Resuscitative and Surgical Care - 30 October 2019

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Anonymous A. 20(2). 25 - 42. (Journal Article)

Keywords:

PMID: 32573740

DOI: MUKJ-NM7U

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Joint Trauma System Clinical Practice Guideline: Global Snake Envenomation Management

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Anonymous A. 20(2). 43 - 74. (Journal Article)

Keywords:

PMID: 32573741

DOI: ZFQW-DWGR

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Journal Club: Ketamine in the Emergency Department

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Banting J, Beriano T. 15(3). 94 - 97. (Journal Article)

Abstract

In this column of Clinical Corner, we are going to switch things up a little. We are going to review a journal article that is applicable to the Special Operations Forces (SOF) Medic. We plan on continuing to present clinically relevant cases, but every so often an article is published that we simply must take a deeper look at.

Keywords: ketamine; pain, acute

PMID: 26360362

DOI: 8I1G-WG8I

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JSOM 20TH ANNIVERSARY SPECIAL INTERVIEWS

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Randles J, Merkle A. 20(2). 149 - 149. (Interview)

Keywords:

PMID: 32573755

DOI: GXWD-683K

Junctional Tourniquet Training Experience

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Kragh JF, Geracci JJ, Parsons DL, Robinson JB, Biever KA, Rein EB, Glassberg E, Strandenes G, Chen J, Benov A, Marcozzi D, Shackelford SA, Cox KM, Mann-Salinas EA. 15(3). 20 - 30. (Journal Article)

Abstract

Since 2009, out-of-hospital care of junctional hemorrhage bleeding from the trunk-appendage junctions has changed, in part, due to the newly available junctional tourniquets (JTs) that have been cleared by the US Food and Drug Administration. Given four new models of JT available in 2014, several military services have begun to acquire, train, or even use such JTs in care. The ability of users to be trained in JT use has been observed by multiple instructors. The experience of such instructors has been broad as a group, but their experience as individuals has been neither long nor deep. A gathering into one source of the collective experience of trainers of JT users could permit a collation of useful information to include lessons learned, tips in skill performance, identification of pitfalls of use to avoid, and strategies to optimize user learning. The purpose of the present review is to record the experiences of several medical personnel in their JT training of users to provide a guide for future trainers.

Keywords: hemorrhage; resuscitation; medical device; education; skill development; emergency medical services

PMID: 26360350

DOI: CHAS-KZBQ

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Junctional Tourniquet Use During Combat Operations in Afghanistan: The Prehospital Trauma Registry Experience

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Schauer SG, April MD, Fisher AD, Cunningham CW, Gurney JM. 18(2). 71 - 74. (Journal Article)

Abstract

Background: Hemorrhage is the leading cause of potentially preventable death on the battlefield. Although the resurgence of limb tourniquets revolutionized hemorrhage control in combat casualties in the recent conflicts, the mortality rate for patients with junctional hemorrhage is still high. Junctional tourniquets (JTQs) offer a mechanism to address the high mortality rate. The success of these devices in the combat setting is unclear given a dearth of existing data. Methods: From the Prehospital Trauma Registry (PHTR) and the Department of Defense Trauma Registry, we extracted cases of JTQ use in Afghanistan. Results: We identified 13 uses of a JTQ. We excluded one case in which an improvised pelvic binder was used. Of the remaining 12 cases of JTQ use, seven had documented success of hemorrhage control, three failed to control hemorrhage, and two were missing documentation regarding success or failure. Conclusion: We report 12 cases of prehospital use of JTQ in Afghanistan. The findings from this case series suggest these devices may have some utility in achieving hemorrhage control strictly at junctional sites (e.g., inguinal creases). However, they also highlight device limitations. This analysis demonstrates the need for continued improvements in technologies for junctional hemorrhage control, prehospital documentation, data fidelity and collection, as well as training and sustainment of the training for utilization of prehospital hemorrhage control techniques.

Keywords: junctional tourniquet; junctional hemorrhage; trauma; combat

PMID: 29889959

DOI: SXCY-5SCX

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Ketamine Administration by Special Operations Medical Personnel During Training Mishaps

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Fisher AD, Schwartz DS, Petersen CD, Meyer SE, Thielemann JN, Redman TT, Rush SC. 20(3). 81 - 86. (Journal Article)

Abstract

Background: Opioids can have adverse effects on casualties in hemorrhagic shock. In 2014, the Committee on Tactical Combat Casualty Care (CoTCCC) recommended the use of ketamine at the point of injury (POI). Despite these recommendations the adherence is moderate at best. Poor use may stem from a lack of access to use ketamine during training. The United States Special Operations Command (USSOCOM) is often in a unique position, they maintain narcotics for use during all training events and operations. The goal of this work is to demonstrate that ketamine is safe and effective in both training and operational environments. Methods: This was a retrospective, observational performance improvement project within United States Special Operations Command and Air Combat Command that included the US Army's 75th Ranger Regiment, 160th Special Operations Aviation Regiment, and US Air Force Pararescue. Descriptive statistics were used to calculate the doses per administration to include the interquartile range (IQR), standard deviation (SD) and the range of likely doses using a 95% confidence interval (CI). A Wilcoxon signed-rank test was used to compare the mean pre-ketamine pain scores to the mean post-ketamine on a 0-to-10 pain scale. Results: From July 2010 to October 2017, there was a total of 34 patients; all were male. A total of 22 (64.7%) received intravenous ketamine and 12 (35.3%) received intramuscular ketamine and 8 (23.5%) received intranasal ketamine. The mean number of ketamine doses via all routes administered to patients was 1.88 (SD 1.094) and the mean total dose of all ketamine administration was 90.29mg (95% CI, 70.09-110.49). The mean initial dose of all ketamine administration was 47.35mg (95% CI, 38.52-56.18). The median preketamine pain scale for casualties was noted to be 8.0 (IQR 3) and the median post-ketamine pain scale was 0.0 (IQR 3). Conclusion: Ketamine appears to be safe and effective for use during military training accidents. Military units should consider allowing their medics to carry and use as needed.

Keywords: ketamine; opioids; training; war-related injuries; analgesia

PMID: 32969009

DOI: ERGU-PEZ2

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Ketamine Use for Prolonged Field Care Reduces Supply Use

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Hall AB, Morrow L, Dixon M. 20(3). 120 - 121. (Journal Article)

Abstract

This case describes the prolonged treatment of a 38-year-old man with a transpelvic gunshot wound requiring a diverting ostomy and cystostomy for damage control procedures with a comminuted acetabular and femoral head fracture. The team used a ketamine drip for prolonged field care over 48 hours. The benefit of using a ketamine drip included low supply requirement, excellent analgesia, and ease of administration, but side-effects included somnolence and atelectasis necessitating oxygen supplementation before evacuation.

Keywords: prolonged field care; trauma; ketamine; analgesia

PMID: 32969016

DOI: ICK7-01Z7

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Ketones and Human Performance

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Scott JM, Deuster PA. 17(2). 112 - 116. (Journal Article)

Abstract

Everyone is seeking nutritional strategies that might benefit performance. One approach receiving much attention is ketones, or ketosis. Ketones are very simple compounds made of hydrogen, carbon, and oxygen, and ketosis is a metabolic state whereby the body uses predominantly ketones. Ketosis can be achieved by fasting for longer than 72 hours or by following a very lowcarbohydrate, high-fat diet (ketogenic diet) for several days to weeks. Alternatively, ketone supplements purportedly induce ketosis rapidly and do not require strict adherence to any specific type of diet; however, much of the touted benefits are anecdotal. A potential role for ketosis as a performance enhancer was first introduced in 1983 with the idea that chronic ketosis without caloric restriction could preserve submaximal exercise capability by sparing glycogen or conserving the limited carbohydrate stores. Few human studies on the effects of a ketogenic diet on performance have yielded positive results, and most studies have yielded equivocal or null results, and a few negative results. Many questions about ketones relevant to Special Operations Forces (SOF) remain unanswered. At present, a ketogenic diet and/or a ketone supplement do not appear confer performance benefits for SOF. Instead, Operators should engage with their unit dietitian to develop individualized nutritional strategies based on unique mission requirements. The authors review the concept of a ketogenic diet, describe some potential benefits and risks of ketosis, review the performance literature and how to measure ketone status, and then summarize the landscape in 2017.

Keywords: ketosis; ketones; diet, ketogenic; ketone supplement; performance

PMID: 28599043

DOI: PGWG-H55J

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Key Facts On Reslilience And Response To Stress For Navy And USMC Leaders

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Johnson DC. 09(4). 110 - 112. (Journal Article)

Keywords:

PMID: 20112656

DOI: WNUN-EHDM

Kitona 2013: A Medical Readiness Training Exercise in the Democratic Republic of the Congo Leading to Lion Rouge

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Hesse E, Okito EA, Mann K, McCullough M, Lesho E. 15(3). 54 - 59. (Journal Article)

Abstract

Background: Health initiatives support regional stability and are a priority for US and African partners. We present data and experience from the Democratic Republic of Congo (DRC), a strategically and epidemiologically ideal location for collaborative medical engagement (CME). Our objectives included relationship building, exposure of US military medical personnel to uncommon tropical diseases, bolstering a referral hospital, and updating Congolese physicians on new treatment or preventive standards of care. Methods: We conducted a CMEstyled medical readiness training exercise (MEDRETE) at the Military Referral Hospital of Kitona in June 2013. US and Congolese healthcare providers presented 20 lectures and evaluated 158 patients collaboratively; 132 for infections. Results: The CME led to Lion Rouge, the first joint military, multidisciplinary engagement between the respective militaries. Equally noteworthy is that some of the same participants returned to the same location for the follow-on exercise, providing continuity. Conclusion: These outcomes suggest the MEDRETE and CME approaches were successful.

Keywords: exercise; medical; MEDRETE; needs assessment; Democratic Republic of the Congo

PMID: 26360354

DOI: T87Y-7A71

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Knife Edge: Life as a Special Forces Surgeon

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Farr WD. 15(3). 120 - 120. (Book Review)

Abstract

Villar, Richard. Knife Edge. Life as a Special Forces Surgeon.
Windmill Hill, United Kingdom: Vineyard Press; 1997.
Paperback, 310 pages, ISBN 0-9542203-0-7.

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DOI:

Knowledge Versus Suspicion

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Turconi M, Dare C, Hampton K. 18(3). 124 - 124. (Journal Article)

Keywords:

PMID: 30222850

DOI: LOPB-VXN4

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Laboratory Model of a Collapsible Tube to Develop Bleeding Control Interventions

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Griffin LV, Kragh JF, Dubick MA. 18(1). 47 - 52. (Journal Article)

Abstract

Background: To develop knowledge of mechanical control of bleeding in first aid, a laboratory model was set up to simulate flow through a blood vessel. A collapsible tube was used to mimic an artery in two experiments to determine (1) the extent of volumetric flow reduction caused by increases in the degree of compression of the vessel and (2) the extent of flow reduction caused by increases in the length of compression. Methods: Water was used in vertical tubing. Gravity applied a pressure gradient of about 100mmHg to cause flow. A silicone tube (10mm-diameter lumen [the inner opening], 1mm-thick wall, 150mm length) was used. Tests of no compression of the external wall constituted the control group for both experiments. For all groups, flow volume was sampled over a period of time, and six samples were averaged. In both experiments, the study group consisted of tests with compression that was measured as the reduced area of the luminal cross section. In the first experiment, six groups with luminal area reductions of 0% (control), 74%, 81%, 91%, 94%, and 97% were tested. In the second experiment at 74% luminal area reduction, the three lengths of compression were 5mm, 20mm, and 70mm. The measured data were compared with calculated data by applying established mathematical equations. Results: In the first experiment, flow decreased with decreasing area due to luminal compression, but the association was a parabolic curve such that 94% or greater reduction in luminal area was required to reduce flow by greater than 50%. A reduction in luminal area of 97% reduced flow by 95%. In the second experiment, mean flow rates were not significantly different among the three lengths of compression. Measured data and calculated data were in good agreement. Conclusions: Compared with an uncompressed vessel, volumetric flow of water through a single, unsupported collapsible tube in steady, nonpulsatile conditions with compression applied to its external wall to produce a reduction in luminal area of 97% reduced flow by 95%. Flow was affected by the degree of compression but not by the length of compression.

Keywords: first aid/therapy, tourniquet; hemorrhage, prevention and control, bleeding control; biomechanics, collapsible tubes, steady flow, rheology, pres; models, theoretical

PMID: 29533433

DOI: E3Z7-1LUV

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Laboratory Testing of Emergency Tourniquets Exposed to Prolonged Heat

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Davinson JP, Kragh JF, Aden JK, DeLorenzo RA, Dubick MA. 15(1). 32 - 28. (Journal Article)

Abstract

Background: Environmental exposure of tourniquets has been associated with component damage rates, but the specific type of environmental exposure, such as heat, is unknown. Emergency-tourniquet damage has been associated with malfunction and loss of hemorrhage control, which may risk loss of life during first aid. The purposes of the study are to determine the damage rate of tourniquets exposed to heat and to compare the rate to that of controls. Methods: Three tourniquet models (Combat Application Tourniquet®; SOF® Tactical Tourniquet; Ratcheting Medical Tourniquet®) were tested using a manikin (HapMed Leg Tourniquet Trainer; www.chisystems .com) that simulates extremity hemorrhage. The study group of 15 tourniquets (five devices per model, three models) was exposed to heat (oven at 54.4°C [130°F] for 91 days), and 15 tourniquets similarly constituted the control group (unexposed to heat). Damage, hemorrhage control, distal pulse stoppage, time to effectiveness, pressure (mmHg), and blood loss volumes were measured. Results: Three tourniquets in both groups had damage not associated with heat exposure (ρ = 1). Heat exposure was not associated with change in effectiveness rates (ρ = .32); this lack of association applied to both hemorrhage control and pulse stoppage. When adjusted for the effects of user and model, the comparisons of time to effectiveness and total blood loss were statistically significant (ρ < .0001), but the comparison of pressure was not (ρ = .0613). Conclusion: Heat exposure was not associated with tourniquet damage, inability to gain hemorrhage control, or inability to stop the distal pulse.

Keywords: tourniquet; hemorrhage; resuscitation; medical device; injuries; wounds

PMID: 25770796

DOI: QGD4-Y6HV

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Larger-Caliber Alternative Devices for Decompression of Tension Hemopneumothorax in the Setting of Hemorrhagic Shock

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McEvoy CS, Leatherman ML, Held JM, Fluke LM, Ricca RL, Polk T. 18(4). 18 - 23. (Case Reports)

Abstract

Background: The 14-gauge (14G) angiocatheter (AC) has an unacceptably high failure rate in treatment of tension pneumothorax (tPTX). Little is known regarding the interplay among hemorrhage, hemothorax (HTX), and tPTX. We hypothesized that increased hemorrhage predisposes tension physiology and that needle decompression fails more often with increased HTX. Methods: This is a planned secondary analysis of data from our recent comparison of 14G AC with 10-gauge (10G) AC, modified 14G Veress needle, and 3mm laparoscopic trocar conducted in a positive pressure ventilation tension hemopneumothorax model using anesthetized swine. Susceptibility to tension physiology was extrapolated from volume of carbon dioxide (CO2) instilled and time required to induce 50% reduction in cardiac output. Failures to rescue and recover were compared between the 10% and 20% estimated blood volume (EBV) HTX groups and across devices. Results: A total of 196 tension hemopneumothorax events were evaluated. No differences were noted in the volume of CO2 instilled nor time to tension physiology. HTX with 10% EBV had fewer failures compared with 20% HTX (7% versus 23%; p = .002). For larger-caliber devices, there was no difference between HTX groups, whereas smaller-caliber devices had more failures and longer time to rescue with increased HTX volume as well as increased variability in times to rescue in both HTX volume groups. Conclusion: Increased HTX volume did not predispose tension physiology; however, smaller-caliber devices were associated with more failures and longer times to rescue in 20% HTX as compared with 10% HTX. Use of larger devices for decompression has benefit and further study with more profound hemorrhage and HTX and spontaneous breathing models is warranted.

Keywords: tension pneumothorax; needle decompression; needle thoracostomy; trauma; prehospital care; hemothorax

PMID: 30566718

DOI: HQ54-B5NO

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Laryngeal Mask Airway Exchange Using a Gum Elastic Bougie With a Rotational Twist Technique

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Stancil S, Miller J, Riddle M. 14(3). 74 - 77. (Journal Article)

Abstract

Previous studies have sought to determine the feasibility of exchanging the laryngeal mask airway (LMA) for an endotracheal tube (ETT) over a gum elastic bougie (GEB) and found the practice to have a success rate of about 50%. It has been speculated that the poor success rate may be due to the upward angle of the bougie tip meeting resistance against the anterior laryngeal wall. The use of a 90- to 180-degree twist technique to angle the bougie tip away from the anterior tracheal wall and caudally along the trachea theoretically could improve results. We conducted a prospective cadaveric study to determine if the use of a bougie 90- to 180-degree twist technique or the use of a more flexible pediatric bougie would improve previously published success rates. Emergency medicine personnel attempted exchange of an LMA for an ETT over a GEB using a twisting technique. Despite using the twisting technique, successful exchange over a bougie remained at 50%, similar to previous studies. Using a smaller, more flexible pediatric bougie led to a successful exchange in only 28% of attempts. In this study, the adding of a twist technique or using a pediatric bougie did not result in consistent successful exchange to an ETT from an LMA.

Keywords: laryngeal mask airway; endotracheal tube; gum elastic bougie; supraglottic airway devices; intubation; airway; tube exchange

PMID: 25344710

DOI: 6SS8-B1PN

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Latent TB Infection in USSOF: A Refresher and Update

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Tang SH, Evans JD, Vostal A, Shishido AA. 21(4). 108 - 111. (Journal Article)

Abstract

Tuberculosis (TB) causes approximately 2 million deaths annually worldwide, with 2 billion persons estimated to be actively infected with TB. While rates of active TB disease in the US military are low, military service in TB-endemic countries remains an uncommon, but important source of infection. United States Special Operations Forces (USSOF) and enablers often operate in TB-endemic countries and, as an inherent risk of their mission sets, are more likely to have high-risk exposure to TB disease. Military medical authorities have provided excellent diagnostic guidance; the Centers for Disease Control and Prevention (CDC) recently updated preferred regimens for the treatment of latent TB infection (LTBI). This review serves as a refresher and update to the management of LTBI in USSOF to optimize medical readiness through targeted testing and short treatment regimens.

Keywords: military medicine; tropical medicine; tuberculosis; latent TB

PMID: 34969139

DOI: XOQC-EZJK

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Lateral Canthotomy In Orbital Compartment Syndrome: Special Operations Medics On The Battlefield Can Save The Eye

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Burns GD, DeLellis SM. 08(1). 54 - 57. (Journal Article)

Abstract

The primary medical role of the Special Operations Forces (SOF) Medic is to stabilize the patient and prevent loss of life, limb, and eyesight on the battlefield. Significant time and resources are invested to ensure that SOF Medics are the best trained and most proficient combat Medics in the world. While considerable focus is placed on teaching the intricacies of saving life and limb, it seems as though only tacit emphasis is placed on the preservation of eyesight. Loss of vision can mean not only decrement of lifestyle for the patient, but could also mean loss to the military of a highly trained operator with years of irreplaceable experience. It is the conclusion of the authors that in addition to the current approach of medical management for orbital compartment syndrome, the skills to perform a lateral canthotomy and cantholysis could easily be introduced into the SOF medical training curriculum. This is a relatively straightforward procedure which could significantly reduce the morbidity from a potentially blinding injury.

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Lead Exposure in the Special Operations Shooter How to Prevent Cognitive Decline and Permanent Disability

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Brandon JW, Solarczyk JK, Durrani TS. 18(1). 81 - 87. (Journal Article)

Abstract

Lead toxicity is an important environmental disease and its effects on the human body can be devastating. Unique exposures to Special Operations Forces personnel may include use of firing ranges, use of automotive fuels, production of ammunition, and bodily retention of bullets. Toxicity may degrade physical and psychological fitness, and cause long-term negative health outcomes. Specific effects on fine motor movements, reaction times, and global function could negatively affect shooting skills and decision-making. Biologic monitoring and chelation treatment are poor solutions for protecting this population. Through primary prevention, Special Operations Forces personnel can be protected, in any environment, from the devastating effects of lead exposure. This article offers tools to physicians, environmental service officers, and Special Operations Medics for primary prevention of lead poisoning in the conventional and the austere or forward deployed environments.

Keywords: lead toxicity; lead poisioning; environmental health; primary prevention

PMID: 29533439

DOI: V3HG-7N31

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Learning Curves of Emergency Tourniquet Use Exploring for Utility in Training

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Kragh JF, Mabry RL, Parsons DL, Broussard DW, Aden JK, Dubick MA. 16(4). 7 - 14. (Journal Article)

Abstract

Background: Emergency tourniquet use to control hemorrhage from limb wounds is associated with improved survival and control of shock. In 2013, we introduced a way to measure learning curves of tourniquet users. With a dataset from an unrelated study, we had an opportunity to explore learning in detail. The study aim was to generate hypotheses about measurement methods in the learning of tourniquet users. Methods: We gathered data from a previous experiment that yielded a convenient sample of repeated tourniquet applications used as a marker of learning. Data on consecutive applications on a manikin were used in the current report and were associated with two users, three models of tourniquet, and six metrics (i.e., effectiveness, pulse cessation, blood loss, time to effectiveness, windlass turn number, and pressure applied). There were 840 tests (140 tests per user, two users, three models). Results: Unique characteristics of learning were associated with each user. Hypotheses generated included the following: trainee learning curves can vary in shape (e.g., flat, curved) by which metric of learning is chosen; some metrics may show much learning, whereas others show almost none; use of more than one metric may assess more comprehensively than using only one metric but may require more assessment time; number of uses required can vary by instructional goal (e.g., expertise, competence); awareness of the utility of specific metrics may vary by instructor; and some, but not all, increases in experience are associated with improved performance. Conclusions: This first-aid study generated hypotheses about caregiver learning for further study of tourniquet education and standards.

Keywords: first aid device; first aid education; first aid standards; first aid methods; caregivers; hemorrhage preventions; hemorrhage control; hemorrhage therapy; resuscitation; emergency medical services

PMID: 28088812

DOI: 3Q90-G23J

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Left Hand Injury With Focal Swelling and Tenderness

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Urbaniak MK, Hampton K. 16(3). 86 - 86. (Journal Article)

Keywords: sonography; injury, hand

PMID: 27734450

DOI: Z0LH-322X

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Leprosy (Hansen's Disease)

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Crecelius EM, Burnett MW. 19(4). 105 - 107. (Journal Article)

Keywords: infectious disease; leprosy; Hansen's Disease

PMID: 31910482

DOI: J8QP-4OGW

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Leptospirosis

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Crecelius EM, Burnett MW. 20(4). 121 - 122. (Journal Article)

Abstract

Leptospirosis is caused by an infection with bacteria of the Leptospira species. These spirochetes are carried by a variety of wild and domestic animals. Humans can become infected with these bacteria; leptospirosis most commonly occurs in the tropics and subtropics. Military personnel are at risk of infection through deployment in the field.

Keywords:

PMID: 33320325

DOI: 8YBJ-0DLP

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Lesions Arising in a Tattoo of an Active Duty US Marine Corps Woman

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Winn AE, Rivard SS, Green B. 16(2). 96 - 100. (Journal Article)

Abstract

Tattoos are ubiquitous in modern society; however, they do not come without risk of medical complications. When complications arise in the military community, a particularly thorough differential diagnosis should be considered based on the increased exposures service members have during deployment and throughout their military career. We present a case of a 38-year-old active duty US Marine Corps woman with worsening skin lesions arising within a tattoo 6 weeks after acquiring the tattoo on her right chest. Given environmental exposures from a recent deployment to the Middle East, a wide differential was considered. Ultimately, a skin biopsy revealed early hypertrophic scar formation responsive to therapy with intralesional triamcinolone acetonide (Kenalog&reg; [ILK]). However, given the Marine had recently deployed and is part of the active duty population, consideration of alternative, albeit rare, etiologies was imperative.

Keywords: scar, hypertrophic; keloid collagen; tattoo; allergy, red ink; Mycobacterium, cutaneous atypical; sacroidosis, cutaneous; foreign body granuloma; cellulitis

PMID: 27450611

DOI: 9NQW-HXGA

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Lessons Learned From a Traumatic Brain Injury Mass Casualty Incident

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Killian B, Clark R, Hu C. 21(3). 123 - 125. (Journal Article)

Abstract

In January 2020, an American base was attacked by the largest theater ballistic missile strike in history. This case report covers the resulting mass casualty (MASCAL) incident. In this case, we defined this incident as a MASCAL due to a lack of medical personnel available to properly and timely evaluate the patients. There was no loss of life during the attack but there were > 80 traumatic brain injuries (TBIs). This article focuses on lessons learned from diagnosing and treating Soldiers during a TBI MASCAL event.

Keywords: lessons learned; mass casualty; traumatic brain injury

PMID: 34529819

DOI: MAZS-N4FP

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Lessons Learned on the Battlefield Applied in a Civilian Setting

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Cordier P, Benoit C, Belot-De Saint Leger F, Pauleau G, Goudard Y. 21(1). 102 - 105. (Journal Article)

Abstract

We report the case of a civilian 27-year-old man treated in a military hospital in France who sustained multiple stab wounds, including one in the left groin, with massive external bleeding. When first responders arrived, the patient was in hemorrhagic shock. A tourniquet and two intraosseous catheters were placed to start resuscitative care. On the patient's arrival at the hospital, bleeding was not controlled, so a junctional tourniquet was put in place and massive transfusion was started. Surgical exploration revealed a laceration of the superficial femoral artery and a disruption of the femoral vein. Vascular damage control was achieved by a general surgeon and consisted of primary repair of the superficial femoral artery injury and venous ligation. The patient was discharged from the intensive care unit after 2 days and from the hospital after 8 days. This case illustrates some of the persistent challenges shared between military and civilian trauma care. The external control of junctional hemorrhage is not easily achievable in the field, and junctional tourniquets have been therefore incorporated in the Tactical Combat Casualty Care guidelines. French lyophilized plasma was used for massive transfusion because it has been proven to be a logistically superior alternative to fresh-frozen plasma. Management of vascular wounds by nonspecialized surgeons is a complex situation that requires vascular damage-control skills; French military surgeons therefore follow a comprehensive structured surgical training course that prepares them to manage complex penetrating trauma in austere environments. Finally, in this case, lessons learned on the battlefield were applied to the benefit of the patient.

Keywords: penetrating trauma; casualty care; junctional tourniquet; damage control

PMID: 33721315

DOI: G2X5-LSPJ

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Letter to the Editor

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Howard CM, Veach S, Lyon RF, Shaw KA. 22(1). 9 - 9. (Letter)

Keywords:

PMID: 35278311

DOI: WUMM-Y4N3

Letter to the Editor

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Steinlage A, Wilson RL. 22(3). 108 - 108. (Letter)

Keywords: CASEVAC; critical care team; personnel recovery; USAFRICOM; MEDEVAC; contractors; medical care; evacuation POSTER RESEARCH AWARD

PMID: 36122557

DOI: PIPP-0176

Leveling the Battlefield: Development of a Pre-Deployment Vascular Access Curriculum for the Nonsurgical Provider

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Walker S, Agree O, Harris R, DesRosiers TT. 23(2). 49 - 54. (Journal Article)

Abstract

Introduction: Timely vascular access is critical, as hemorrhage is the number one cause of death on the battlefield. Anecdotal evidence in the Military Health System identified an operationally relevant procedural skills gap in vascular access, and data exist in civilian literature showing high rates of iatrogenic injuries when lack of robust procedural opportunity exists. Multiple pre-deployment training courses are available for surgical providers, but no comprehensive pre-deployment vascular access training exists for non-surgical providers. Methods: This mixed-method review aimed to find relevant, operationally focused, vascular access training publications. A literature review was done to identify both relevant military clinical practice guidelines (CPGs) and full text articles. Reviewers also investigated available pre-deployment trainings for both surgeons and non-surgeons in which course administrators were contacted and details regarding the courses were described. Results: We identified seven full-text articles and four CPGs. Two existing surgical training programs and Army, Navy, and Air Force pre-deployment training standards for non-surgeons were evaluated. Conclusion: A cost-effective and accessible pre-deployment curriculum utilizing reviewed literature in a "learn, do, perfect" structure is suggested, building on pre-existing structures while incorporating remotely accessible didactics, hands-on practice with portable simulation models, and live-feedback training.

Keywords: vascular access; military medicine; arterial access; arterial line; central venous access; central line; IV; intravenous; literature review; training, military; deployed medicine; simulation training; austere environments; emergency medical care

PMID: 37302144

DOI: HKH7-GWDW

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Leveraging Combat Casualty Reporting in the Afghan National Army Special Operations Command for Evidence-Based Changes in the ANASOC School of Excellence

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Florance JM, Hicks M. 19(4). 59 - 61. (Journal Article)

Abstract

The Afghan National Army Special Operations Command (ANASOC) uses several documents for casualty reporting. By analyzing these documents from a period of March to December 2018, the authors demonstrate the predominance of gunshot fatalities within ANASOC at approximately 63% of combat deaths and a high rate of prehospital death at approximately 97% of combat deaths. The data also demonstrate relatively few cases of long-term disability from ANASOC soldiers wounded in action. The authors used these conclusions to create a Combined Joint Special Operations Task Force-Afghanistan (CJSOTF-A) working group that recommended changes to the medical curriculum at the ANASOC School of Excellence. These recommendations centered on an increased emphasis on bleeding control to prevent death from hemorrhagic shock.

Keywords: Afghanistan; military medicine; warfare; wounds and injuries; war wounds; violence; military personnel; wounds; gunshot; wounds; penetrating; blast injuries

PMID: 31910472

DOI: KXOJ-GI5N

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Life and Limb In-Flight Surgical Intervention: Fifteen Years of Experience by Joint Medical Augmentation Unit Surgical Resuscitation Teams

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DuBose JJ, Stinner DJ, Baudek A, Martens D, Donham B, Cuthrell M, Stephens T, Schofield J, Conklin CC, Telian S. 20(4). 47 - 52. (Journal Article)

Abstract

Background: Expedient resuscitation and emergent damage control interventions remain critical tools of modern combat casualty care. Although fortunately rare, the requirement for life and limb salvaging surgical intervention prior to arrival at traditional deployed medical treatment facilities may be required for the care of select casualties. The optimal employment of a surgical resuscitation team (SRT) may afford life and limb salvage in these unique situations. Methods: Fifteen years of after-action reports (AARs) from a highly specialized SRTs were reviewed. Patient demographics, specific details of encounter, team role, advanced emergent life and limb interventions, and outcomes were analyzed. Results: Data from 317 casualties (312 human, five canines) over 15 years were reviewed. Among human casualties, 20 had no signs of life at intercept, with only one (5%) surviving to reach a Military Treatment Facility (MTF). Among the 292 casualties with signs of life at intercept, SRTs were employed in a variety of roles, including MTF augmentation (48.6%), as a transport capability from other aeromedical platforms, critical care transport (CCT) between MTFs (27.7%), or as an in-flight damage control capability directly to point of injury (POI) (18.2%). In the context of these roles, the SRT performed in-flight life and limb preserving surgery for nine patients. Procedures performed included resuscitative thoracotomy (7/9; 77.8%), damage control laparotomy (1/9; 11.1%) and extremity fasciotomy for acute lower extremity compartment syndrome (1/11; 11%). Survival following in-flight resuscitative thoracotomy was 33% (1/3) when signs of life (SOL) were absent at intercept and 75% (3/4) among patients who lost SOL during transport. Conclusion: In-flight surgery by a specifically trained and experienced SRT can salvage life and limb for casualties of major combat injury. Additional research is required to determine optimal SRT utilization in present and future conflicts.

Keywords: in-flight; surgical resuscitation team; casualty; limb salvage; military treatment facility; trauma

PMID: 33320312

DOI: SI6S-XHCZ

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Life Over Limb: Why Not Both? Revisiting Tourniquet Practices Based on Lessons Learned From the War in Ukraine

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Patterson J, Bryan RT, Turconi M, Leiner A, Plackett TP, Rhodes LL, Sciulli L, Donnelly S, Reynolds CW, Leanza J, Fisher AD, Kushnir T, Artemenko V, Ward KR, Holcomb JB, Schmitzberger FF. Ahead of Print. (Journal Article)

Abstract

The use of tourniquets for life-threatening limb hemorrhage is standard of care in military and civilian medicine. The United States (U.S.) Department of Defense (DoD) Committee on Tactical Combat Casualty Care (CoTCCC) guidelines, as part of the Joint Trauma System, support the application of tourniquets within a structured system reliant on highly trained medics and expeditious evacuation. Current practices by entities such as the DoD and North Atlantic Treaty Organization (NATO) are supported by evidence collected in counter-insurgency operations and other conflicts in which transport times to care rarely went beyond one hour, and casualty rates and tactical situations rarely exceeded capabilities. Tourniquets cause complications when misused or utilized for prolonged durations, and in near-peer or peer-peer conflicts, contested airspace and the impact of high-attrition warfare may increase time to definitive care and limit training resources. We present a series of cases from the war in Ukraine that suggest tourniquet practices are contributing to complications such as limb amputation, overall morbidity and mortality, and increased burden on the medical system. We discuss factors that contribute to this phenomenon and propose interventions for use in current and future similar contexts, with the ultimate goal of reducing morbidity and mortality.

Keywords: tourniquets; amputation; traumatic injury; war-related injuries

PMID: 38300880

DOI: V057-2PCH

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Lighting Did Not Affect Self-application of a Stretch and Wrap Style Tourniquet

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Wall PL, Welander JD, Sahr SM, Buising CM. 12(3). 68 - 73. (Journal Article)

Abstract

The objective was to determine the effects of darkness on self-application of a stretch and wrap style tourniquet. Methods: Following training and practice, 15 volunteers self-applied the Stretch, Wrap, and Tuck-Tourniquet (SWAT-T) to their leg, thigh, dominant forearm, and dominate arm. Proper application in lighted conditions was followed by the same applications in darkness. Proper stretch was determined by alteration of shapes printed on the tourniquet. Results: High rates of proper application and successful arterial occlusion (60 second Doppler signal elimination) occurred in darkness just as in lighted conditions (darkness: 56 proper and 60 successful of 60 applications, lighted: 57 proper and 53 successful of 60 applications). Lighting did not affect ease of application or discomfort. Males (8) and females (7) were similarly successful. Lower limb applications were predominantly rated easy (51 of 60). Upper limb applications had fewer easy ratings (15 easy, 32 challenging, 13 difficult ratings). Arterial occlusion took < 60 seconds in 112 of 113 successful applications; completion took < 60 seconds in 88 of all 120 applications. Upper limb applications took longer for completion. Conclusions: The SWAT-T stretch and wrap style tourniquet can be self-applied properly even in darkness. When properly applied, it can stop limb arterial flow.

Keywords: hemorrhage control; first aid; emergency treatment; resuscitation

PMID: 23032323

DOI: 6PIY-8IFY

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Limb Position Change Affects Tourniquet Pressure

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Wall PL, Buising CM, Hingtgen E, White A, Jensen J. 21(1). 11 - 17. (Journal Article)

Abstract

Background: Limb position changes are likely during transport from injury location to definitive care. This study investigated passive limb position change effects on tourniquet pressure and occlusion. Methods: Triplicate buddy-applied OMNA® Marine Tourniquet applications to Doppler-based occlusion were done to sitting and laying supine mid-thigh (n=5) and sitting mid-arm (n=3). Tourniqueted limb positions were bent/straight/bent and straight/bent/straight (randomized first position order, 5 seconds/position, pressure every 0.1 second, two-way repeated measures ANOVA). Results: Sitting thigh occlusion pressures leg bent were higher than straight (median, minimum-maximum; 328, 307-403mmHg versus 312, 295-387mmHg, p = .013). In each recipient, the pressure change for each position change for each limb had p < .003. In each recipient, when sitting, leg bent to straight increased pressure (326, 276-415mmHg to 371, 308-427mmHg bent first and 275, 233-354mmHg to 311, 241-353mmHg straight first), and straight to bent decreased pressure (371, 308-427mmHg to 301, 262-388mmHg bent first and 312, 265-395mmHg to 275, 233-354mmHg straight first). When laying, position changes from leg bent first resulted in pressure changes in each recipient but not in the same directions in each recipient. From laying leg straight first, in each recipient changing to bent increased the pressure (295, 210-366mmHg to 328, 255-376mmHg) and to straight decreased the pressure (328, 255-376 mmHg to 259, 210-333 mmHg). Sitting arm bent occlusion pressures were lower than straight (230, 228-252mmHg versus 256, 250-287mmHg, p = .026). Arm position changes resulted in pressure changes in each recipient but not in the same directions in each recipient. Changes in pressure trace character (presence or absence of rhythmically pulsatile traces) and Doppler-based occlusion were consistent with limb position-induced changes in tourniquet pressure (each p ≤ .001 leg, p = .071 arm traces, and p = .188 arm occlusion). Conclusions: Passive limb position changes can cause significant changes in tourniquet pressure. Therefore, tourniquet adequacy should be reassessed after any limb position change.

Keywords: tourniquet; hemorrhage; first aid; emergency treatment

PMID: 33721300

DOI: H5BB-27ZC

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Limb Tourniquet Configuration: Preliminary Investigation of Problems and Principles

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Kragh JF, Aden JK, Dubick MA. 19(1). 35 - 43. (Journal Article)

Abstract

Background: A tourniquet's readiness during emergencies depends on how it is configured. We investigated configuration so ways of improving readiness can be developed. Methods: This study was conducted at the Institute of Surgical Research in 2018 as sequential investigations by one user of Combat Application Tourniquets (C-A-Ts) in a band-and-rod design. Results: Each tourniquet comes packaged with paper instructions for use, which include directions on how to configure it in preparation for caregiving. The paper and video instructions for use omit tensioning of the tourniquet in configuration, and the video misconfigured a time strap over the rod. In first-aid classrooms, we saw unwitting learners troubleshoot that misconfiguration. Problems with configuration were also seen in caregiving and with tourniquets stowed in kits. In deliberate practice, we self-applied a tourniquet to a thigh. In configuration after each of 100 uses, tourniquet elongation due to tensioning averaged 2.4 in was important for restoring the tourniquet to its full length. During configuration, if the C-A-T's stabilization plate slid along the band, out of position, the user slid the plate back into position. In various ways of testing other C-A-Ts, elongations averaged from 0.4 in to 0.9 in, depending on whether the tourniquet was self-applied or applied to a firm manikin. Elongation increments accrued as the tourniquet's band flattened. Configuration time averaged 22 seconds, and accrued experience improved the compactness of configuration. Conclusion: People are too often unreliable at putting C-A-Ts into the optimal configuration for use. That ready-to-use configuration includes the tourniquet being at its full length, having the stabilization plate positioned correctly along the band, and having the strap fastened to its clip of origin. When used, tourniquets had normal, small elongations in part due to band flattening. This tourniquet study showed the importance of optimal configuration to first-aid readiness practices.

Keywords: Combat Application Tourniquet; tourniquet configuration; limb tourniquet; Stop the Bleed; medical device; combat injury first aid; tourniquet band flattening; tourniquet elongation; use instruction; resuscitation; emergency

PMID: 30859524

DOI: PZZ4-TWQ6

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Limb Tourniquet Holding Location: Model Results Fail to Translate to Human Results

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Wall PL, Buising CM. 21(3). 30 - 35. (Journal Article)

Abstract

Background: During strap pulling, how limb tourniquet sliding is prevented affects secured pressure achievement. Data from model setups indicated moving the Tactical Ratcheting Medical Tourniquet (Tac RMT; m2 inc.) holding loop location could be advantageous regarding strap-pulling pressure achievement. Methods: Self- and buddy-strap pull applications to the arm and mid-thigh were done with the commercially available Tac RMT with the holding loop adjacent to the strap redirect buckle (NEAR) and with a modified Tac RMT with the holding loop moved to the far end of the toothed ladder from the redirect (FAR). Arm applications had the strap redirect buckle on the lateral aspect of the arm. Thigh applications had the strap redirect buckle on the lateral aspect and included applications with the strap's free end pulled downward and applications with the strap free end pulled upward. Buddy- arm and thigh pull-upward applications with FAR allowed a nonstandard technique of including thumb assistance of the strap into the redirect. Results: With standard technique, five of six pairs had lower FAR secured pressures (median difference, 16mmHg). When thumb assistance was used, four of five NEAR-FAR pairs had higher FAR secured pressures (median difference, 40mmHg). The thumb strap feeding technique was neither simple nor obvious. Conclusions: Moving the holding loop location is unlikely to be advantageous for Tac RMT actual applications. Model setup findings need to be checked with applications by humans to humans.

Keywords: tourniquet; hemorrhage; first aid; emergency treatment; equipment design

PMID: 34529801

DOI: VNT3-19OA

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Linear Regression as a Method to Prioritize Humanitarian Efforts in Stability Operations

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Nicholson J, Perry MJ. 22(1). 92 - 96. (Journal Article)

Abstract

With a mandate to work by, with, and through host nation partners, Special Operations Forces (SOF) often face the challenge of pursuing humanitarian endeavors in the hopes of securing access to a specific population and mapping the human terrain. Likewise, should limitations in the rules of engagement (ROE) shift incentives from lethal to non-lethal effects, commanders must find unique ways to exert influence on the operational environment. However, with inevitable resource constraints such as money and time, it can be exceedingly difficult to determine which humanitarian project to undertake, especially in a population whose needs are multifaceted. Linear regression, a statistical tool available within the standard Microsoft Excel package on government computers, permits the modeling of predictive outcomes between a number of independent variables against a dependent variable. This allows the determination of significance and effect for each independent variable, which can facilitate a thoughtful recommendation to commanders for project selection. Using Iraq as an example, publicly available information (PAI) provides a wealth of records to make data-driven assessments for mutually beneficial shaping efforts in a stability operations framework. Additionally, this paper will highlight how data can be analyzed without a reliance on statistical software that is unlikely to be present in the tactical environment.

Keywords: humanitarian; stability operations; linear regression

PMID: 35278321

DOI: GOO4-57N3

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Literature Evidence on Live Animal Versus Synthetic Models for Training and Assessing Trauma Resuscitation Procedures

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Hart D, McNeil M, Hegarty C, Rush RM, Chipman J, Clinton J, Reihsen T, Sweet R. 16(2). 44 - 51. (Journal Article)

Abstract

There are many models currently used for teaching and assessing performance of trauma-related airway, breathing, and hemorrhage procedures. Although many programs use live animal (live tissue [LT]) models, there is a congressional effort to transition to the use of nonanimal- based methods (i.e., simulators, cadavers) for military trainees. We examined the existing literature and compared the efficacy, acceptability, and validity of available models with a focus on comparing LT models with synthetic systems. Literature and Internet searches were conducted to examine current models for seven core trauma procedures. We identified 185 simulator systems. Evidence on acceptability and validity of models was sparse. We found only one underpowered study comparing the performance of learners after training on LT versus simulator models for tube thoracostomy and cricothyrotomy. There is insufficient data-driven evidence to distinguish superior validity of LT or any other model for training or assessment of critical trauma procedures.

Keywords: trauma; airway; hemorrhage; resuscitation; training; assessment; live tissue; simulation

PMID: 27450602

DOI: N00B-D15M

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Load Carriage-Related Paresthesias (Part 2): Meralgia Paresthetica

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Knapik JJ, Reynolds K, Orr R, Pope R. 17(1). 94 - 100. (Journal Article)

Abstract

This is the second of a two-part series addressing symptoms, evaluation, and treatment of load carriage- related paresthesias. Part 1 addressed rucksack palsy and digitalgia paresthetica; here, meralgia paresthetica (MP) is discussed. MP is a mononeuropathy involving the lateral femoral cutaneous nerve (LFCN). MP has been reported in load carriage situations where the LFCN was compressed by rucksack hipbelts, pistol belts, parachute harnesses, and body armor. In the US military, the rate of MP is 6.2 cases/10,000 personyears. Military Servicewomen have higher rates than Servicemen, and rates increase with age, longer loadcarriage distance or duration, and higher body mass index. Patients typically present with pain, itching, and paresthesia on the anterolateral aspect of the thigh. There are no motor impairments or muscle weakness, because the LFCN is entirely sensory. Symptoms may be present on standing and/or walking, and may be relieved by adopting other postures. Clinical tests to evaluate MP include the pelvic compression test, the femoral nerve neurodynamic test, and nerve blocks using lidocaine or procaine. In cases where these clinical tests do not confirm the diagnosis, specialized tests might be considered, including somatosensory evoked potentials, sensory nerve conduction studies, high-resolution ultrasound, and magnetic resonance imaging. Treatment should initially be conservative. Options include identifying and removing the compression if it is external, nonsteroidal inflammatory medication, manual therapy, and/or topical treatment with capsaicin cream. Treatments for intractable cases include injection of corticosteroids or local anesthetics, pulsed radiofrequency, electroacupuncture, and surgery. Military medical care providers may see cases of MP, especially if they are involved with units that perform regular operations involving load carriage.

Keywords: paresthesias, load carriage-related; meralgia paresthetica; mononeuropathy; nerve, lateral femoral cutaneous; Bernhardt-Roth syndrome

PMID: 28285487

DOI: 6KRP-71DF

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Load Carriage-Related Paresthesias: Part 1: Rucksack Palsy and Digitalgia Paresthetica

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Knapik JJ, Reynolds K, Orr R, Pope R. 16(4). 74 - 79. (Journal Article)

Abstract

This is the first of a two-part article discussing loadcarriage- related paresthesias, including brachial plexus lesions (rucksack palsy), digitalgia paresthetica, and meralgia paresthetica. Paresthesias are sensations of numbness, burning, and/or tingling, usually experienced as a result of nerve injury, compression, traction, or irritation. Rucksack palsy is a traction or compression injury to the brachial plexus, caused by the shoulder straps of the rucksack. The patient presents with paresthesia, paralysis, cramping with pain, and muscle weakness of the upper limb. Muscle-strength losses appear to be greater in those carrying heavier loads. Hypothetical risk factors for rucksack palsy include improper load distribution, longer carriage distances, and load weight. Nerve traction, compression, and symptoms may be reduced by use of a rucksack hip belt; wider, better-padded, and proper adjustment of the shoulder straps; reduction of weight in the rucksack; a more symmetric distribution of the load; and resistance training to improve the strength and hypertrophy of the shoulder muscles. Assessment and neck joint and nerve mobilization may relieve brachial plexus tension and reduce symptoms. Another load-carriage-related disorder is digitalgia paresthetica, likely caused by compression of the sensory digital nerves in the foot during load carriage. Patients have paresthesia in the toes. Although no studies have demonstrated effective prevention measures for digitalgia paresthetica, reducing loads and march distances may help by decreasing the forces and repetitive stress on the foot and lower leg. Specialty evaluations by a physical therapist, podiatrist, or other healthcare provider are important to rule out entrapment neuropathies such as tarsal tunnel syndrome. Part 2 of this article will discuss meralgia paresthetica.

Keywords: load-carriage-related paresthesia; brachial plexus lesion; rucksack palsy; digitalgia paresthetica; nerve compression; load distribution

PMID: 28088822

DOI: 7HEK-VMKV

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Lower Extremity Compartment Syndrome From Prolonged Limb Compression and Immobilization During an Airborne Operation

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Smedick BC, van Wyck D. 16(3). 5 - 9. (Journal Article)

Abstract

Acute compartment syndrome (ACS) involving the leg can occur in association with various traumatic and nontraumatic conditions, and it can have serious longterm consequences when unrecognized or untreated. Nontraumatic causes of ACS, such as those associated with cases of prolonged immobilization and/or extremity compression, can be easily overlooked, and several cases of ACS occurring with prolonged surgical positioning can be found in the literature. We present the case of a 19-year-old Army paratrooper who developed acute anterior and lateral compartment syndrome of the lower extremity after being immobilized in an aircraft for hours with several hundred pounds of equipment compressing his lower extremities. To our knowledge, this is the first documented case of ACS occurring as a result of prejump conditions. It demonstrates a potentially serious complication that could result in medical separation and/or permanent disability of the service member. ACS of the extremity should be considered in any Soldier who is required to bear heavy loads, is immobilized for several hours at a time, and complains of symptoms such as extremity pain, numbness, and weakness.

Keywords: acute compartment syndrome, pressure; immobilization

PMID: 27734435

DOI: 4EZ3-1J3N

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Low-Level Blast Exposure in Humans A Systematic Review of Acute and Chronic Effects

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Belanger HG, Bowling F, Yao EF. 20(1). 87 - 93. (Journal Article)

Abstract

There is growing concern that military breaching and training and firing artillery and mortars, grenades, and shoulder-fired weapons may have some type of cumulative deleterious effects. There are anecdotal reports of those with repetitive exposure to low-level blast complaining of various symptoms, as well as increasing empirical evidence. The purpose of this report is to provide a systematic review of the literature on repetitive lowlevel blast as it pertains to military and police training protocols. An extensive literature search was conducted, resulting in detailed review of 18 studies. Results suggest few consistent findings, likely due to the heterogeneity of methods, high risk of bias, and lack of reliance on objective blast-exposure data. Adverse effects, when present, dissipated over time. All studies that used blast gauges found significant associations, though only a subset actually reported using the blast-gauge data (to correlate objective exposure with outcomes). When comparing studies within an outcome domain (e.g., cognitive), findings were largely inconsistent. Research with larger sample sizes, followed longitudinally, is needed.

Keywords: blast; low-level blast; concussion; traumatic brain injury; biomarker; neuropsychology

PMID: 32203612

DOI: 3AC6-AX9I

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Low-Resource Tactical Combat Casualty Care Training for Peshmerga Units in Remote Areas of Kurdistan

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Taylor D, Murphy J, Stolley Z. 19(1). 81 - 87. (Journal Article)

Abstract

The Peshmerga are the official military of the autonomous region of Kurdistan, Iraq. There remains a high level of variability across Peshmerga units in medical equipment and training. Presumably, Peshmerga soldiers are dying from preventable causes of death due to combat-related injuries, just as US troops did before the introduction of Tactical Combat Casualty Care (TCCC) training and supplies. This report outlines the efforts of a small US-based collective to provide TCCC training at the TCCC for all combatants skill level to Peshmerga forces and develop members of the Peshmerga as trainers.

Keywords:

PMID: 30859533

DOI: ADSK-02HQ

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Maggot Therapy for Wound Care in Austere Environments

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Sherman RA, Hetzler MR. 17(2). 154 - 162. (Journal Article)

Abstract

The past 25 years have seen an increase in use of maggot therapy for wound care. Maggot therapy is very effective in wound debridement; it is simple to apply and requires very little in the way of resources, costs, or skilled personnel. These characteristics make it well suited for use in austere environments. The use of medical-grade maggots makes maggot therapy nearly risk free, but medical grade maggots may not always be available, especially in the wilderness or in resource-limited communities. By understanding myiasis and fly biology, it should be possible even for the nonentomologist to obtain maggots from the wild and apply them therapeutically, with minimal risks.

Keywords: maggot; maggot therapy; wound; wound care; austere; field hospital

PMID: 28599051

DOI: DLAA-2TUT

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Making Use of Your Assets: Clinical Use of EOD Radiography in the Forward-Deployed Setting

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Howard CM, Veach S, Lyon RF, Shaw KA. 21(1). 87 - 89. (Journal Article)

Abstract

Ultrasonography is currently the primary means of imaging for forward surgical teams/forward resuscitative surgical teams (FSTs/FRSTs). As FSTs/FRSTs are pushed farther forward into more austere environments, access to other imaging modalities may be limited, potentially affecting resources. On a recent deployment, the 126th FRST was able to use radiography equipment from a co-located explosive ordnance disposal (EOD) team to assist in the diagnosis and treatment of medical and surgical patients, thereby saving time and resources. We provide three case examples in which using EOD radiography assisted in clinical decision making. Although the safety profile has not been assessed for clinical use in humans, EOD radiography can be a useful technique to aid in time-sensitive decision making in resource-constrained operational areas.

Keywords: explosive ordnance disposal radiography; forward resuscitative surgical team; portable x-ray machine

PMID: 33721312

DOI: OJ79-KOWI

Maladaptive Cognitions in EMS Professionals as a Function of the COVID-19 Pandemic

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Renkiewicz G, Hubble MW, Hunter SL, Kearns RD. 23(2). 60 - 68. (Journal Article)

Abstract

Introduction: The coronavirus disease pandemic has pro-foundly affected emergency medical services (EMS) profes-sionals, but the emotional impact is unknown. Methods: This was a cross-sectional survey of North Carolina EMS profes-sionals from April to May 2021. EMS professionals on an ac-tive roster were included. With pandemic-related perceptions, the 15-item Posttraumatic Maladaptive Beliefs Scale (PMBS) was used to quantify the severity of maladaptive cognition. Significant univariate variables were used to create a hier-archical linear regression to assess the potential impact of pandemic-related factors on maladaptive cognition scores. Results: Overall, 811 respondents were included; of those, 33.3% were female, 6.7% were minorities, and 3.2% were Latinx; the mean age was 41.11 ± 12.42 years. Mean scores on the PMBS were 37.12 ± 13.06 and ranged from 15 to 93. PMBS scores were 4.62, 3.57, and 3.99 points higher, respec-tively, in those with increased anxiety, those who trusted their sources of information, and those who reported to work de-spite being symptomatic. Pandemic-specific factors accounted for 10.6% of the variance in PMBS total scores (ΔR2 = 0.106, ΔF[9, 792]; p < .001). Psychopathological factors accounted for an additional 4.7% of the variance in PMBS total scores (ΔR2 = 0.047, ΔF[3, 789]; p < .001). Conclusion: Given that 10.6% of the difference in PMBS scores can be explained by pandemic- related factors, maladaptive cognitions in EMS are a considerable concern and could lead to the development of significant psychopathology post-trauma.

Keywords: paramedic; EMS; maladaptive cognition; COVID-19; pandemic; stress; PTSI

PMID: 37071890

DOI: Q0ZF-7JXR

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Management of Acute Lung Injuries and Acute Respiratory Distress Syndrome in the Tactical and Prolonged Field Care Setting

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Bagley GF, Ciochirca C. 22(2). 104 - 109. (Journal Article)

Abstract

The authors examine two acute lung injuries (ALI) that can occur in the tactical setting - positive pressure pulmonary edema and inhalation injury - as well as acute respiratory distress syndrome (ARDS), all of which can quickly progress in a prolonged field care (PFC) environment. These conditions present complex problems to emergency department (ED) and intensive care unit (ICU) teams worldwide, requiring intimate knowledge of their distinct disease pathophysiology and advanced critical care equipment. These challenges are compounded in the world of the Special Operations Forces (SOF) medic who often operates as the sole provider in environments with both limited resources and prolonged evacuation times. It is the hope of the authors that by breaking down these complex critical care topics and providing concrete guidance and treatment recommendations that we can ultimately improve the care SOF medics provide overseas in an austere operational environment.

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

PMID: 35639903

DOI: 0XCG-P9WH

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Management of Anaphylaxis in an Austere or Operational Environment

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Ellis BC, Brown SG. 14(4). 1 - 5. (Case Reports)

Abstract

We present a case report of a Special Operations Soldier who developed anaphylaxis as a consequence of a bee sting, resulting in compromise of the operation. We review the current literature as it relates to the pathophysiology of the disease process, its diagnosis, and its management. An evidence-based field treatment algorithm is suggested.

Keywords: anaphylaxis; anaphylactic shock; epinephrine; epinephrine infusion; review; remote; austere

PMID: 25399361

DOI: WD01-ZTXR

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Management of Burn Wounds Under Prolonged Field Care

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Cancio LC, Powell D, Adams B, Bull K, Keller A, Gurney J, Pamplin JC, Shackelford S, Keenan S. 16(4). 87 - 98. (Classical Conference)

Keywords:

PMID: 28088826

DOI: KNX8-LXSO

Management of Critically Injured Burn Patients During an Open Ocean Parachute Rescue Mission

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Staak BP, DeSoucy ES, Petersen CD, Smith J, Hartman M, Rush SC. 20(3). 135 - 140. (Journal Article)

Abstract

Best practices and training for prolonged field care (PFC) are evolving. The New York Pararescue Team has used part task training, cadaver labs, clinical rotations, and a complicated sim lab to prepare for PFC missions including critical care. This report details an Atlantic Ocean nighttime parachute insertion to provide advanced burn care to two sailors with 50% and 60% body surface area burns. Medical mission planning included pack-out of ventilators, video laryngoscopes, medications, and 50 L of lactated Ringer's (LR). Over the course of 37 hours, the patients required high-volume resuscitation, analgesia, wound care, escharotomies, advanced airway and ventilator management, continuous sedation, telemedicine consultation, and complicated patient movement during evacuation. A debrief survey was obtained from the Operators highlighting recommendation for more clinical rotations and labs, missionspecific pack-outs, and tactical adjustments. This historic mission represents the most sophisticated PFC ever performed by PJs and serves to validate and share our approach to PFC.

Keywords: prolonged field care; military medicine; austere medicine; burns; critical care

PMID: 32969019

DOI: I8UZ-80S9

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Management of Crush Syndrome Under Prolonged Field Care

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Walters TJ, Powell D, Penny A, Stewart I, Chung KK, Keenan S, Shackelford S. 16(3). 79 - 85. (Journal Article)

Keywords:

PMID: 27734449

DOI: AW4P-UO9F

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Management of External Hemorrhage in Tactical Combat Casualty Care: Chitosan-Based Hemostatic Gauze Dressings

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Bennett BL, Littlejohn LF, Kheirabadi BS, Butler FK, Kotwal RS, Dubick MA, Bailey HH. 14(3). 40 - 57. (Journal Article)

Abstract

Hemorrhage remains the leading cause of combat death and a major cause of death from potentially survivable injuries. Great strides have been made in controlling extremity hemorrhage with tourniquets, but not all injuries are amenable to tourniquet application. Topical hemostatic agents and dressings have also contributed to success in controlling extremity and compressible junctional hemorrhage, and their efficacy continues to increase as enhanced products are developed. Since the addition of Combat Gauze™ (Z-Medica Corporation, Wallingford, CT, USA; http://www.z-medica.com/) in April 2008 to the Tactical Combat Casualty Care (TCCC) Guidelines, there are consistent data from animal studies of severe hemorrhage that chitosan-based hemostatic gauze dressings developed for battlefield application are, at least, equally efficacious as Combat Gauze. Successful outcomes are also reported using newer chitosan-based dressings in civilian hospitalbased surgical case reports and prehospital (battlefield) case reports and series. Additionally, there have been no noted complications or safety concerns in these cases or across many years of chitosan-based hemostatic dressing use in both the military and civilian prehospital sectors. Consequently, after a decade of clinical use, there is added benefit and a good safety record for using chitosan- based gauze dressings. For these reasons, many specific US military Special Operations Forces, NATO militaries, and emergency medical services (EMS) and law enforcement agencies have already implemented the widespread use of these new recommended chitosanbased hemostatic dressings. Based on the past battlefield success, this report proposes to keep Combat Gauze as the hemostatic dressing of choice along with the new addition of Celox™ Gauze (Medtrade Products Ltd., Crewe, UK; http://www.celoxmedical.com/usa/products /celox-gauze/) and ChitoGauze® (HemCon Medical Technologies, Portland, OR, USA; http://www.hemcon.com/) to the TCCC Guidelines.

Keywords: hemorrhage; hemostasis; hemostatic agents; topical; dressing; bandage

PMID: 25344707

DOI: 03VO-8FLO

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Management of External Hemorrhage in Tactical Combat Casualty Care: The Adjunctive Use of XStat™ Compressed Hemostatic Sponges: TCCC Guidelines Change 15-03

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Sims K, Montgomery HR, Dituro P, Kheirabadi BS, Butler FK. 16(1). 19 - 28. (Journal Article)

Abstract

Exsanguination from wounds in the so-called junctional regions of the body (i.e., the neck, the axilla, and the groin) was responsible for 19% of the combat fatalities who died from potentially survivable wounds sustained in Afghanistan or Iraq during 2001 to 2011. The development of improved techniques and technology to manage junctional hemorrhage has been identified in the past as a high-priority item by the Committee on Tactical Combat Casualty Care (CoTCCC) and the Army Surgeon General's Dismounted Complex Blast Injury (DCBI) Task Force. Additionally, prehospital care providers have had limited options with which to manage hemorrhage resulting from deep, narrow-track, penetrating trauma. XStat™ is a new product recently approved by the US Food and Drug Administration as a hemostatic adjunct to aid in the control of bleeding from junctional wounds in the groin or axilla. XStat has now been recommended by the CoTCCC as another tool for the combat medical provider to use in the management of junctional hemorrhage. The evidence that supports adding XStat to the TCCC Guidelines for the treatment of external hemorrhage is summarized in this paper.

Keywords: hemorrhage, junctional; hemorrhage, external; hemostatic; tourniquets; TCCC Guideline; XStat™

PMID: 27045490

DOI: 6CEM-36IY

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Management of Hemorrhage From Craniomaxillofacial Injuries and Penetrating Neck Injury in Tactical Combat Casualty Care: iTClamp Mechanical Wound Closure Device TCCC Guidelines Proposed Change 19-04 06 June 2019

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Onifer DJ, McKee JL, Faudree LK, Bennett BL, Miles EA, Jacobsen T, Morey JK, Butler FK. 19(3). 31 - 44. (Journal Article)

Abstract

The 2012 study Death on the battlefield (2001-2011) by Eastridge et al.1 demonstrated that 7.5% of the prehospital deaths caused by potentially survivable injuries were due to external hemorrhage from the cervical region. The increasing use of Tactical Combat-Casualty Care (TCCC) and other medical interventions have dramatically reduced the overall rate of combat-related mortality in US forces; however, uncontrolled hemorrhage remains the number one cause of potentially survivable combat trauma. Additionally, the use of personal protective equipment and adaptations in the weapons used against US forces has caused changes in the wound distribution patterns seen in combat trauma. There has been a significant proportional increase in head and neck wounds, which may result in difficult to control hemorrhage. More than 50% of combat wounded personnel will receive a head or neck wound. The iTClamp (Innovative Trauma Care Inc., Edmonton, Alberta, Canada) is the first and only hemorrhage control device that uses the hydrostatic pressure of a hematoma to tamponade bleeding from an injured vessel within a wound. The iTClamp is US Food and Drug Administration (FDA) approved for use on multiple sites and works in all compressible areas, including on large and irregular lacerations. The iTClamp's unique design makes it ideal for controlling external hemorrhage in the head and neck region. The iTClamp has been demonstrated effective in over 245 field applications. The device is small and lightweight, easy to apply, can be used by any level of first responder with minimal training, and facilitates excellent skills retention. The iTClamp reapproximates wound edges with four pairs of opposing needles. This mechanism of action has demonstrated safe application for both the patient and the provider, causes minimal pain, and does not result in tissue necrosis, even if the device is left in place for extended periods. The Committee on TCCC recommends the use of the iTClamp as a primary treatment modality, along with a CoTCCC-recommended hemostatic dressing and direct manual pressure (DMP), for hemorrhage control in craniomaxillofacial injuries and penetrating neck injuries with external hemorrhage.

Keywords: craniomaxillofacial injury; penetrating neck injury; junctional hemorrhage; compressible hemorrhage; hemorrhage control; iTClamp; TCCC; Tactical Combat Casualty Care

PMID: 31539432

DOI: H8BG-8OUP

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Management of Hypothermia in Tactical Combat Casualty Care: TCCC Guideline Proposed Change 20-01 (June 2020)

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Bennett BL, Giesbrect G, Zafren K, Christensen R, Littlejohn LF, Drew B, Cap AP, Miles EA, Butler FK, Holcomb JB, Shackelford SA. 20(3). 21 - 35. (Journal Article)

Abstract

As an outcome of combat injury and hemorrhagic shock, trauma-induced hypothermia (TIH) and the associated coagulopathy and acidosis result in significantly increased risk for death. In an effort to manage TIH, the Hypothermia Prevention and Management Kit™ (HPMK) was implemented in 2006 for battlefield casualties. Recent feedback from operational forces indicates that limitations exist in the HPMK to maintain thermal balance in cold environments, due to the lack of insulation. Consequently, based on lessons learned, some US Special Operations Forces are now upgrading the HPMK after short-term use (60 minutes) by adding insulation around the casualty during training in cold environments. Furthermore, new research indicates that the current HPMK, although better than no hypothermia protection, was ranked last in objective and subjective measures in volunteers when compared with commercial and user-assembled external warming enclosure systems. On the basis of these observations and research findings, the Committee on Tactical Combat Casualty Care decided to review the hypothermia prevention and management guidelines in 2018 and to update them on the basis of these facts and that no update has occurred in 14 years. Recommendations are made for minimal costs, low cube and weight solutions to create an insulated HPMK, or when the HPMK is not readily available, to create an improvised hypothermia (insulated) enclosure system.

Keywords: trauma; coagulopathy; shock; hypothermia; rewarming; improvised

PMID: 32969001

DOI: QQ9R-RR8A

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Management of Junctional Hemorrhage in Tactical Combat Casualty Care: TCCC Guidelines-Proposed Change 13-03

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Kotwal RS, Butler FK, Gross K, Kheirabadi BS, Billings S, Dubick MA, Rasmussen TE, Weber MA, Bailey JA. 13(4). 85 - 93. (Journal Article)

Abstract

The vast majority of combat casualties who die from their injuries do so prior to reaching a medical treatment facility. Although most of these deaths result from nonsurvivable injuries, efforts to mitigate combat deaths can still be directed toward primary prevention through modification of techniques, tactics, and procedures and secondary prevention through improvement and use of personal protective equipment. For deaths that result from potentially survivable injuries, mitigation efforts should be directed toward primary and secondary prevention as well as tertiary prevention through medical care with an emphasis toward prehospital care as dictated by the fact that the preponderance of casualties die in the prehospital environment. Since the majority of casualties with potentially survivable injuries died from hemorrhage, priority must be placed on interventions, procedures, and training that mitigate death from truncal, junctional, and extremity exsanguination. In response to this need, multiple novel and effective junctional tourniquets have recently been developed.

Keywords: junctional hemorrhage; Tactical Combat Casualty Care guidelines

PMID: 24227566

DOI: MS8T-ZUPX

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Management of Open Chest Wounds in Tactical Emergency Casualty Care: Application of Vented Versus Nonvented Chest Seals

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Margolis AM, Tang N, Levy MJ, Callaway DW. 14(4). 136 - 138. (Journal Article)

Abstract

The 2014 midyear, full meeting of the Committee for Tactical Emergency Combat Care (C-TECC) was hosted by the Johns Hopkins University Center for Law Enforcement Medicine on June 9 and 10 in Baltimore, Maryland. As the C-TECC guidelines are increasingly recognized as the best-practice recommendations for civilian, high-threat, prehospital trauma response, a focused guidelines discussion occurred to develop bestpractice recommendations for the management of open chest wounds, specifically regarding the application of vented and nonvented chest seals.

Keywords:

PMID: 25399384

DOI: SGB8-4X9C

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Management of Open Pneumothorax in Tactical Combat Casualty Care: TCCC Guidelines Change 13-02

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Butler FK, DuBose JJ, Otten EJ, Bennett DR, Gerhardt RT, Kheirabadi BS, Gross K, Cap AP, Littlejohn LF, Edgar EP, Shackelford SA, Blackbourne LH, Kotwal RS, Holcomb JB, Bailey JA. 13(3). 81 - 86. (Journal Article)

Abstract

During the recent United States Central Command (USCENTCOM) and Joint Trauma System (JTS) assessment of prehospital trauma care in Afghanistan, the deployed director of the Joint Theater Trauma System (JTTS), CAPT Donald R. Bennett, questioned why TCCC recommends treating a nonlethal injury (open pneumothorax) with an intervention (a nonvented chest seal) that could produce a lethal condition (tension pneumothorax). New research from the U.S. Army Institute of Surgical Research (USAISR) has found that, in a model of open pneumothorax treated with a chest seal in which increments of air were added to the pleural space to simulate an air leak from an injured lung, use of a vented chest seal prevented the subsequent development of a tension pneumothorax, whereas use of a nonvented chest seal did not. The updated TCCC Guideline for the battlefield management of open pneumothorax is: "All open and/ or sucking chest wounds should be treated by immediately applying a vented chest seal to cover the defect. If a vented chest seal is not available, use a non-vented chest seal. Monitor the casualty for the potential development of a subsequent tension pneumothorax. If the casualty develops increasing hypoxia, respiratory distress, or hypotension and a tension pneumothorax is suspected, treat by burping or removing the dressing or by needle decompression." This recommendation was approved by the required two-thirds majority of the Committee on TCCC in June 2013.

Keywords: pneumothorax; chest seal; TCCC Guideline

PMID: 24048995

DOI: 739G-PP0W

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Management of Pediatric Sepsis: Considerations for the Austere Prehospital Setting

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Williams NC. 22(2). 120 - 125. (Journal Article)

Abstract

Septic children are among the most challenging and resource-intensive patients that clinicians see around the world daily. These patients often require a broad range of therapies and assessment techniques, frequently relying on expertise across multiple specialties such as radiology and laboratory services. In developed nations, these resources are readily available or in close proximity, as transport is often logistically feasible to coordinate transfer to definitive care. In developing nations and areas of conflict, this is not the case. Most of the world's population lives in developing nations, resulting in inadequate access to specialized pediatric intensive care resources. As a result, many clinicians globally face the unique challenge of caring for septic children in resource-deprived and austere settings. Areas recovering from natural disasters, remote villages, and conflict zones are examples of austere environments where children have an increased risk of sepsis while having the fewest medical resources available. This creates a unique challenge that prehospital clinicians are specifically tasked with managing, sometimes lasting for multiple days pending the possibility of a transport option. Clinicians in these environments must be aggressive in identifying and treating critically-ill children in resource limited environments, but also nuanced in their care plan due to the limitations of the environment.

Keywords: sepsis; austere; pediatric; prehospital; child; critical care; resources; limited

PMID: 35639905

DOI: 5ZVE-JKY8

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Management of Rib Fractures in the Combat Environment

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Smith S, Hilsden R, Patton P, Vogt K, Beckett A, Ball IM. Ahead of Print. (Journal Article)

Abstract

Rib fractures in combat casualties are an under-appreciated injury, and their treatment may become more common as more patients survive because of modern body armor and point-ofinjury care. The combat environment has challenges such as equipment availability and sterility. A simple and thoughtful rib fracture treatment algorithm may be useful to reduce the morbidity and mortality of rib fractures in the combat environment. Intravenous lidocaine infusions for patients with traumatic rib fractures may have important combat applications. We propose an algorithm for the management of combat casualties with traumatic rib fractures.

Keywords: military medicine; rib fractures; lidocaine; combat medicine; pain management

PMID: 38457121

DOI: FTLJ-MQXX

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Management of Scalp hemorrhage and lacerations

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Arne BC. 12(1). 11 - 16. (Journal Article)

Abstract

Scalp lacerations can vary in severity from a minor injury up to a complete degloving of the scalp. Severe scalp injuries can occur in a combat zone as a result of blunt trauma, penetrating trauma or blast-related mechanisms. More severe scalp wounds tend to cause a greater than expected blood loss and can contribute to patient destabilization relatively quickly. This article will discuss the source of blood supply to the scalp and concentrate on the management of scalp wounds with before and after pictures to demonstrate these techniques. The cases presented will exclude cranial fractures and concentrate more on the management of lacerations specifically

Keywords:

PMID: 22427044

DOI: 2IFQ-SDJH

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Management of Severe Crush Injuries in Austere Environments: A Special Operations Perspective

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Anderson JL, Cole M, Pannell D. 22(2). 43 - 47. (Journal Article)

Abstract

Crush injuries present a challenging case for medical providers and require knowledge and skill to manage the subsequent damage to multiple organ systems. In an austere environment, in which resources are limited and evacuation time is extensive, a medic must be prepared to identify trends and predict outcomes based on the mechanism of injury and patient presentation. These injuries occur in a variety of environments from motor vehicle accidents (at home or abroad) to natural disasters and building collapses. Crush injury can lead to compartment syndrome, traumatic rhabdomyolysis, arrythmias, and metabolic acidosis, especially for patients with extended treatment and extrication times. While crush syndrome occurs due to the systemic effects of the injury, the onset can be as early as 1 hour postinjury. With a comprehensive understanding of the pathophysiology, diagnosis, management, and tactical considerations, a prehospital provider can optimize patient outcomes and be prepared with the tools they have on hand for the progression of crush injury into crush syndrome.

Keywords: crush injury; Special Operations Medicine; tactical medicine; compartment syndrome; rhabdomyolysis

PMID: 35639893

DOI: 2Y7A-IGK7

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Management of Suspected Tension Pneumothorax in Tactical Combat Casualty Care: TCCC Guidelines Change 17-02

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Butler FK, Holcomb JB, Shackelford SA, Montgomery HR, Anderson S, Cain JS, Champion HR, Cunningham CW, Dorlac WC, Drew B, Edwards K, Gandy JV, Glassberg E, Gurney JM, Harcke T, Jenkins DA, Johannigman J, Kheirabadi BS, Kotwal RS, Littlejohn LF, Martin MJ, Mazuchowski EL, Otten EJ, Polk T, Rhee P, Seery JM, Stockinger Z, Torrisi J, Yitzak A, Zafren K, Zietlow SP. 18(2). 19 - 35. (Journal Article)

Abstract

This change to the Tactical Combat Casualty Care (TCCC) Guidelines that updates the recommendations for management of suspected tension pneumothorax for combat casualties in the prehospital setting does the following things: (1) Continues the aggressive approach to suspecting and treating tension pneumothorax based on mechanism of injury and respiratory distress that TCCC has advocated for in the past, as opposed to waiting until shock develops as a result of the tension pneumothorax before treating. The new wording does, however, emphasize that shock and cardiac arrest may ensue if the tension pneumothorax is not treated promptly. (2) Adds additional emphasis to the importance of the current TCCC recommendation to perform needle decompression (NDC) on both sides of the chest on a combat casualty with torso trauma who suffers a traumatic cardiac arrest before reaching a medical treatment facility. (3) Adds a 10-gauge, 3.25-in needle/ catheter unit as an alternative to the previously recommended 14-gauge, 3.25-in needle/catheter unit as recommended devices for needle decompression. (4) Designates the location at which NDC should be performed as either the lateral site (fifth intercostal space [ICS] at the anterior axillary line [AAL]) or the anterior site (second ICS at the midclavicular line [MCL]). For the reasons enumerated in the body of the change report, participants on the 14 December 2017 TCCC Working Group teleconference favored including both potential sites for NDC without specifying a preferred site. (5) Adds two key elements to the description of the NDC procedure: insert the needle/ catheter unit at a perpendicular angle to the chest wall all the way to the hub, then hold the needle/catheter unit in place for 5 to 10 seconds before removing the needle in order to allow for full decompression of the pleural space to occur. (6) Defines what constitutes a successful NDC, using specific metrics such as: an observed hiss of air escaping from the chest during the NDC procedure; a decrease in respiratory distress; an increase in hemoglobin oxygen saturation; and/or an improvement in signs of shock that may be present. (7) Recommends that only two needle decompressions be attempted before continuing on to the "Circulation" portion of the TCCC Guidelines. After two NDCs have been performed, the combat medical provider should proceed to the fourth element in the "MARCH" algorithm and evaluate/treat the casualty for shock as outlined in the Circulation section of the TCCC Guidelines. Eastridge's landmark 2012 report documented that noncompressible hemorrhage caused many more combat fatalities than tension pneumothorax.1 Since the manifestations of hemorrhagic shock and shock from tension pneumothorax may be similar, the TCCC Guidelines now recommend proceeding to treatment for hemorrhagic shock (when present) after two NDCs have been performed. (8) Adds a paragraph to the end of the Circulation section of the TCCC Guidelines that calls for consideration of untreated tension pneumothorax as a potential cause for shock that has not responded to fluid resuscitation. This is an important aspect of treating shock in combat casualties that was not presently addressed in the TCCC Guidelines. (9) Adds finger thoracostomy (simple thoracostomy) and chest tubes as additional treatment options to treat suspected tension pneumothorax when further treatment is deemed necessary after two unsuccessful NDC attempts-if the combat medical provider has the skills, experience, and authorizations to perform these advanced interventions and the casualty is in shock. These two more invasive procedures are recommended only when the casualty is in refractory shock, not as the initial treatment.

Keywords: guidelines; tension pneumothorax; Tactical Combat Casualty Care

PMID: 29889952

DOI: XB1Z-3BJU

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Management of the Mangled Face by a Forward Surgical Team

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Brisson PA, Woll M, Welden B. 11(1). 25 - 27. (Case Reports)

Abstract

A mangled face is an uncommon injury that can occur in a combat zone as a result of blunt trauma, penetrating trauma or explosion injury. Despite the patient's dramatic disfigurement, attention needs to focus on the basic ABC's of initial trauma management. We present an injured Afghan civilian with a severe facial injury. Our approach to airway management, breathing evaluation and hemorrhage control are described. In addition we utilized two emergency hemorrhage control modalities that are usually associated with other areas of the body, a circumferential compression sling and a laparotomy sponge packing.

Keywords:

PMID: 22113723

DOI: DNZ7-O779

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Management of Type 3c Diabetes in an Elite Tactical Athlete

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Avilla J, Rerucha C, Hu C. 23(2). 99 - 101. (Journal Article)

Abstract

The presentation of Type 3c diabetes is atypical, accounting for 0.5-1% of all types of diabetes. Combining this with the healthy Special Operations community is even more profound. A 38-year-old active-duty male in Special Operations developed acute abdominal pain and vomiting while deployed. He was diagnosed with severe acute necrotizing pancreatitis secondary to Type 3c diabetes, and the management of his condition became increasingly difficult. This case highlights Type 3c diabetes and the complexity of formulating a comprehensive treatment plan for a tactical athlete.

Keywords: tactical; type 3c diabetes; abdominal pain; pancreatitis; athlete; Special Operations

PMID: 37224391

DOI: XTQ3-78WA

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Management Of Urinary Retention In An Austere Environment: Suprapubic Catheter Placement

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Smith CP, Sorrells A, Coburn M. 10(3). 36 - 40. (Journal Article)

Abstract

Abstract Urinary retention is a true urologic emergency. First-line treatment with a transurethral catheter can and will fail. SOF medics need a reliable and durable method to resolve this problem using a minimal amount of resources and time. Current SOF Medical Handbook guidance for the management of unsuccessful urethral catheterization is inadequate. This article and accompanying video link, functions as a starting point for incorporating suprapubic tube placement in the training regimen and therapeutic armamentarium of SOF medical personnel. Case Scenario #1 You are a SOF medic assigned to a remote area in Africa. A Soldier is brought to you after a rollover MVA. He is noted to have an obvious pelvic fracture and on physical exam is found to have blood at the urethral meatus. On digital rectal exam his prostate is not palpable. You suspect a posterior urethral injury. A gentle pass with a transurethral catheter is unsuccessful - resistance is encountered and blood returns through the catheter, so no further advancement is attempted. The patient's suprapubic area is distended and he complains of an unbearable urge to urinate. How do you manage this soldier's urinary retention? Case Scenario #2 You are a SOF medic assigned to a remote firebase in Afghanistan. A prominent and influential tribal chief is brought into your clinic complaining of an inability to urinate. He gives a long history of urethral stricture disease treated in the past with rudimentary urethral dilations. On physical exam, he has a palpable mass to the level of the umbilicus that is dull to percussion and he describes a strong and painful urge to void when pressure is applied. You are unsuccessful in your attempts to pass a transurethral catheter. You do not have the ability or resources to perform urethral dilation. Aerial evacuation assets are not available. What do you do next?

Keywords:

PMID: 21049433

DOI: J1R4-9P5Z

Manikin Human-Patient Simulator Training

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Horn GT, Bowling F, Lowe DE, Parimore JG, Stagliano DR, Studer NM. 17(2). 89 - 95. (Journal Article)

Abstract

Background: Human-patient simulators (HPSs) may help enhance medical education. Manikin HPS devices respond to common field medical interventions, such as cricothyroidotomy, and have realistic feedback features, such as respirations and pulses. This study surveys Special Operations Medics for evaluations of HPS features. Methods: Of 518 subjects, 376 completed testing and surveys with valid responses. A total of 102 variables were divided into three categories-general characteristics, procedures, and injuries-and assessed on a fivepoint Likert scale. The Student t test was used to analyze data together and as separate groups against each other and against an aggregated mean. Results: Features that received high scores (i.e., higher than 4.5/5) corresponded closely with pillars of the Tactical Combat Casualty Care (TCCC) curriculum, basic life support, and realism. Discussion: US Army Special Operations Command and US Special Operations Command Medics have overall high confidence in manikin HPS devices and specifically in those that align with TCCC training and lifesaving procedures. The skills most valued coincide with difficult-to-practice measures, such as cricothyroidotomy and wound packing. Features such as prerecorded sounds, sex, automated movements, skin color, defibrillation, bowel sounds, and electrocardiogram are rated lower. These evaluations may guide future development or procurement of manikin HPS devices.

Keywords: human-patient simulator; manikin; Tactical Combat Casualty Care; training

PMID: 28599039

DOI: 0SE6-Q7TF

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Maritime Applications of Prolonged Casualty Care: A Series Introduction

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Tadlock MD, Kitchen LK, Brower JJ, Tripp MS. Ahead of Print. (Journal Article)

Abstract

The current United States Navy and North Atlantic Treaty Organization (NATO) maritime strategy is coalescing around the concept of Distributed Maritime Operations (DMOs) to prepare for future large-scale combat operations with peer or near-peer competitors. As a result, individual components of naval forces will be more geographically dispersed and oper- ating at a significant time and distance from higher levels of medical care. We developed a series of educational scenarios informed by real-world events to enhance the ability of Role 1 medical caregivers to apply the principles of Prolonged Ca- sualty Care during current routine, crisis, and contingency DMOs.

Keywords: prolonged casualty care; Tactical Combat Casualty Care; military; maritime; critical care

PMID: 38373046

DOI: GOPF-AS1O

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Masimo Perfusion Index Versus Doppler for Tourniquet Effectiveness Monitoring

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Wall PL, Buising CM, Nelms D, Grulke L, Renner CH. 19(1). 44 - 46. (Journal Article)

Abstract

Background: In addition to a plethysmograph, Masimo pulse oximeters display a Perfusion Index (PI) value. This study investigated the possible usefulness of PI for monitoring limb tourniquet arterial occlusion. Methods: Tactical Ratcheting Medical Tourniquets were applied to the thighs of 15 subjects. Tightening ended at one ratchet-tooth advance beyond Doppler- indicated occlusion. The times and pressures of Doppler and PI signal absences and returns were recorded. Results: Intermittent PI signal error occurred in 149 of 450 runs (PI, 33% versus Doppler, 0%; p < .0001). PI signal loss lagged Doppler-indicated occlusion by 19 ± 15 seconds (mean ± standard deviation, p < .0001). PI Signal Return lagged tourniquet release by 13 ± 7 seconds (Doppler Signal Return took 1 ± 1 seconds following tourniquet release; p < .0001). PI failed to detect early Doppler audible pulse return in 30 of 39 occurrences. Conclusion: The PI available on Masimo pulse oximeters is not appropriate for monitoring limb tourniquet effectiveness

Keywords: tourniquet; monitoring; hemorrhage; first aid; emergency treatment

PMID: 30859525

DOI: HOAU-RLAW

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Mastering the Basics Makes the Best Medics in the World: An Interview With Shawn Kane, SWMG (A) Commander and Dean of the JSOMTC

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Pennardt A. 17(4). 128 - 129. (Interview)

Abstract

Keywords:

PMID: 29256211

DOI: NMRP-O9OL

Measles (Rubeola): An Ongoing Series on Infectious Diseases of Importance to the Deployed Special Forces

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Burnett MW. 13(1). 66 - 67. (Journal Article)

Keywords:

PMID: 23526326

DOI: Q1KH-JDKS

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Measles (Rubeola): An Update

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Crecelius EM, Burnett MW. 20(2). 136 - 138. (Journal Article)

Abstract

Measles is a significant concern with approximately 10 million people infected annually causing over 100,000 deaths worldwide. In the US before use of the measles vaccine, there were estimated to be 3 to 4 million people infected with measles annually, causing 400 to 500 deaths. Complications of measles include otitis media, diarrhea, pneumonia, and acute encephalitis. Measles is a leading cause of blindness in the developing world, especially in those who are vitamin A deficient. Malnourished children with measles are also at higher risk of developing noma (or cancrum oris), a rapidly progressive gangrenous infection of the mouth and face. Most deaths due to measles are caused by pneumonia, diarrhea, or neurological complications in young children, severely malnourished or immunocompromised individuals, and pregnant women. A rare sequela of measles is subacute sclerosing panencephalitis.

Keywords: Paramyxoviridae; measles; vaccinatins

PMID: 32573751

DOI: 3NFC-341T

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Measles Cases and Outbreaks: Centers for Disease Control and Prevention; World Health Organization

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Anonymous A. 20(1). 123 - 123. (Journal Article)

Keywords:

PMID: 32203617

DOI: 6PAR-BZJG

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Measles Vaccination: A Matter of Confidence and Commitment

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Turner R. 19(2). 105 - 106. (Journal Article)

Keywords:

PMID: 31201761

DOI: EWGG-TJHP

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Measuring Special Operations Forces Readiness

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Berry KG, Sakallaris B, Deuster PA. 19(4). 100 - 104. (Journal Article)

Abstract

Special Operations Force (SOF) Operators, spouses, and component representatives were asked to describe what readiness looks like to them and what is needed to achieve it. Their views informed a broad and deep dive into the academic and gray literature for believable measures relevant to operational readiness. This commentary is a synthesis of that work and provides recommendations for ways to improve "readying" strategies, practices, and outcomes to better achieve human- based mission performance. The key modifiers of Operator readiness are family, SOF culture and leadership, and time. Recommendations are to measure SOF mission performance to define premission Operator readiness; conceptualize mission readiness in terms of assets and not just deficits; combine experiential wisdom with that gained from the study of in-mission performance and premission readiness data; establish SOF phenotypes for use by all components; address emerging fields (doping, sleep, mental toughness, spiritual readiness, moral injury); and develop a simple readiness index.

Keywords: family readiness; mission performance; operator readiness; POTFF; Special Operations Forces

PMID: 31910481

DOI: MPAK-RB6Q

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Mechanical Forces Experienced by Simulated Patients Evacuated During Dismounted Military Movement in Mountainous Terrain

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Florance JM, Florance C. 18(3). 28 - 32. (Journal Article)

Abstract

Background: Given a denied or resource-limited area of operations, when air medical evacuation would require extended delay, should dismounted movement through difficult terrain dissuade an attempt of immediate ground evacuation? Understanding the magnitude of external forces during dismounted movement would inform planning in such circumstances. Objectives: We assessed the mechanical impact experienced during dismounted evacuation from mountainous terrain. We also describe a protocol using a portable accelerometer to evaluate evacuation. Materials and Methods: A triaxial accelerometer and a semiflexible litter were used to collect data during the Army Mountain Warfare School Rough Terrain Evacuation Course. We used the generalized extreme value (GEV) distribution, using maximum likelihood estimation, to model maximum acceleration values. Results: It was determined that the accelerometer should be mounted directly onto a mannequin when using semiflexible litters. GEV analysis from a mannequin-mounted trial revealed that for 1-minute evacuation intervals, 10% would have a maximum acceleration over a value between 2.4g and 3.7g. This interval encompasses the maximum acceleration from evacuation using a Mine-Resistant Ambush Protected (MRAP) vehicle, measured by the US Army Aeromedical Research Laboratory. The peak acceleration from a 75-minute, mannequin-mounted trial was 5.5g, approximately twice as large as the MRAP maximum. Conclusion: For the evacuee, the acceleration experienced during dismounted evacuation in mountainous terrain can be comparable to MRAP evacuation, especially with sufficient planning that avoids points of maximum impact. Leaders can consider this comparison during planning.

Keywords: acceleration; movement; military personnel; emergencies; warfare; stretchers; transportation; rescue work

PMID: 30222833

DOI: T6U2-SOJK

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Mechanical Ventilation: A Review for Special Operations Medical Personnel

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Friedman J, Assar SM. 22(2). 97 - 102. (Journal Article)

Abstract

Mechanical ventilation is machine-delivered flow of gases to both oxygenate and ventilate a patient who is unable to maintain physiological gas exchange, and positive-pressure ventilation (PPV) is the primary means of delivering invasive mechanical ventilation. The authors review invasive mechanical ventilation to give the Special Operations Force (SOF) medic a comprehensive conceptual understanding of a core application of critical care medicine.

Keywords: Mechanical Ventilation; invasive ventilation; ventilator; portable ventilator

PMID: 35639902

DOI: QAPJ-75KX

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MEDCAN-GRO: Medical Capacity for African Nations-Growing Regional Operability. A Case Study in Special Operations Forces Capacity Building

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Givens ML, Verlo AR. 15(1). 105 - 112. (Journal Article)

Abstract

Medical Capacity for African Nations-Growing Regional Operability (MEDCAN-GRO) is a framework for addressing healthcare engagements that are intended to provide sustainable capacity building with partner nations. MEDCAN-GRO provides SOF units with a model that can be scaled to partner nation needs and aligned with the goals of the TSOC in an effort to enhance partner nation security.

Keywords: MEDCAN-GRO; Africa; partner nations

PMID: 25770807

DOI: MFSO-CLYU

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MEDEVAC Use of Ketamine for Postintubation Transport

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Grumbo R, Hoedebecke KL, Berry-Caban CS, Mazur A. 13(3). 36 - 41. (Journal Article)

Abstract

The use of traditional sedatives and analgesics in intubated patients can have undesired hemodynamic consequences with increases in sedation exacerbating hypotension and potentially avoidable morbidity and mortality. This project compared 50 intubated patients using traditional analgesics and sedatives to 20 intubated patients using ketamine with the hypothesis that there would be a significant difference in subsequent blood pressure drop between the two groups. Though the results did not prove to be statistically significant within this small study, the authors did observe a trend toward significance. Additionally, some hypotensive patients had traditional analgesics and sedatives withheld altogether, which did not occur within the ketamine group. Due to the reduced side-effect profile, deployed medical providers should have increased training with and use of ketamine in the pre-hospital setting.

Keywords: MEDEVAC; ketamine; prehospital care; operational medicine; Special Operations

PMID: 24048987

DOI: GCXF-H7JU

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Medical Humanitarian Missions

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Mulvaney SW, Mcbeth MJ. 10(1). 73 - 74. (Previously Published)

Previously Published as an Editorial in the American Family Physician. Permission to republish granted by American Academy of Family Physicians.

Keywords:

PMID: 37702603|REJECTED: Cannot Replace Article: Replacement file must use the original ArticleIds

DOI:

Medical Mission to Dominican Republic: One Dermatology Group's Experiences

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Ahmed A, Peine S. 13(2). 69 - 74. (Journal Article)

Abstract

The intents of this article are to share our experiences during a medical mission in the Dominican Republic and to provide the reader with a cross-sectional view of conditions seen and an overview of interesting and challenging cases encountered. We also discuss treatments and techniques used and share lessons learned.

Keywords: dermatology; albinism; chemdestruction; chromoblastomycosis; lesions; skin dermatoses; ecthyma; intertrigo; folliculitis; fungal; scabies; eczematoid spectrum; atopic dermatitis; xerosis cutis; polymorphous; eruption; mycetoma; leprosy; scarlatina; genoderms

PMID: 23817882

DOI: QDLB-CR5Y

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Medical Operations of the 6th Ranger Infantry Battalion

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Downs JW. 14(2). 66 - 73. (Journal Article)

Abstract

The author gives a history of the formation of the 6th Ranger Infantry Battalion and varied aspects of Ranger medical operations, including personnel composition of the medical detachment, the work of the battalion's surgeon during combat and noncombat operations, medical aspects of operational planning, available medical supplies, medical evacuation procedures, and preventive care.

Keywords: 6th Ranger Infantry Battalion; medical operations; World War II

PMID: 24952043

DOI: WEYK-2Q58

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Medical Provider Ballistic Protection at Active Shooter Events

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Stopyra JP, Bozeman WP, Callaway DW, Winslow J, McGinnis HD, Sempsrott J, Evans-Taylor L, Alson RL. 16(3). 36 - 40. (Journal Article)

Abstract

There is some controversy about whether ballistic protective equipment (body armor) is required for medical responders who may be called to respond to active shooter mass casualty incidents. In this article, we describe the ongoing evolution of recommendations to optimize medical care to injured victims at such an incident. We propose that body armor is not mandatory for medical responders participating in a rapid-response capacity, in keeping with the Hartford Consensus and Arlington Rescue Task Force models. However, we acknowledge that the development and implementation of these programs may benefit from the availability of such equipment as one component of risk mitigation. Many police agencies regularly retire body armor on a defined time schedule before the end of its effective service life. Coordination with law enforcement may allow such retired body armor to be available to other public safety agencies, such as fire and emergency medical services, providing some degree of ballistic protection to medical responders at little or no cost during the rare mass casualty incident. To provide visual demonstration of this concept, we tested three "retired" ballistic vests with ages ranging from 6 to 27 years. The vests were shot at close range using police-issue 9mm, .40 caliber, .45 caliber, and 12-gauge shotgun rounds. Photographs demonstrate that the vests maintained their ballistic protection and defeated all of these rounds.

Keywords: body armor; ballistics; active shooter; active assailant; mass-casualty event

PMID: 27734440

DOI: JSVD-I5JW

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Medical Rules Of Engagement Negative Patients: The Dilemma Of Forward Surgical Teams In Counterinsurgency Operations

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Becker T, Ray PD, Link M, Ziemba M. 11(3). 12 - 15. (Journal Article)

Abstract

By definition, Forward Surgical Teams (FSTs) are located far forward in the battlespace to allow for emergent treatment of life and limb threatening trauma sustained by United States and coalition forces as well as those injured according to the medical rules of engagement (MROE). While official doctrine dictates that MROE negative patients are not entitled to care by American military medical assets, experience has shown that some FSTs do not always adhere to that doctrine during counterinsurgency (COIN) operations. Medical civic action programs (MEDCAPS) have been used in modern COIN conflicts in an attempt to gain favor with and influence the host nations' local population. However, the results have frequently been counterproductive to the intended mission. The FST, by doctrine, is not equipped to take part in traditional MEDCAPS. The focus of this paper is to explore the potential role of the FST in COIN operations. Possible roles for the FST in COIN include improving the host nation medical capabilities through education and training. Further, surgery can be a useful commodity to gain positive influence with or to trade for intelligence from key local national leaders.

Keywords:

PMID: 21706456

DOI: 1GPR-FVN8

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Medical Screening of a Repatriated Afghan National Army Special Operations Command Prisoner of War

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Florance JM, Hicks M. 19(4). 16 - 18. (Case Reports)

Abstract

The Combined Joint Special Operations Task Force-Afghanistan (CJSOTF-A) Surgeon partnered with the Afghan National Army Special Operations Command (ANASOC) Surgeon to complete medical screening of a repatriated ANASOC soldier following a 2019 combined raid on a Taliban prison that freed 35 prisoners of war (POWs). This article discusses the presentation and management of the ANASOC POW while also providing a literature review of common pathologies within the POW population. The purpose of this document is to address a unique aspect of military medicine in the expectation that future military providers are prepared to receive repatriated soldiers and prepared to care for fellow prisoners should they themselves become captured.

Keywords: Afghanistan; Afghan Campaign 2001-present; military medicine; warfare; war wounds; military personnel; prisoners; veterans; prisons; terrorism

PMID: 31910467

DOI: BBMD-S7WI

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Medical Seminars: A New Paradigm For SOF Counterinsurgency Medical Programs

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Alderman SM, Christensen JB, Crawford I. 10(1). 16 - 22. (Journal Article)

Abstract

Medical programs are valuable tools when they properly align with operational objectives. In counterinsurgency operations, the medical program should promote the capacity of the host nation government and lead to greater self-sufficiency. The Medical Civic Action Program (MEDCAP) often fails to fully integrate host nation providers and officials which may undermine local medical infrastructure and rarely provides sustainable improvement. The Medical Seminar (MEDSEM) was developed during Operation Enduring Freedom- Philippines to address the shortcomings of the traditional MEDCAP. The MEDSEM greatly enhanced the MEDCAP by adding education to the venue, thereby promoting self reliance and improving the sustainability of medical interventions. Furthermore, the MEDSEM forged relationships and promoted interoperability through collaboration between local medical providers, governmental leaders, host nation forces, and U.S. Special Operations Forces.

Keywords:

PMID: 20306411

DOI: NSVG-6MEE

Medicine and the American Revolution How Diseases and Their Treatments Affected the Colonial Army

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Farr WD. 20(1). 147 - 147. (Book Review)

Abstract

Reiss O. Medicine and the American Revolution: How Diseases and Their Treatments Affected the Colonial Army. Jefferson, NC: McFarland & Company; 1998. ISBN 978-0-7864-2160-2. Paperback, 280 pages.

Keywords:

PMID: 38112184|REJECTED: Cannot Replace Article: Replacement file must use the original ArticleIds

DOI:

Medicine on the Edge of Darkness

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Christensen PA. 18(1). 150 - 154. (Journal Article)

Abstract

Austere care of the wounded is challenging for all Western medical professionals-nurse, medic, or physician. There can be no doubt that working for the first time, either for a nongovernment organization or in the Special Forces, you will be taking care of wounded patients outside your training and experience. You must have the ability to adapt to and overcome lack of resources and equipment, and accept standards of treatment often very different and lower than that common in western hospitals. The International Committee of the Red Cross (ICRC) was asked to provide relief for the Pakistan Red Crescent in 1982 and set up the ICRC Hospital for Afghan War Wounded in Peshawar on the border to Afghanistan. This article relates how a western-trained young anesthetist on a ICRC surgical team experienced this, at the time, austere environment.

Keywords: austere; ICRC; Pakistan; Afghanistan; nongovernment organization

PMID: 29533453

DOI: XZJX-1FR7

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Melioidosis

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Anonymous A. 21(4). 104 - 105. (Journal Article)

Abstract

The Centers for Disease Control and Prevention warned that two people are dead and two have recovered after being infected with the bacterial disease melioidosis - a disease that had never before been detected on contiguous US soil. The cases occurred between March and July 2021 in Georgia, Kansas, Texas, and Minnesota. Melioidosis, also called Whitmore's disease, is an infectious disease that can infect humans or animals. The disease is caused by the bacterium Burkholderia pseudomallei. It is predominately a disease of tropical climates, especially in Southeast Asia and northern Australia where it is widespread.

Keywords: bacteria; melioidosis; contaminated source; Whitmore's disease; Burkholderia pseudomallei

PMID: 34969137

DOI: WEJ5-A5CA

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Meningococcal Disease

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Burnett MW. 17(1). 90 - 92. (Journal Article)

Keywords: infection, meningococcal; disease, infectious

PMID: 28285486

DOI: URE1-Z992

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Methods for Early Control of Abdominal Hemorrhage: An Assessment of Potential Benefit

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Cantle PM, Hurley MJ, Swartz MD, Holcomb JB. 18(2). 98 - 104. (Journal Article)

Abstract

Background: Noncompressible truncal hemorrhage (NCTH) after injury is associated with a mortality increase that is unchanged during the past 20 years. Current treatment consists of rapid transport and emergent intervention. Three early hemorrhage control interventions that may improve survival are placement of a resuscitative endovascular balloon occlusion of the aorta (REBOA), injection of intracavitary self-expanding foam, and application of the Abdominal Aortic Junctional Tourniquet (AAJT™). The goal of this work was to ascertain whether patients with uncontrolled abdominal or pelvic hemorrhage might benefit by the early or prehospital use of one of these interventions. Methods: This was a single-center retrospective study of patients who received a trauma laparotomy from 2013 to 2015. Operative reports were reviewed. The probable benefit of each hemorrhage control method was evaluated for each patient based on the location(s) of injury and the severity of their physiologic derangement. The potential scope of applicability of each control method was then directly compared. Results: During the study period, 9,608 patients were admitted; 402 patients required an emergent trauma laparotomy. REBOA was potentially beneficial for hemorrhage control in 384 (96%) of patients, foam in 351 (87%), and AAJT in 35 (9%). There was no statistically significant difference in the potential scope of applicability between REBOA and foam (ρ = .022). There was a significant difference between REBOA and AAJT (ρ < .001) and foam and AAJT™ (ρ < .001). The external surface location of signs of injury did not correlate with the internal injury location identified during laparotomy. Conclusion: Early use of REBOA and foam potentially benefits the largest number of patients with abdominal or pelvic bleeding and may have widespread applicability for patients in the preoperative, and potentially the prehospital, setting. AAJT may be useful with specific types of injury. The site of bleeding must be considered before the use of any of these tools.

Keywords: trauma; resuscitation; abdominal hemorrhage; foam; baloon aortic occlusion; junctional tourniquet

PMID: 29889964

DOI: I0EU-SQE7

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Middle East Respiratory Syndrome

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Shishido AA, Letizia A. 15(4). 99 - 101. (Journal Article)

Abstract

Middle East respiratory syndrome (MERS) emerged in the Arabian Peninsula in 2012, and subsequently spread to other countries in Europe and Asia, and to the United States. As of August 2015, the disease has infected 1,400 patients, of whom 500 have died, yielding a 36% mortality rate. The exact mode of transmission is unknown and there are no proven treatments. While the overall case rate for MERS has been low, its presence in countries that house US troops, unknown mode of transmission, and high mortality rate make it a significant health concern among US military personnel.

Keywords: Middle East Respiratory Syndrome; Coronavirus; epidemiology; clinical presentation

PMID: 26630103

DOI: XPOY-6J47

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Mild Traumatic Brain Injury Literature Review and Proposed Changes To Classification

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Krainin BM, Forsten RD, Kotwal RS, Lutz RH, Guskiewicz KM. 11(4). 38 - 47. (Journal Article)

Abstract

Mild traumatic brain injury (mTBI) reportedly occurs in 8-22% of U.S. servicemembers who conduct combat operations in Afghanistan and Iraq. The current definition for mTBI found in the medical literature, to include the Department of Defense (DoD) and Veterans Administration (VA) clinical practice guidelines is limited by the parameters of loss of consciousness, altered consciousness, or post-traumatic amnesia, and does not account for other constellations of potential symptoms. Although mTBI symptoms typically resolve within seven days, some servicemembers experience symptoms that continue for weeks, months, or years following an injury. Mild TBI is one of few disorders in medicine where a benign and misleading diagnostic classification is bestowed on patients at the time of injury, yet still can be associated with lifelong complications. This article comprehensively reviews the clin ical literature over the past 20 years and proposes a new classification for TBI that addresses acute, sub-acute, and chronic phases, and includes neurocognitive, somatic, and psychological symptom presentation.

Keywords:

PMID: 22173595

DOI: D7HH-ZGPK

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Mild Traumatic Brain Injury: Situational Awareness for Special Operations Medical Providers

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Forsten RD, Roberts RJ, Stewart C, Solomon BE, Baggett MR. 08(3). 74 - 87. (Journal Article)

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DOI:

Military History of Increasing Survival: The U.S. Military Experience with Tourniquets and Hemostatic Dressings in the Afghanistan and Iraq Conflicts

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Butler FK. 15(4). 149 - 152. (Journal Article)

Keywords:

PMID: 26630110

DOI: DXBQ-YHD0

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Military Medical Evacuation After the Benghazi Embassy Attack: Implications for Military Support of Diplomatic Missions

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Tekmal S, Lockett C, Long B, Schauer S. 22(4). 83 - 86. (Journal Article)

Abstract

Background: The Department of State has the primary responsibility of diplomatic operations in foreign countries. The US military often supports these missions and, when needed, may be called upon to provide security in the event of changes in the host nation's government stability. The US military was requested to help evacuate the consulate in Benghazi after the attack on September 11, 2012. The medical requirements to support such a mission remain unclear, and data are lacking. We sought to describe the medical care required during this evacuation mission. Methods: This is a secondary analysis of a previously described dataset from the United States Transportation Command (TRANSCOM) Regulating Command & Control and Evacuation System (TRAC2ES) from 2008 to 2018, with a focus on cases involving the evacuation after the Libyan consulate attack in September 2012. Within our dataset, we isolated all cases of evacuation from the attack on US government facilities in Benghazi. We describe the available data within TRAC2ES, including the free text information placed by the initiating medical personnel. Results: We identified three cases of evacuations within TRAC2ES associated with the Benghazi consulate attack. All cases were evacuated from host nation hospitals to Landstuhl Regional Medical Center (LRMC) by military aircraft under urgent status. Case 1 was an adult male injured by an undocumented mechanism. He was found to be in severe shock, received four units of blood prior to transport, and was intubated. Case 2 was an adult male injured by an undocumented mechanism. He had documented smoke inhalation injury and was found to be coughing up black sputum. Case 3 was an adult male injured by an undocumented mechanism. He had a compound radial fracture with an external fixator in place and subsequently developed compartment syndrome. He was intubated prior to transport. Conclusions: Our case series focuses on the unique aspects of military support of diplomatic missions in countries lacking a stable government-specifically, what transpired in Benghazi. Such events showcase areas of potential collaboration between the Department of State and the Department of Defense in coordinating medical evacuations for casualties sustained during diplomatic missions.

Keywords: Libya; Benghazi; embassy; attack; military; evacuation

PMID: 36525018

DOI: TSY7-5TA7

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Military Medicine in Iraq and Afghanistan: A Comprehensive Review

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Quinn JM. 19(2). 139 - 140. (Book Review)

Abstract

Greaves I, ed. Military Medicine in Iraq and Afghanistan: A Comprehensive Review. Taylor & Francis Group, LLC, CRC Press, 2019. Paperback, 687 pp. ISBN 13: 978-0-8153-7759-7. Available in paperback, hardback, eBook, and eBook rental.

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Military Prehospital Use of Low Titer Group O Whole Blood

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Warner N, Zheng J, Nix G, Fisher AD, Johnson JC, Williams JE, Northern DM, Hellums JS. 18(1). 15 - 18. (Case Reports)

Abstract

The military's use of whole-blood transfusions is not new but has recently received new emphasis by the Tactical Combat Casualty Care Committee. US Army units are implementing a systematic approach to obtain and use whole blood on the battlefield. This case report reviews the care of the first patient to receive low titer group O whole blood (LTOWB) transfusion, using a new protocol.

Keywords: blood transfusion; group O whole blood; Tactical Combat Casualty Care

PMID: 29533426

DOI: FYTI-EA5O

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Military Standard Testing of Commercially Available Supraglottic Airway Devices for Use in a Military Combat Setting

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Bedolla C, Zilevicius D, Copeland G, Guerra M, Salazar S, April MD, Long B, Naylor JF, De Lorenzo RA, Schauer SG, Hood RL. 23(2). 19 - 32. (Journal Article)

Abstract

Introduction: Airway obstruction is the second leading cause of death on the battlefield. The harsh conditions of the military combat setting require that devices be able to withstand extreme circumstances. Military standards (MIL-STD) testing is necessary before devices are fielded. We sought to determine the ability of supraglottic airway (SGA) devices to withstand MIL-STD testing. Methods: We tested 10 SGA models according to nine MIL-STD-810H test methods. We selected these tests by polling five military and civilian emergency-medicine subject matter experts (SMEs), who weighed the relevance of each test. We performed tests on three devices for each model, with operational and visual examinations, to assign a score (1 to 10) for each device after each test. We calculated the final score of each SGA model by averaging the score of each device and multiplying that by the weight for each test, for a possible final score of 2.6 to 26.3. Results: The scores for the SGA models were LMA Classic Airway, 25.9; AuraGain Disposable Laryngeal Mask, 25.5; i-gel Supraglottic Airway, 25.2; Solus Laryngeal Mask Airway, 24.4; LMA Fastrach Airway, 24.4; AuraStraight Disposable Laryngeal Mask, 24.1; King LTS-D Disposable Laryngeal Tube, 22.1; LMA Supreme Airway, 21.0; air-Q Disposable Intubating Laryngeal Airway, 20.1; and Baska Mask Supraglottic Airway, 18.1. The limited (one to three) samples available for testing provide adequate preliminary information but restrict the range of failures that could be discovered. Conclusions: Lower scoring SGA models may not be optimal for military field use. Models scoring sufficiently close to the top performers (LMA Classic, AuraGain, i-gel, Solus, LMA Fastrach, AuraStraight) may be viable for use in the military setting. The findings of our testing should help guide device procurement appropriate for different battlefield conditions.

Keywords: supraglottic; extraglottic; military; standard; testing; combat; medic

PMID: 37083896

DOI: B4KU-GB0V

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Military Static Line Parachuting Injuries Seen By The Airborne Battalion Provider

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Healy ML. 11(3). 45 - 51. (Journal Article)

Abstract

Military static line parachuting exposes jumpers to a variety of novel methods of injury. Providers assigned to Airborne units need to develop and maintain a high index of suspicion when dealing with jump-related injuries. Understanding the incident rate and the mechanism of injury can help a provider better identify injuries based on the history of the incidence and develop that index of suspicion. Injuries can happen at almost any point during the jump process and each step has both common and unique injuries associated with it. In addition to identifying, managing, and treating the injuries involved, providing information on estimated time until return to duty can be beneficial for the commander. In the end, a provider's best tools for managing Airborne-related injuries are an understanding of Airborne operations, quality orthopedic skills, and a high index of suspicion.

Keywords:

PMID: 21706461

DOI: 6KJH-GVYH

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Military Use of Point of Care Ultrasound (POCUS)

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Savell SC, Baldwin DS, Blessing A, Medelllin KL, Savell CB, Maddry JK. 21(2). 35 - 42. (Journal Article)

Abstract

Background: Point of care ultrasound (POCUS) offers multiple capabilities in a relatively small, lightweight device to military clinicians of all types and levels in multiple environments. Its application in diagnostics, procedural guidance, and patient monitoring has not been fully explored by the Military Health System (MHS). The purpose of this narrative review of the literature was to examine the overall use of POCUS in military settings, as well as the level of ultrasound training provided. Methods: Studies related to use of POCUS by military clinicians with reported sensitivity/specificity, accuracy of exam, and/or clinical decision impact met inclusion criteria. After initial topical review and removal of duplicates, two authors selected 17 papers for consideration for inclusion. Four of the authors reviewed the 17 papers and determined the final inclusion of 14 studies. Results: We identified seven prospective studies, of which three randomized subjects to groups. Five reports described use of POCUS in patients, two used healthy volunteers, two were in simulation training environments, four used animal models to simulate specific conditions, and one used a cadaver model. Clinician subjects ranged from one to 34. Conventional medics were subjects in six studies. Four studies included special operations medics. One study included nonmedical food service inspectors. The use of ultrasound in theater by deployed consultant radiologists is described in three reports. Conclusions: Military clinicians demonstrated the ability to perform focused exams, including FAST exams and fracture detection with acceptable sensitivity and specificity. POCUS in the hands of trained military clinicians has the potential to improve diagnostic accuracy and ultimately care of the war fighter.

Keywords: ultrasound; military; point of care ultrasound; POCUS

PMID: 34105119

DOI: AJTO-LW17

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Mindfulness: A Fundamental Skill for Performance Sustainment and Enhancement

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Deuster PA, Schoomaker E. 15(1). 93 - 99. (Journal Article)

Abstract

The term "mindfulness" has become very fashionable within the military and across multiple sectors of civilian and first responder populations. Overall, the key concept of mindfulness is intentionally being acutely aware of what is going on internally as well as externally, without reacting. Mindfulness and the awareness that underlies it are inherent capabilities that can be honed through training. As such, classes in mindfulness are being offered in many venues and medical clinics are using mindfulness-based interventions for patients for a wide range of medical issues. The evidence behind the benefits of mindfulness is extensive and instructive. Importantly, evidence suggests that mindfulness can be helpful for many operational, leadership, and personal activities and is likely beneficial for enhancing resilience and overall health. Many current military leaders are using mindfulness as a tool to better prepare for a dynamic and uncertain future.

Keywords: mindfulness; performance sustainment; performance enhancement

PMID: 25770805

DOI: LOWD-0U6I

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Mitigating Exertional Heat Illness in Military Personnel: The Science Behind a Rice-Based Electrolyte and Rehydration Drink

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Moore B, O'Hara R. 16(4). 49 - 53. (Journal Article)

Abstract

Background: Exertional heat illness continues to be prevalent among members of active duty personnel, especially those in specific military occupational specialties such as loadmasters, flight crew, flight maintainers, and Special Operations Forces. Therefore, the primary objective of this article was to elucidate the various oral rehydration solutions (ORSs) on the market that are used to mitigate exertional heat illness (EHI) in military personnel, and to focus on the science behind a ricebased electrolyte drink, CeraSport®, currently used by US military personnel in mitigating EHI during sustained training operations in high-heat environments. Methods: A search of the literature (through March 2016) was performed using PubMed and ProQuest, in addition to searching bibliographies and text books. We reviewed 63 articles and three texts. Articles were limited to those published in English and to studies that used only carbohydrates (e.g., no amino acids) and drinks reported to be used by the military in field training and deployment. Conclusion: Heat illness is prevalent among military personnel operating in high-heat environments and a variety of ORSs and sports drinks are available to help mitigate this. However, CeraSport, compared with other ORSs and sports drinks, may offer benefits such as faster gastric emptying rates and improved absorption from the gastrointestinal tract, which can provide rapidly available carbohydrate substrates for energy needs, and increased water retention for maintenance of blood plasma volume.

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PMID: 28088817

DOI: 71KU-VW7D

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Mobility Solutions After a Lower Extremity Fracture and Applicability to Battlefield and Wilderness Medicine

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Childers W, Alderete JF, Eliason TD, Goldman SM, Nicolella DP, Pierrie SN, Stark GE, Studer NM, Wenke JC, Wilson JB, Dearth CL. 23(3). 91 - 100. (Journal Article)

Abstract

The potential for delayed evacuation of injured Service members from austere environments highlights the need to develop solutions that can stabilize a wound and enable mobility during these prolonged casualty care (PCC) scenarios. Lower extremity fractures have traditionally been treated by immobilization (splinting) followed by air evacuation - a paradigm not practical in PCC scenarios. In the civilian sector, treatment of extremity injuries sustained during remote recreational activities have similar challenges, particularly when adverse weather or terrain precludes early ground or air rescue. This review examines currently available fracture treatment solutions to include splinting, orthotic devices, and biological interventions and evaluates their feasibility: 1) for prolonged use in austere environments and 2) to enable patient mobilization. This review returned three common types of splints to include: a simple box splint, pneumatic splints, and traction splints. None of these splinting techniques allowed for ambulation. However, fixed facility-based orthotic interventions that include weight-bearing features may be combined with common splinting techniques to improve mobility. Biologically-focused technologies to stabilize a long bone fracture are still in their infancy. Integrating design features across these technologies could generate advanced treatments which would enable mobility, thus maximizing survivability until patient evacuation is feasible.

Keywords: prolonged casualty care; combat fractures; lower extremity; mobility; splinting; wilderness

PMID: 37733954

DOI: QM3U-JZB1

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Moderate To Severe Traumatic Brain Injury From The Battlefield To The Community

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Girard P, Helmick K, Parkinson G. 07(2). 55 - 62. (Journal Article)

Abstract

Traumatic brain injury (TBI) has been recognized as one of the signature injuries of recent warfare. Tactical combat casualty care (TCCC) plays an integral part in triaging and treating combat wounded troops including Special Operations Forces with TBI and other life threatening injuries. Patients with the most severe brain injuries require rapid evacuation from the battlefield to emergency medical centers capable of providing computerized tomography (CT) imaging, intracranial pressure (ICP) monitoring and ongoing neurological care. Medical treatment to manage brain injury is often provided in tandem with lifesaving surgery and immediate medical services for other injuries. Once stabilized, servicemen with TBI enter a continuum of care which extends across the globe. Joint military and VA trauma and rehabilitation teams work to ensure the best possible outcomes for patients with brain injury. Military and VA medical centers have established new systems of care to help treat increasing numbers of troops with TBI and community-based care and reentry programs help patients with moderate and severe TBI adjust to physical and cognitive changes allowing them to live meaningful and productive lives.

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Modern Irregular Warfare in Defense Policy and as a Military Phenomenon

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Farr WD. 16(2). 115 - 115. (Book Review)

Abstract

English Edition: von der Heydte, Friedrich August Freiherr. Modern Irregular Warfare in Defense Policy and as a Military Phenomenon. New York, NY: New Benjamin Franklin House; 1986.
ISBN: 0-933488-49-1. 299 pages.

German Edition: von der Heydte, Friedrich August Freiherr. Der moderne Kleinkrieg als wehrpolitisches und militärisches Phänomen. Würzburg, West Germany: Holzner-Verlag; 1986.
ISBN-10: 3925725032/ISBN-13: 978-3925725036. 312 pages.

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Monitoring Training for Human Performance Optimization

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Austin KG, Deuster PA. 15(2). 102 - 108. (Journal Article)

Abstract

Physical fitness can significantly impact the mission success of Special Operations Forces (SOF). Much like athletes, Operators have multiple training components including technical, tactical, physical and mental conditioning, which must simultaneously be developed for mission success. Balancing multiple physical stressors to ensure positive results from training can be achieved through periodization-the intentional planning for success. Monitoring the training load can assist SOF in managing training stress and designing periodization that minimizes fatigue. The present article provides an overview of modern technology developed to quantify the stress of training. The training load maintained by SOF consists of external loads created through physical work and internal units of load determined by the rate of perceived effort during training that must be integrated in a manner that minimizes the accumulation of fatigue. Methods for determining training load are discussed in this article and examples are provided for determining training load, developing conditioning sessions and utilizing training load to maintain physical fitness, and improve return from injury.

Keywords: training, monitoring; load, training; load, external; load, internal; rate of perceived effort

PMID: 26125172

DOI: EVU4-W8LW

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Monkey Bite Exposure Treatment Protocol

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Newton F. 10(1). 48 - 49. (Journal Article)

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PMID: 20306415

DOI: FBRG-HMXT

Moral, Legal, and Ethical Considerations for Operational Medicine in the Austere Environment: An Introduction

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Hetzler MR. 18(4). 152 - 152. (Journal Article)

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PMID: 30566743

DOI: S1D6-OUMM

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Mosquito Soldiers: Malaria, Yellow Fever, and the Course of the American Civil War

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Gephart WJ. 11(3). 63 - 63. (Book Review)

Abstract

Andrew M. Bell
Louisiana State Univ Press, Baton Rouge, 2010. ISBN 978-0-8071-3561-7. Hardback,192 pages.

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Motion Analysis: An Objective Assessment of Special Operations Forces and Tactical Medics Performing Point-of-Care Ultrasound

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Baribeau V, Murugappan K, Sharkey A, Lodico DN, Walsh DP, Lin DC, Wong VT, Weinstein J, Matyal R, Mahmood F, Mitchell JD. 23(1). 67 - 73. (Journal Article)

Abstract

Background: Point-of-care ultrasound (POCUS) is commonly employed to image the heart, lungs, and abdomen. Rapid ultrasound for shock and hypotension (RUSH) exams are a critical component of POCUS employed in austere environments by Special Operations Forces (SOF) and tactical medics for triage and diagnosis. Despite its utility, training for POCUS remains largely unstandardized with respect to feedback and markers of proficiency. We hypothesized that motion analysis could objectively identify improvement in medics' performance of RUSH exams. Furthermore, we predicted that motion metrics would correlate with qualitative ratings administered by attending anesthesiologists. Methods: A team of civilian and military attending anesthesiologists trained 24 medics in POCUS during a 5-day course. Each medic performed eight RUSH exams using an ultrasound probe equipped with an electromagnetic motion sensor to track total distance travelled (path length), movements performed (translational motions), degrees rotated (rotational sum), and time. Instructors (experts) observed and rated the exams on the following items: image finding, image fine-tuning, speed, final image accuracy, and global assessment. Motion metrics were used to provide feedback to medics throughout the course. Generalized estimating equations were used to analyze the trends of motion metrics across all trials. Correlations amongst motion metrics and expert ratings were assessed with Pearson correlation coefficients. Results: Participants exhibited a negative trend in all motion metrics (p < 0.001). Pearson correlation coefficients revealed moderate inverse correlations amongst motion metrics and expert ratings. Conclusion: Motion analysis was able to quantify and describe the performance of medics training in POCUS and correlated with expert ratings.

Keywords: medic; motion analysis; point-of-care ultrasound; POCUS; rapid ultrasound for shock and hypotension

PMID: 36800523

DOI: PASZ-WMVJ

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Mottled, Blanching Skin Changes After Aggressive Diving

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Lau AM, Johnston MJ, Rivard SS. 19(2). 14 - 17. (Case Reports)

Abstract

The initial livedo skin changes of cutis marmorata, also known as cutaneous decompression sickness (DCS), are transient in nature. Accordingly, early images of violaceous skin changes with variegated, marbled, or mottled appearance are rare, whereas later images of deep, erythematous, or violaceous skin changes are readily available. This case presents the opportunity to view the early skin changes characteristic of cutaneous DCS, which would likely manifest at Level I care in the setting of a diving injury during Special Operations missions in austere environments. The unique diving context also allows an overview of DCS in addition to a review of skin eruptions associated with various marine life. As diving is frequently used by Naval Special Warfare, topics presented in this case have significant relevance to Special Operations.

Keywords: skin; dermatology; cutis marmorata; cutaneous decompression sickness

PMID: 31201746

DOI: K7M6-ANOA

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Mouthguards for the Prevention of Orofacial Injuries in Military and Sports Activities: Part 1: History of Mouthguard Use

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Knapik JJ, Hoedebecke BL, Mitchener TA. 20(2). 139 - 143. (Journal Article)

Abstract

This is the first of a two-part series on the history and effectiveness of mouthguards (MGs) for orofacial injury protection. Military studies have shown that approximately 60% of orofacial injuries are associated with military training activities and 20% to 30% with sports. MGs are hypothesized to reduce orofacial injuries by separating the upper and lower dentation, preventing tooth fractures, redistributing and absorbing the force of direct blows to the mouth, and separating teeth from soft tissue, preventing lacerations and bruises. In 1975, CPT Leonard Barber was the first to advocate MGs for military sports activities. In 1998, Army health promotion campaigns promoted MG education and fabrication. A US Army basic training study in 2000-2003 showed that more MG use could reduce orofacial injuries and the Army Training and Doctrine Command subsequently required that basic trainees be issued and use MGs. Army Regulation 600-63 currently directs commanders to enforce MG use during training and sports activities that could involve orofacial injuries. In the civilian sector, MGs were first used by boxers and then were required for football. MGs are currently required nationally for high school and college football, field hockey, ice hockey, and lacrosse, and are recommended for 29 sport and exercise activities.

Keywords: dental health; dental injury; maxillofacial injury; mouthguards; orofacial injury

PMID: 32573752

DOI: Y472-M9XP

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Mouthguards for the Prevention of Orofacial Injuries in Military and Sports Activities: Part 2, Effectiveness of Mouthguard for Protection From Orofacial Injuries

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Knapik JJ, Hoedebecke BL, Mitchener TA. 20(3). 114 - 116. (Journal Article)

Abstract

This is second of a two-part series on the history and effectiveness of mouthguards (MGs) for protection from orofacial injuries. MGs are hypothesized to reduce orofacial injuries by separating the upper and lower dentation, preventing tooth fractures, redistributing and absorbing the force of direct blows to the mouth, and separating teeth from soft tissue which helps prevent lacerations and bruises. The single study on MG use in military training found that when boil-and-bite MGs were required for four training activities, orofacial injury rates were reduced 56% compared with when MGs were required for just one training activity. A recent systematic review on the effectiveness of MGs for prevention of orofacial injuries included 23 studies involving MG users and nonusers and a wide variety of sports. For cohort studies that directly collected injury data, the risk of an orofacial injury was 2.33 times higher among MG nonusers (95% confidence interval, 1.59-3.44). More well-designed studies are needed on the effectiveness of MGs during military training. Despite some methodological limitations, the current data suggest that MGs can substantially reduce the risk of orofacial injuries in sport activities. MGs should be used in activities where there is a significant risk of orofacial injuries.

Keywords: mouthguards; orofacial injury; sports injuries; oral health

PMID: 32969014

DOI: IFCD-6D3A

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Mumps

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Burnett MW. 17(2). 117 - 119. (Journal Article)

Keywords: mumps; infectious disease

PMID: 28599044

DOI: SWWG-QACE

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Murphy's Law?

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Hampton K, Van Humbeeck L. 20(2). 148 - 148. (Journal Article)

Keywords: ultrasound; testicles; austere

PMID: 32573754

DOI: NBB9-T126

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Nasal Foreign Body: Case Review For The Advanced Tactical Practitioner

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Paul J. 11(4). 69 - 71. (Journal Article)

Keywords:

PMID: 22173601

DOI: 4NZ4-YD4Z

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National TEMS Initiative and Council NTIC Competency Domains/The TACMED Challenge!

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Pennardt A. 16(4). 132 - 132. (Classical Conference)

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PMID: 28088835

DOI: SFGN-JX7C

NATO Military Medical Exercise Vigorous Warrior 2017

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Fazekas L, McCown ME, Taylor JB, Ferland KA. 19(1). 27 - 30. (Journal Article)

Abstract

Our intent in presenting this information is to increase the awareness of the Special Operations Forces (SOF) medical community and the overall international medical/military communities about the North Atlantic Treaty Organization (NATO) military medicine's premiere Vigorous Warrior Exercises organized by NATO Centre of Excellence for Military Medicine (MILMED COE). The Vigorous Warrior medical exercise series is conducted biennially, with four successful iterations since 2011. These international medical exercises engage military medical elements that enhance NATO capabilities and ensure that new NATO medical concepts are being exercised and tested across the full capability-requirement spectrum. The primary aims of these exercises are to provide NATO and partner nations a multipurpose platform to collectively train their medical forces and personnel; test and experiment new concepts and doctrines; medically evaluate national or multinational medical treatment facilities in accordance with NATO doctrine; produce medical lessons identified and lessons learned; and provide the participants with multinational experience to enhance the provision of health care in NATO operations. These exercises directly strengthen partnerships, improve military medical interoperability, and demonstrate the Alliance's commitment to improving international military collaboration. More than 1,000 medical personnel from 26 NATO and partner nations successfully conducted the joint, multilevel, multinational, medical live exercise Vigorous Warrior 2017 (VW17) throughout three locations in Germany during 4-22 September 2017. This article details the highly successful VW17 and paves the way for a very bright future for the Alliance's military medicine as well as a Vigorous Warrior 2019.

Keywords: NATO; Vigorous Warrior; NATO Centre of Excellence for Military Medicine; NATO Deployment Health Surveillance Capability; Article 5; joint multinational medical exercise; interoperability; international military collaboration; NATO Concept Development and Experimentation; bioresponsiveness

PMID: 30859522

DOI: 6AU3-1R5Z

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NATO SOF Transformation And The Development Of NATO SOF Medical Doctrine And Policy

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Wallace GR. 09(3). 7 - 13. (Journal Article)

Abstract

The North Atlantic Treaty Organization (NATO) Special Operations Forces (SOF) Coordination Center (NSCC) is a new NATO memorandum of understanding (MOU) organization that is effecting rapid advancement in NATO's ability to efficiently utilize SOF at the strategic/operational level. The NSCC's lines of development in communications information systems (CIS), education, training, and real life support to the International Security Assistance Force (ISAF) SOF and the development of pivotal documents to develop and mature NATO SOF doctrine and policy are all occurring at lightning speed. Within this process of establishing a SOF community in NATO, the author's focus is the development of previously non-existent NATO SOF medical doctrine and policy. Many barriers to change lie ahead, but through unity of effort, we will ensure certainty of our actions.

Keywords:

PMID: 19739471

DOI: O5AA-9AXG

NATO Special Operations Forces Medical Engagements and Partnering Course: Initial Curriculum Recommendations from the NSHQ SOFMEP Committee

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Alderman SM, Arvidsson CJ, Boedeker BH, Durck CH, Ferguson JL, Harreld CE, House JH, Irizarry DJ, Oshiki MS, Sanchack KE, Torres JE. 12(2). 27 - 32. (Journal Article)

Abstract

Military partnering operations and military engagements with host nation civil infrastructure are fundamental missions for NATO Special Operations Forces (SOF) conducting military assistance operations. Unit medical advisors are frequently called upon to support partnering operations and execute medical engagements with host nation health systems. As a primary point of NATO SOF medical capability development and coordination, the NATO Special Operations Headquarters (NSHQ) sought to create a practical training opportunity in which medical advisors are taught how to prepare for, plan, and execute these complex military assistance operations. An international committee of SOF medical advisors, planners and teachers was assembled to research and develop the curriculum for the first NSHQ SOF Medical Engagement and Partnering (SOFMEP) course. The committee found no other venues offering the necessary training. Furthermore, a lack of a common operating language and inadequate outcome metrics were identified as sources of knowledge deficits that create confusion and inhibit process improvement. These findings provided the foundation of this committee's curricular recommendations. The committee constructed operational definitions to improve understanding and promote dialogue between medical advisors and commanders. Active learning principles were used to construct a curriculum that engages learners and enhances retention of new material. This article presents the initial curriculum recommendations for the SOFMEP course, which is currently scheduled for October 2012.

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PMID: 22707022

DOI: 9UPI-Q2I7

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Necessity Of Medical Personnel On The Advance Party

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Horsley GW, Wilson K. 08(2). 48 - 50. (Journal Article)

Abstract

Often when a unit sends an advanced echelon party forward, medical and preventive medicine personnel are not included. Medical planners make plans based upon their best estimates. Any opportunity for the medical personnel to gain ground truth prior to the deployment of the main body is an opportunity that should be taken. This article tries to reinforce this by providing a personal example. It also provides examples of effective preventive measures taken to decrease exposure to the filth fly.

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Needle Decompression

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Studer NM, Horn GT. 16(1). 72 - 73. (Editorial)

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PMID: 27045500

DOI: 4GCE-M6XB

Needle Thoracentesis Decompression: Observations From Postmortem Computed Tomography and Autopsy

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Harcke HT, Mabry RL, Mazuchowski EL. 13(4). 53 - 58. (Journal Article)

Abstract

Background: Needle thoracentesis decompression (NTD) is a recommended emergency treatment for tension pneumothorax. Current doctrine recognizes two suitable sites: the second intercostal space in the midclavicular line and the fourth or fifth intercostal space in the anterior axillary line. Methods: A review was conducted of postmortem computed tomography and autopsy results in 16 cases where NTD was performed as an emergency procedure. Results: In 16 cases with 23 attempted procedures, the outcome was confirmed in 17 attempts. In 7 placements, the catheter was in the pleural cavity; in 7 placements, the catheter never entered the pleural cavity; and in 3 placements, cavity penetration was verified at autopsy even though the catheter was no longer in the cavity. Success was noted in 6 of 13 anterior attempts and 4 of 4 lateral attempts, for an overall success rate of 59% (10 of 17). In the remaining 6 attempted procedures, a catheter was noted in the soft tissue on imaging; however, presence or absence of pleural cavity penetration was equivocal. All placements were attempted in the combat environment; no information is available about specifically where or by whom. Conclusion: NTD via a lateral approach was more successful than that via an anterior approach, although it was used in fewer cases. This supports the revision of the Tactical Combat Casualty Care Guidelines specifying the lateral approach as an alternative to an anterior approach.

Keywords: needle thoracentesis decompression; Tactical Combat Casualty Care guidelines; tension pneumothorax

PMID: 24227562

DOI: FWAO-F36G

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Needle Thoracostomy In The Treatment Of A Tension Pneumothorax In Trauma Patients: What Size Needle?

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Zengerink I, Brink PR, Laupland KB, Raber EL, Zygun D, Kortbeek JB. 08(2). 92 - 95. (Previously Published)

Previously published in The Journal of Trauma Injury, Infection, and Critical Care. 2008;64:111–114. Permission granted by Lippincott Williams & Wilkins to republish in JSOM.

Abstract

Background: A tension pneumothorax requires immediate decompression using a needle thoracostomy. According to advanced trauma life support guidelines this procedure is performed in the second intercostal space (ICS) in the midclavicular line (MCL), using a 4.5cm (2-inch) catheter (5cm needle). Previous studies have shown a failure rate of up to 40% using this technique. Case reports have suggested that this high failure rate could be because of insufficient length of the needle. Objectives: To analyze the average chest wall thickness (CWT) at the second ICS in the MCL in a trauma population and to evaluate the length of the needle used in needle thoracostomy for emergency decompression of tension pneumothoraces. Methods: Retrospective review of major trauma admissions (Injury Severity Score >12) at the Foothills Medical Centre in Calgary, Canada, who underwent a computed tomography chest scan admitted in the period from October 2001 until March 2004. Subgroup analysis on men and women, <40 years of age and >40 years of age was defined a priori. CWT was measured to the nearest 0.01cm at the second ICS in the MCL. Results: The mean CWT in the 604 male patients and 170 female patients studied averaged 3.50cm at the left second ICS MCL and 3.51cm on the right. The mean CWT was significantly higher for women than men (ρ < 0.0001). About 9.9% to 19.3% of the men had a CWT >4.5 cm and 24.1% to 35.4% of the women studied. Conclusions: A catheter length of 4.5cm may not penetrate the chest wall of a substantial amount (9.9% - 35.4%) of the population, depending on age and gender. This study demonstrates the need for a variable needle length for relief of a tension pneumothorax in certain population groups to improve effectiveness of needle thoracostomy.

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New and Established Models of Limb Tourniquet Compared in Simulated First Aid

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Kragh JF, Newton NJ, Tan AR, Aden JK, Dubick MA. 18(2). 36 - 41. (Journal Article)

Abstract

Background: The performance of a new tourniquet model was compared with that of an established model in simulated first aid. Methods: Four users applied the Combat Application Tourniquet (C-A-T), an established model that served as the control tourniquet, and the new SAM Extremity Tourniquet (SXT) model, which was the study tourniquet. Results: The performance of the C-A-T was better than that of the SXT for seven measured parameters versus two, respectively; metrics were statistically tied 12 times. The degree of difference, when present, was often small. For pretime, a period of uncontrolled bleeding from the start to a time point when the tourniquet first contacts the manikin, the bleeding rate was uncontrolled at approximately 10.4mL/s, and for an overall average of 39 seconds of pretime, 406mL of blood loss was calculated. The mean time to determination of bleeding control (± standard deviation [SD]) was 66 seconds (SXT, 70 ± 30 seconds; C-A-T, 62 ± 18 seconds; p = .0075). The mean ease-of-use score was 4 (indicating easy) on a scale of 1 to 5, with 5 indicating very easy (mean ± SD: SXT, 4 ± 1; C-A-T, 5 ± 0; p < .0001). C-A-T also performed better for total trial time, manikin damage, blood loss rate, pressure, and composite score. SXT was better for pretime and unwrap time. All users intuitively self-selected the speed at which they applied the tourniquets and that speed was similar in all of the required steps. However, by time segments, one user went slowest in each segment while the other three generally went faster. Conclusions: In simulated first aid with tourniquets, better results generally were seen with the C-A-T than with the SXT in terms of performance metrics. However, the degree of difference, when present, was often small.

Keywords: tourniquet; manual skill; psychomotor performance; first aid device comparison/education/standards; hemorrhage prevention and control

PMID: 29889953

DOI: 4WVW-AE0T

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No Crown of Laurels: An Account of the Author's Plastic Surgery on Resistance Leaders and of Their Adventures

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Farr WD. 20(2). 150 - 150. (Book Review)

Abstract

Borodin G. No Crown of Laurels: An Account of the Author's Plastic Surgery on Resistance Leaders and of Their Adventures. London, UK: Werner Laurie, Ltd; 1950. ASIN:B0000CHO0V; OCLC:316094528. 224 pages, hardcover. Sava G. No Crown of Laurels. London, UK: Werner Laurie, Ltd; 1950. ASIN:B0000CHO0V.

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No Ordinary Sleeper Cell: Managing the Varied Problems of Plasmodium vivax Malaria

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Jarvis J. 17(3). 90 - 94. (Journal Article)

Abstract

Plasmodium vivax malaria is an essential yet elusive target of tropical disease eradication efforts, and is the focus of this literature review. This review will reacquaint Special Operations Forces (SOF) Medics with the basic principles of malaria as context for understanding the several confounding issues particular to P. vivax infections. The review concludes with current malaria guidelines and malaria mitigation strategies.

Keywords: malaria; Plasmodium vivax; glucose-6-phosphate dehydrogenase (G6PD) enzyme deficiency

PMID: 28910476

DOI: 7NRD-TVX7

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No Shit, There I Was: The Case for Narrative-Based Clinical Knowledge

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Froede K. 11(1). 21 - 24. (Journal Article)

Abstract

Relevant literature demonstrates the absolute necessity of Special Operations Forces (SOF) clinical narratives to the medics they teach and care they deliver, and discusses the concept of narrative pedagogy via review of extant literature and also SOF-specific clinical literature. SOF clinicians (medics, physicians' assistants, physicians, etc.) provide advanced trauma, clinical, and preventive care in the most austere of combat environments. SOF clinicians have adopted specific paradigms for schooling, teaching, learning, and practice. An overarching theme within SOF-generated clinical literature is that of hermeneutics and the narrative pedagogy; SOF clinicians generate their evidence from experience and frequently tell stories to educate their peers, colleagues, and student medics to increase the knowledge of the entire community.

Keywords: Special Forces; medics; narrative pedagogy; hermeneutics; clinical evidence

PMID: 22113722

DOI: 0UPL-E44X

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No Slackers in Tourniquet Use to Stop Bleeding

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Polston RW, Clumpner BR, Kragh JF, Jones JA, Dubick MA, Billings S. 13(2). 12 - 19. (Journal Article)

Abstract

Background: Tourniquets on casualties in war have been loose in 4%-9% of uses, and such slack risks death from uncontrolled bleeding. A tourniquet evidence gap persists if there is a mechanical slack-performance association. Objective: The purpose of the present study was to determine the results of tourniquet use with slack in the strap versus no slack before windlass turning, in order to develop best practices. Methods: The authors used a tourniquet manikin 254 times to measure tourniquet effectiveness, windlass turns, time to stop bleeding, and blood volume lost at 5 degrees of strap slack (0mm, 25mm, 50mm, 100mm, and 200mm maximum). Results: When comparing no slack (0mm) to slack (any positive amount), there were increases with slack in windlass turns (ρ < .0001, 3-fold), time to stop bleeding (ρ < .0001, 2-fold), and blood volume lost (ρ < .0001, 2-fold). When comparing no slack to 200mm slack, the median results showed an increase in slack for windlass turns (ρ < .0001), time to stop bleeding (ρ < .0001), and blood volume lost (ρ < .0001). Conclusions: Any slack presence in the strap impaired tourniquet performance. More slack had worse results. Trainers can now instruct tourniquet users with concrete guidance.

Keywords: hemorrhage; first aid; trauma; damage control; resuscitation

PMID: 23817873

DOI: PBOM-EDWG

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Nongovernment Organizations Providing Medical Care in Austere Environments and Challenges They Face

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Glavacevic L, Karlovic K, Gallagher E. 20(2). 144 - 147. (Journal Article)

Abstract

Nongovernment organizations (NGOs) have become increasingly common in conflict zones throughout the world. They provide services that have been the responsibility of understaffed, undersupplied, and undertrained local nations and communities. However, these organizations face many difficulties. They are walking a thin line between militaries, governments, and local politics. They must find ways to stay supplied and staffed. The research presented in this article focuses on three NGOs and the impact they are making throughout the world. By understanding the role these organizations play in providing medical relief to conflict zones without the help of government agencies, one can see the importance of their work and the struggles they face.

Keywords: organizations; international agencies; government agencies; NATO Special Operations Combat Medic; NSOCM

PMID: 32573753

DOI: EU2J-LLWT

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Norovirus

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Burnett MW. 18(3). 92 - 93. (Journal Article)

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PMID: 30222845

DOI: R3UP-QW3B

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Nursing Interventions in Prolonged Field Care

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Ostberg D, Loos PE, Mann-Salinas EA, Creson C, Powell D, Riesberg JC, Keenan S, Shackelford SA. 18(2). 123 - 132. (Journal Article)

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PMID: 29889969

DOI: 935P-DO49

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Obstacle Course Events: Hazards and Prevention Measures

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Knapik JJ. 22(2). 129 - 138. (Journal Article)

Abstract

This article reviews hazards associated with obstacle course events (OCEs) like the Spartan Race and Tough Mudder, which are becoming increasingly popular, and provides strategies to mitigate these hazards. In seven studies, the overall weighted incidence of participants seeking medical care during OCEs was only 1.4% with ~6% of these requiring higher level medical care at a hospital. Nonetheless, 27% of participants self-reported =1 extremity injury. Common OCE medical problems included sprains/strains and dermatological injuries (abrasions/laceration/blisters); the ankle and knee were common injury locations. There are reports microorganism infections during OCEs, associated with ingestion of contaminated water and mud. On military obstacle courses, ~5% were injured, but this activity has the highest injury rate (injuries/hour of training) of all major testing or training activities. Ankle sprain risk can be reduced with proprioceptive training and prophylactic ankle bracing. Knee injury risk can be reduced with exercise-based programs that incorporate various components of proprioceptive training, plyometrics, resistance exercises, stretching, and shuttle/bounding running. Reducing abrasions and lacerations involve wearing low friction clothing, gloves, and prophylactic covering of skin areas prone to abrasions/lacerations with specific protective materials. Reducing blister likelihood involves use of antiperspirants without emollients, specialized sock systems, and covering areas prone to blisters with paper tape. Reducing infections from microorganism can be accomplished by protective covering open wounds, rinsing off mud post-race, and avoiding ingestion of food and drink contaminated with mud. These chiefly evidence-based injury and illness prevention measures should minimize the risks associated with OCEs.

Keywords: infection; obstacle course events; injury

PMID: 35649408

DOI: M457-YZ98

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Occlusion Pressures of Tactical Pneumatic Tourniquet 2"

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Wall P, Buising CM, Eernisse D, Rentschler T, Winters C, Renner CH. Ahead of Print. (Journal Article)

Abstract

Background: The Tactical Pneumatic Tournqiuet 2" (TPT2, 5.1cm-wide deflated) allows total average applied pressure measurement, which should be useful toward development of emergency-use limb tourniquet certification devices. Methods: The TPT2 hand bulb was replaced with stopcocks and syringes, allowing filling with continuous pressure measurement. Forearm and mid-thigh applications involved two sets of five Doppler-based pulse gone/return pairs. Second set pulse gones were chosen a priori for occlusion pressures (preliminary work indicated greater consistency in second sets). Results: All 68 forearms occluded (30 female, 38 male, median circumference 17.8cm, range 14.6-23.5cm; median second set of pulse gone tourniquet pressures 176mmHg, range 128-282mmHg). Fifty-five thighs occluded (median circumference 54.3cm, range 41.6-62.4cm; median systolic pressure 126mmHg, range 102-142mmHg; median second set of pulse gone pressures 574mmHg, range 274-1158mmHg). Thirteen thigh applications were stopped without occlusion because of concerning pressures combined with no indication of imminent occlusion and difficulties forcing more air into the TPT2 (3 female, 10 male, peak pressures from 958-1377mmHg, median 1220mmHg, p<.0001 versus occluded thighs; median circumference 63.3cm, range 55.0-72.9cm, p<.0001 versus occluded thighs; median systolic pressure 126mmHg, range 120-173mmHg, p<.019 versus occluded thighs). Thigh TPT2 impression widths on five subjects after occlusion were as follows: 3.5cm, occlusion 274mmHg; 2.8cm, occlusion 348mmHg; 2.9cm, occlusion 500mmHg; 2.8cm, occlusion 782mmHg; 2.7cm, occlusion 1114mmHg. Conclusions: Though probably useful to tourniquet certification, the required pressures for thigh occlusion make the TPT2 undesirable for any clinical use, emergency or otherwise.

Keywords: tourniquet; hemorrhage; first aid; emergency treatment

PMID: 38300879

DOI: P75U-HM00

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Ocular Injuries and Cultural Influences in Afghanistan During 5 Months of Operation Enduring Freedom

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Paz DA, Thomas KE, Primakov DG. 18(1). 77 - 80. (Journal Article)

Abstract

In support of Operation Enduring Freedom, American, North American Treaty Organization (NATO) Coalition, and Afghan forces worked together in training exercises and counterinsurgency operations. While serving at the NATO Role 3 Multinational Medical Unit, Kandahar, Afghanistan, numerous patients with explosive blast injuries (Coalition and Afghan security forces, and insurgents) were treated. A disparity was noted between the ocular injury patterns of US and Coalition forces in comparison with their Afghan counterparts, which were overwhelmingly influenced by the use, or lack thereof, of eye protection. Computed tomography imaging coupled, with a correlative clinical examination, demonstrated the spectrum of ocular injuries that can result from an explosive blast. Patient examination was performed by Navy radiologists and an ophthalmologist. A cultural analysis by was performed to understand why eye protection was not used, even if available to Afghan forces, by the injured patients in hope of bridging the gap between Afghan cultural differences and proper operational risk management of combat forces.

Keywords: ocular injury; culture; explosive blast injury

PMID: 29533438

DOI: NH9N-B5LA

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OK, Doc . . . What Do I Really Have? Posttraumatic Stress Disorder Versus Traumatic Brain Injury

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Figueroa XA, Wright JK. 15(4). 59 - 66. (Journal Article)

Abstract

The authors review the diagnostic overlap that exists between posttraumatic stress disorder (PTSD) and traumatic brain injury (TBI). Achieving the correct diagnosis is much more difficult and the potential to inappropriately treat patients is greater than most physicians realize. The need to properly diagnose and select appropriate treatment strategies is essential, especially with TBI cases. A number of new and experimental therapies are being used to treat PTSD effectively and reverse the neurological sequelae of TBI, potentially returning to active duty Servicemembers who are undergoing a medical review board.

Keywords: posttraumatic stress disorder; traumatic brain injury

PMID: 26630096

DOI: LIPN-JHNI

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Old Tricks for New Dogs? John Caddy and the Victorian Origins of TCCC

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Reynolds PS. 18(2). 58 - 62. (Journal Article)

Abstract

The success of Tactical Combat Casualty Care (TCCC) in reducing potentially preventable combat deaths may rely on both specific interventions (such as tourniquets) and the systematized application of immediate care. Essential elements of a combat care system include clear specification of immediate care priorities, standardized methodology, and inclusion and training of all nonmedical personnel in early response. Although TCCC is fairly recent, the construct is similar to that first suggested during the mid-nineteenth century by John Turner Caddy (1822-1902), a British Royal Navy staff surgeon. Although naval warfare engagements at the time were relatively infrequent, casualties could be numerous and severe and often overwhelmed the small medical staff on board. Caddy recognized that nonmedical personnel properly trained in the fundamentals of combat injury management would result in lives saved and greatly improved morale. The novelty was in his attempt to make procedures simple enough to be performed by nonmedical personnel under stress. However, Caddy's guidelines were completely overlooked for nearly two centuries. The principles of best practice for managing combat trauma injuries learned in previous wars have often been lost between conflicts. Understanding the historical roots of combat first responder care may enable us to better understand and overcome barriers to recognition and retention of essential knowledge.

Keywords: combat casualty care; Crimea; hemorrhage; military medicine; tourniquet; wounds and injuries

PMID: 29889957

DOI: HEB7-KO2V

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Omega-3 Fatty Acid Ingestion as a TBI Prophylactic

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Barringer N, Conkright W. 12(3). 5 - 7. (Journal Article)

Abstract

Given the hazardous nature of combat operations and training exercises (e.g. airborne operations) conducted by the United States military, servicemembers are at high risk for sustaining a traumatic brain injury (TBI). Since the beginning of the Iraq and Afghanistan wars, almost a quarter of a million servicemembers have sustained a TBI.1 A large number of TBIs are a result of the concussive forces generated by improvised explosive devices (IED). A smaller number are a result of penetrating head wounds. Others may be caused by activities resulting in powerful acceleration, deceleration, or rotational forces. Therapies for treating TBI thus far have been limited. Much of the research conducted to date has focused on post-injury pharmacological interventions.2 Additionally, better protective equipment could help in preventing TBIs; however, these issues are outside the scope of this paper. A relatively new area of research is investigating prophylactic measures taken to lessen the effects of TBI. One such measure involves nutritional interventions and their effects on TBI severity. Therefore, the purpose of this paper is to elucidate the potential benefits of omega-3 fatty acid intake as it relates to TBI severity.

Keywords:

PMID: 23032313

DOI: E1W8-7PLC

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Omega-3 Fatty Acids: Benefits for Performance and Recovery

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Rittenhouse M, Deuster PA. 22(4). 97 - 101. (Journal Article)

Abstract

Full-spectrum human performance optimization (HPO) is essential for Special Operations Forces (SOF). Nutrition is one part of HPO and is important for all aspects of performance. One area of increased interest in this regard is omega-3 polyunsaturated fatty acids (omega-3). Research has indicated that Servicemembers (SM), including SOF, do not eat the recommended 2 to 3 servings per week of fatty fish and have low omega-3 levels. Therefore, alternative approaches are warranted. The purpose of this article is to highlight the potential mental and physical health and performance benefits of omega-3. Consuming omega-3 on a regular basis would not only be beneficial for the health of SOF but also for their training and overall performance.

Keywords: omega-3; Special Operations Forces; full-spectrum human performance optimization; nutrition dietary supplements

PMID: 36525021

DOI: 6I33-5IPR

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OMNA Marine Tourniquet Self-Application

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Hingtgen E, Wall PL, Buising CM. 20(3). 52 - 61. (Journal Article)

Abstract

Background: The OMNA Marine Tourniquet is a 5.1cm-wide, simple redirect buckle, hoop-and-loop secured, ratcheting tourniquet designed for storage and use in marine environments. This study evaluated self-application effectiveness and pressures. Methods: Triplicate secured, occlusion, and completion pressures were measured during 60 subjects pulling down or up thigh applications and nondominant, single-handed arm applications. Arm pressure measurements required circumferences =30cm. Results: Thirty-one subjects had arm circumferences ≥30cm. All 540 applications were effective; 376 of 453 applications had known secured pressures >150mmHg (89 of 93 arm). Thigh down versus up pulling directions were not different (secured, occlusion, and completion pressures and ladder tooth advances). Occlusion pressures were 348mmHg (275-521mmHg) for combined thighs and 285mmHg (211-372mmHg) for arms. Completion pressures were 414mmHg (320-588mmHg) for combined thighs and 344mmHg (261-404mmHg) for arms. Correlations between secured pressures and occlusion ladder tooth advances (clicks) were r2 = 0.44 for combined thighs and 0.68 for arms. Correlations between occlusion pressures and occlusion clicks were poor (r2 = 0.24, P < .0001 for combined thighs and r2 = 0.027, P = .38 for arms). Conclusions: The OMNA Marine Tourniquet can be self-applied effectively, including one-handed applications. Occlusion and completion pressures are similar to reported 3.8cm-wide Ratcheting Medical Tourniquet pressures.

Keywords: tourniquet; hemorrhage; first aid; emergency treatment

PMID: 32969004

DOI: 6KC3-CFTS

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One Up: A Woman in Action With the S.A.S.

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Farr WD. 16(4). 127 - 127. (Book Review)

Abstract

Ford, Sarah. One Up. A Woman in Action With the S.A.S. London, UK: Harper Collins Publishers; 1997. ISBN-10: 000638837X and ISBN-13: 978-00063883711997. 288 pages.

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Only Break Glass in Case of War? The Difficulty With Combat Medic Skills Sustainment Within Our Military Treatment Facilities

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Cunningham CW. 15(1). 90 - 92. (Letter)

Keywords:

PMID: 25770804

DOI: K9F0-1LK7

Operation Blood Rain Phase 2: Evaluating the Effect of Airdrop on Fresh and Stored Whole Blood

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Fuentes RW, Shawler EK, Smith WD, Tong RL, Barnes WJ, Moncada M, Bohlke CW, Mitchell AL. 22(3). 9 - 14. (Journal Article)

Abstract

Background: Transfusion of whole blood (WB) is a lifesaving treatment that prolongs life until definitive surgical intervention can be performed; however, collecting WB is a time-consuming and resource-intensive process. Furthermore, it may be difficult to collect sufficient WB at the point of injury to treat critically wounded patients or multiple hemorrhaging casualties. This study is a follow-up to the proof-of-concept study on the effect of airdrop on WB. In addition, this study confirms the statistical significance for the plausibility of using airdrop to deliver WB to combat medics treating casualties in the pre-hospital setting when Food and Drug Administration (FDA)-approved cold-stored blood products are not available. Methods: Forty-eight units of WB were collected and loaded into a blood cooler that was dropped from a fixed-wing aircraft under a Standard Airdrop Training Bundle (SATB) parachute or 68-in pilot chute. Twenty-four of these units were dropped from a C-145 aircraft, and 24 were dropped from a C-130 aircraft. A control group of 15 units of WB was storedin a blood cooler that was not dropped. Baseline and post-intervention laboratory tests were measured in both airdroppedand control units, including complete blood count; prothrombin time/partial thromboplastin time (PT/PTT); pH, lactate, potassium, bilirubin, glucose, fibrinogen, and lactate dehydrogenase (LDH) levels; and peripheral blood smears. Results: The blood cooler, cooling packs, and all 48 WB units did not sustain any major damage from the airdrop. There was no evidence of hemolysis. Except for the one slightly damaged bag that was not sampled, all airdropped blood met parameters for transfusion per the Joint Trauma System Whole Blood Transfusion Clinical Practice Guideline and the Association for the Advancement of Blood and Biotherapies (AABB) Circular of Information for the Use of Human Blood and Blood Components. Conclusions: Airdrop of fresh or stored WB in a blood cooler with a chute is a viable way of delivering blood products to combat medics treating hemorrhaging patients in the pre-hospital setting. This study also demonstrated the portability of this technique for multiple aircraft. The techniques evaluated in this study have the potential for utilizationin other austere settings such as wilderness medicine or humanitarian disasters where an acute need for WB delivery by airdrop is the only option.

Keywords: whole blood transfusion; airdrop; airdrop blood; aerial resupply; Tactical Combat Casualty Care

PMID: 35862850

DOI: A10N-KTMD

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Operation Blood Rain: The Effect of Airdrop on Fresh Whole Blood

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Tong RL, Bohlke CW, Clemente Fuentes RW, Moncada M, Schloe AD, Ashley RL. 21(2). 29 - 33. (Journal Article)

Abstract

Background: Administration of fresh whole blood (FWB) is a life-saving treatment that prolongs life until definitive surgical intervention can be performed; however, collecting FWB is a time-consuming and resource-intensive process. Furthermore, it may be difficult to collect sufficient FWB to treat critically wounded patients or multiple-hemorrhaging casualties. This study describes the effect of airdrop on FWB and explores the possibility of using airdrop to deliver FWB to combat medics treating casualties in the prehospital setting when FDA-approved, cold-stored blood products are not readily available and timely casualty evacuation (CASEVAC) is not feasible. Methods: Four units of FWB were collected from volunteer donors and loaded into a blood cooler that was dropped from a fixed-wing aircraft under a standard airdrop training bundle (SATB) parachute. A control group of 4 units of FWB was stored in a blood cooler that was not dropped. Baseline and postintervention laboratory samples were measured in both airdropped and control units, including full blood counts, prothrombin time/partial thromboplastin time/international normalized ratio (PT/PTT/INR), pH, lactate, potassium, indirect bilirubin, glucose, fibrinogen, lactate dehydrogenase, and peripheral blood smears. Results: The blood cooler, cooling bags, and all 4 FWB units did not sustain any damage from the airdrop. There was no evidence of hemolysis. All airdropped blood met parameters for transfusion per the Whole Blood Transfusion Clinical Practice Guideline of the Joint Trauma System (JTS). Conclusions: Airdrop of FWB in a blood cooler with a SATB parachute may be a viable way of delivering blood products to combat medics treating hemorrhaging patients in the prehospital setting, although further research is needed to fully validate the safety of this method of FWB delivery.

Keywords: fresh whole blood transfusion; airdrop; airdrop blood; aerial resupply; Tactical Combat Casualty Care

PMID: 34105118

DOI: 6Q4Y-H71J

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Operation Sams

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Zimmerman DJ. 09(4). 80 - 83. (Previously Published)

Previously Published in The Year in Speical Operations 2009. Reprinted with Permission

Keywords:

PMID: 20112652

DOI: B2RR-AEEW

Operational Advantages of Enteral Resuscitation Following Burn Injury in Resource-Poor Environments: Palatability of Commercially Available Solutions

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Burmeister DM, Little JS, Gomez BI, Gurney J, Chao T, Cancio LC, Kramer GC, Dubick MA. 19(3). 76 - 81. (Journal Article)

Abstract

Background: In recent combat operations, 5% to 15% of casualties sustained thermal injuries, which require resource-intensive therapies. During prolonged field care or when caring for patients in a multidomain battlefield, delayed transport will complicate the challenges that already exist in the burn population. A lack of resources and/or vascular access in the future operating environment may benefit from alternative resuscitation strategies. The objectives of the current report are 1) to briefly review actual and potential advantages/caveats of resuscitation with enteral fluids and 2) to present new data on palatability of oral rehydration solutions. Methods: A review of the literature and published guidelines are reported. In addition, enlisted US military active duty Servicemembers (N = 40) were asked to taste/rank five different oral rehydration solutions on several parameters. Results and Conclusions: There are several operational advantages of using enteral fluids including ease of administration, no specialized equipment needed, and the use of lightweight sachets that are easily reconstituted/ administered. Limited clinical data along with slightly more extensive preclinical studies have prompted published guidelines for austere conditions to indicate consideration of enteral resuscitation for burns. Gatorade® and Drip-Drop® were the overall preferred rehydration solutions based on palatability, with the latter potentially more appropriate for resuscitation. Taken together, enteral resuscitation may confer several advantages over intravenous fluids for burn resuscitation under resource-poor scenarios. Future research needs to identify what solutions and volumes are optimal for use in thermally injured casualties.

Keywords: burns; prolonged field care; resuscitation; enteral fluids; rehydration solutions

PMID: 31539437

DOI: BS0H-005K

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Operational Consideration for Definitive Airway Management in the Austere Setting: A Case Report

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Morvan J, Cotte J, des Deserts MD, Worlton T, Menini W, Cathelinaud O, Pasquier P. 22(3). 90 - 93. (Journal Article)

Abstract

In modern and asymmetric conflicts, traumatic airway obstruction caused by penetrating injury to the face and neck anatomy is the second leading cause of preventable mortality. Definitive airway management in the emergency setting is most commonly accomplished by endotracheal intubation. When this fails or is not possible, a surgical airway, usually cricothyrotomy, is indicated. The clinical choice for establishing a definitive airway in the austere setting is impacted by operational factors such as a mass casualty incident or availability and type of casualty evacuation. This is a case report of a patient with severe cervicofacial injuries with imminent airway compromise in the setting of a mass casualty incident, without possibility of sedation and mechanical ventilation during his evacuation. The authors seek to highlight the considerations and lessons learned for emergency cricothyrotomy.

Keywords: Tactical Combat Casualty Care; cricothyrotomy; airway; mass casualties; medical evacuation

PMID: 35862841

DOI: WNNO-WIUG

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Operational K9s in the COVID-19 World

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Gray BO, St. George D, Cativo M, Tagore A, Ariyaprakai N, Palmer LE. 20(3). 103 - 108. (Journal Article)

Abstract

Severe acute respiratory syndrome coronavirus 2 (SARSCov- 2) is hypothesized to have originated from a spillover event from an animal reservoir. This has raised many questions, with an important one being whether the widely disseminated coronavirus disease 2019 (COVID-19) is transmissible to other animal species. SARS-CoV-2 is primarily transmitted person to person. K9-to-human transmission, although theoretically possible via fomites, is considered minimal, if at all, and there have been no reported cases of K9-to-human transmission. Human-to-K9 transmission, although rare, seems more likely; however, in only one case has a K9 been suspected to have displayed symptoms of COVID-19. Preparation, decontamination, hand hygiene, and distancing remain the key factors in reducing transmission of the virus. The information presented is applicable to personnel operating within the military conventional and Special Operation Forces as well as civilian Tactical Emergency Medical Services communities who may have the responsibility of supporting an operational K9.

Keywords: canine; transmission; disease; COVID-19; Coronavirus; pandemic; SARS-CoV-2

PMID: 32969012

DOI: W1F0-9CQG

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Operational Point-of-Care Ultrasound Review: Low-Cost Simulators and Resources for Advanced Prehospital Providers

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Ross EM, Deaton TG, Hurst N, Siefert J. 15(1). 71 - 78. (Journal Article)

Abstract

Prehospital ultrasound use is a relatively new skill set. The military noted the clear advantages of this skill set in the deployed setting and moved forward with teaching their advanced combat trauma medics skills to perform specific examinations. The training curriculum for Special Operations-level clinical ultrasound was created and adapted from training guidelines set forth by the American College of Emergency Physicians with a focus on the examinations relevant to the Special Operations community. Once providers leave the training environment, skill sustainment can be difficult. We discuss the relevant ultrasound exams for the prehospital setting. We address opportunities to improve point-of-care ultrasound skills through hands-on experience while in a fixed medical facility. Options for simulation-based training are discussed with descriptions for creating lowcost simulation models. Finally, a list of online resources is provided to review specific ultrasound examinations.

Keywords: point-of-care ultrasound; prehospital ultrasound; Special Operations-level clinical ultrasound; simulation

PMID: 25770801

DOI: VO9N-9D45

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Operational Stressors on Physical Performance in Special Operators and Countermeasures to Improve Performance: A Review of the Literature

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O'Hara R, Henry A, Serres J, Russell D, Locke R. 14(1). 67 - 78. (Journal Article)

Abstract

Objective: Military training in elite warfighters (e.g., U.S. Army Rangers, Navy SEALs, and U.S. Air Force Battlefield Airmen) is challenging and requires mental and physical capabilities that are akin to that of professional athletes. However, unlike professional athletes, the competitive arena is the battlefield, with winning and losing replaced by either life or death. The rigors of both physical training and prolonged deployments without adequate rest and food intake can compromise physical performance. Therefore, the primary purpose of this effort was to identify occupational stressors on the physical performance of Special Operators during training and while on missions. The secondary purpose was to suggest specific countermeasures to reduce or prevent significant decrements in physical performance and reduce musculoskeletal injuries. Methods: A search of the literature for 2000-2012 was performed using the Air Force Institute of Technology search engines (i.e., PubMed and ProQuest). There were 29 articles located and selected that specifically addressed the primary and secondary purposes of this literature review. The remaining 32 of 61 referenced articles were reviewed after initial review of the primary literature. Conclusions: This review indicates that operational stress (e.g., negative energy balance, high-energy expenditure, sleep deprivation, environmental extremes, heavy load carriage, etc.) associated with rigorous training and sustained operations negatively affects hormonal levels, lean muscle mass, and physical performance of Special Operators. The number of musculoskeletal injuries also increases as a result of these stressors. Commanders may use simple field tests to assess physical decrements before and during deployment to effectively plan for missions. Specific countermeasures for these known decrements are lacking in the scientific literature. Therefore, future researchers should focus on studying specific physical training programs, equipment, and other methods to minimize the effects of operational stress and reduce recovery time. These countermeasures could prevent mission mishaps and may save the lives of Special Operators during severe operational stress.

Keywords: Special Forces; Operators; physical training; military; injury prevention; human performance

PMID: 24604441

DOI: NIDG-U4UD

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Operational Stressors on Physical Performance in Special Operators and Countermeasures to Improve Performance: A Review of the Literature

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Hoedebecke KL, Brink W. 14(2). 84 - 85. (Letter)

Keywords:

PMID: 24952046

DOI: A9WE-5U3D

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Operator Training and TEMS Support: A Survey of Unit Leaders in Northern and Central California

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Young JB, Galante JM, Sena MJ. 13(3). 92 - 97. (Journal Article)

Abstract

Background: Members of Special Weapons and Tactics (SWAT) teams routinely work in high-risk tactical situations. Awareness of the benefit of Tactical Emergency Medical Support (TEMS) is increasing but not uniformly emphasized. Objectives: To characterize the current regional state of tactical medicine and identify potential barriers to more widespread implementation. Methods: A multiple-choice survey was administered to SWAT team leaders of 22 regional agencies in northern and central California. Questions focused on individual officer self-aid and buddy care training, the use and content of individual first aid kits (IFAKs), and the operational inclusion of a dedicated TEMS provider. Results: Respondents included city police (54%), local county sheriff (36%), state law enforcement (5%), and federal law enforcement (5%). Results showed that 100% of respondents thought it was "Very Important" for SWAT officers to understand the basics of self-aid and buddy care and to carry an IFAK, while only 71% of respondents indicated that team members actually carried an IFAK. In addition, 67% indicated that tourniquets were part of the IFAK, and 91% of surveyed team leaders thought it was "Very Important" for teams to have a trained medic available onsite at callouts or high-risk warrant searches. Also, 59% of teams used an organic TEMS element. Conclusion: The majority of SWAT team leaders recognize the benefit of basic Operator medical training and the importance of a TEMS program. Despite near 100% endorsement by unit-level leadership, a significant proportion of teams are lacking one of the key components including Operator IFAKs and/or tourniquets. Tactical team leaders, administrators, and providers should continue to promote adequate Operator training and equipment as well as formal TEMS support

Keywords: TEMS; tactical emergency medical support; SWAT; law enforcement; tactical medics

PMID: 24048997

DOI: CEYD-3287

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Opposition to Soviet Rule in Lithuania, 1945-1980

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Farr WD. 17(1). 133 - 133. (Book Review)

Abstract

Remeiki, Thomas. Opposition to Soviet Rule in Lithuania, 1945-1980. Chicago, IL: Institute of Lithuanian Studies Press; 1980. Hardback, 680 pages. ASIN: B0006COSGE

Keywords:

DOI:

Optimization of Simulation and Moulage in Military-Related Medical Training

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Petersen CD, Rush SC, Gallo I, Dalere B, Staak BP, Moore L, Kerr W, Chandler M, Smith W. 17(3). 74 - 80. (Journal Article)

Abstract

Preparation of Special Operations Forces (SOF) Medics as first responders for the battle space and austere environments is critical to optimize survival and quality of life for our Operators who may sustain serious and complex wounding patterns and illnesses. In the absence of constant clinical exposure for these medics, it is necessary to maximize all available training opportunities. The incorporation of scenario-based training helps weave together teamwork and the ability to practice treatment protocols in a tactical, controlled training environment to reproduce, to some degree, the environment in and stressors under which care will need to be delivered. We reviewed the evolution of training scenarios within one Pararescue (PJ) team since 2008 and codified various tools used to simulate physical findings and drive medical exercises as part of scenario-based training. We also surveyed other SOF Medic training resources.

Keywords: pararescue; training, scenario-based; SOF medics; simulation; moulage; training, military-related medical

PMID: 28910473

DOI: X6BB-TZ0C

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Optimizing Brain Health of United States Special Operations Forces

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Edlow BL, Gilmore N, Tromly SL, Deary KB, McKinney IR, Hu CG, Kelemen JN, Maffei C, Tseng CJ, Llorden GR, Healy BC, Masood M, Cali RJ, Baxter T, Yao EF, Belanger HG, Benjamini D, Basser PJ, Priemer DS, Kimberly WT, Polimeni JR, Rosen BR, Fischl B, Zurcher NR, Greve DN, Hooker JM, Huang SY, Caruso A, Smith GA, Szymanski TG, Perl DP, Dams-O'Connor K, Mac Donald CL, Bodien YG. 23(4). 47 - 56. (Journal Article)

Abstract

United States Special Operations Forces (SOF) personnel are frequently exposed to explosive blasts in training and combat. However, the effects of repeated blast exposure on the human brain are incompletely understood. Moreover, there is currently no diagnostic test to detect repeated blast brain injury (rBBI). In this "Human Performance Optimization" article, we discuss how the development and implementation of a reliable diagnostic test for rBBI has the potential to promote SOF brain health, combat readiness, and quality of life.

Keywords: blast overpressure; brain injury; Special Operations Forces; SOF; human performance optimization

PMID: 37851859

DOI: 99QW-K0HG

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Optimizing Musculoskeletal Performance Through Injury Prevention

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de la Motte SJ, Gribbin TC, Deuster PA. 17(4). 97 - 101. (Journal Article)

Abstract

Musculoskeletal injuries (MSK-Is) are ubiquitous throughout the Special Operations Forces (SOF) because of the physical demands of executing missions and carrying heavy loads. Preventing MSK-I has been a priority among SOF but is especially challenging because most MSK-Is are chronic or recurring. For many SOF, musculoskeletal issues and MSK pain are just part of doing their job. Ways to focus, target, and integrate injury prevention efforts across the continuum of training, active duty and SOF status are critical because MSK-Is are a significant barrier to human performance optimization. In this article, we describe how to incorporate these efforts at all levels of training. The need for improving valid, objective, fit-for-full-duty metrics after injury and sharing such information continuously with SOF is discussed. Last, strategies for engaging all levels to begin a culture shift away from the acceptance of MSK-I and pain as a way of life toward embracing MSK-I prevention as a regular part of everyday training are presented.

Keywords: musculoskeletal injury; injury prevention; pain; human performance optimization

PMID: 29256204

DOI: NG2D-CLQU

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Optimizing Nutrition For Performance At Altitude: A Literature Review

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Kechijian D. 11(2). 12 - 17. (Journal Article)

Abstract

Human beings are unique for their capacity to maximize their physical potential through various means. High altitude mountaineering is one such way that people challenge generally accepted notions about what is biologically and evolutionarily possible. While a 20,000+ ft summit may be uninhabitable for extended periods of time, enterprising individuals have demonstrated that even the most remote locations are accessible with sufficient physical effort and proper strategy. High altitude athletes, and the scientists who study them, generally focus their research and preparation on physiological parameters, with a particular emphasis on the cardiopulmonary system. While careful scrutiny in this area is certainly justified, the relationship between physiological output at altitude and nutrition is somewhat neglected in the literature. Many athletes, alpinists included, consider eating to be instinctive and mundane. However, very few activities at 30,000ft or even 15,000ft are intuitive. Furthermore, nutrition is one of the few variables mountain athletes can control in an otherwise unpredictable environment. Despite the intrinsic limitations and seemingly contradictory findings often associated with performance nutrition studies at high altitude, mountain athletes should adhere to certain dietary guidelines related to macronutrient composition, micronutrient supplementation, and hydration status.

Keywords:

PMID: 21455904

DOI: LXQK-O2RD

Optimizing Special Operations Forces Operator Talents and Mission Capabilities: Human Performance Optimization and Total Force Fitness Capability-Based Blueprint and Targeting System

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Chamberlin RA, Lunasco T, Deuster PA. 20(1). 113 - 119. (Journal Article)

Abstract

The Special Operations Forces (SOF) community represents an impressive degree of diversity in talents, culture, mission essential tasks, and occupational risk exposures across Service branches, their career fields, and units. Sustaining the capabilities of the SOF Operator across a career lifespan requires collaboratively addressing the current gap between medical readiness and mission readiness with support services and their SOF end users. Given the diverse needs of SOF Operators and their units, realigning performance and health (P&H) service delivery to meet their specific needs will require the adoption of an alternative business framework, operationally focused metrics, and retargeting to ensure SOF Operators are not just medically ready, but mission ready. With restructuring of P&H service delivery occurring across the Department of Defense at all levels to support the 2018 National Defense Strategy, there is a greater need for collaborative synchronization, targeting, and validating operational return on investment with SOF Operators and SOF stakeholders. Here, we present the Human Performance Optimization (HPO) and Total Force Fitness (TFF) Capabilities-Based Blueprint (CBB) and Targeting System as an initial step to realigning service delivery. We examine the use of CBB as a translational tool to bridge the divide between P&H services and SOF Operator communities, and demonstrate how the CBB has significant applications to help construct appropriate programming and program evaluation, align resources and needs, and provide culturally appropriate services that should sustainably preserve SOF Operators' unique capabilities and their mission.

Keywords:

PMID: 32203615

DOI: YOQW-CY47

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Optimizing Tactical Medical Performance: The Effect of Light Hue on Vision Testing

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Van Buren JP, Wake J, McLaughlin J, LaPorta AJ, Enzenauer RW, Calvano CJ. 18(2). 75 - 78. (Journal Article)

Abstract

Background: Red and blue are the historical tactical lighting hues of choice to ensure light discipline and to preserve dark adaptation. As yet, no scientifically ideal hue for use in Special Operations medicine has been identified. We propose red/green polychromatic light as a superior choice that preserves visual function for tactical medical tasks in austere settings. Methods: Thirty participants were enrolled in this institutional review board-approved study. Participants completed four vision tasks in low-light settings under various lighting conditions. The Pelli-Robson Near Contrast Sensitivity test (PR), tumbling E visual acuity test, Farnsworth D-15 color-vision test (FD15), and pseudoisochromatic plate (PiP) testing was performed under white, green, or red light illumination and also red/green and red/green/yellow lights. PR and tumbling E tests were performed using blue and blue/red lights. Results: The test results for each light were compared against a white-light standard. Contrast sensitivity as measured by PR testing showed no statistical difference when white light was used compared with red/green or red/green/yellow light, and the differences between red, green, blue, and blue/red all were statistically different from when white light was used. When measuring visual acuity, blue light was the only color for which there was a statistically significant decrease in visual acuity in comparison with white. There was no reduction in visual acuity with any other lights compared with white. Performance on FD15 testing with all single-hue and multihue lights was significantly worse than with white light for measuring color-vision perception. Color discrimination as measured by PiP testing showed red and green light was significantly worse than with white light, whereas test results when green/red and green/red/yellow lights were used were not statistically different from white. Conclusion: Red/Green/yellow and red/green were superior light sources and performance results only were worse than white light on FD15 testing.

Keywords: SOFMED; tactical lighting; visual acuity; contrast sensitivity; color vision

PMID: 29889960

DOI: VZ0Q-Y41S

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Optimizing Teamwork for Human Performance Teams: Strategies for Enhancing Team Effectiveness

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Park GH, Lunasco T, Chamberlin RA, Deuster PA. 20(4). 115 - 120. (Journal Article)

Abstract

Human performance teams (HPTs) are highly capable and complex teams comprised of medical and performance professionals dedicated to supporting health and sustaining mission capabilities of the Special Operations Forces (SOF) warfighter community. As resources continue to be devoted to recruiting, hiring, and organizing HPTs, there is an increased need to support team-based capabilities, or their ability to work collaboratively and cooperatively across boundaries. In this article, we draw on existing evidence-based approaches to supporting team-based competencies to present a set of strategies designed to address barriers to cross-boundary teaming, catalyze innovation and precision of human performance optimization (HPO) service delivery, and maximize the impact of HPTs on warfighter medical and mission readiness. We begin by offering a conceptual paradigm shift that broadens the lens through which HPO intervention opportunities exist. We then explore how to promote a common understanding of the needs, performance demands, and occupational risks, which should clarify shared goals and targets for service delivery. We also discuss a refined strategy for hiring and recruiting members of HPTs, and finally, we propose opportunities for cultivating communication and collaboration across and within the HPO spectrum. By elevating HPT-based capabilities, the SOF community should be able to amplify the investment made in these invaluable resources.

Keywords: human performance teams; human performance optimization; mission readiness; operational readiness; teaming; teamwork

PMID: 33320324

DOI: CIRE-T4D3

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Optimizing the Use of Limb Tourniquets in Tactical Combat Casualty Care: TCCC Guidelines Change 14-02

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Shackelford SA, Butler FK, Kragh JF, Stevens RA, Seery JM, Parsons DL, Montgomery HR, Kotwal RS, Mabry RL, Bailey JA. 15(1). 17 - 31. (Journal Article)

Abstract

Keywords: tourniquet; Tactical Combat Casualty Care guidelines; external hemorrhage control; shock; resuscitation; emergency medical services

PMID: 25770795

DOI: TDTK-RIN8

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Optimizing Warfighter Lethality Through Human Performance Education

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Deuster PA, Lunasco T, Messina LA. 19(2). 100 - 104. (Journal Article)

Abstract

Humans are the heart of our warfighting efforts and, as such, human performance must be optimized and sustained to maintain effective and successful SOF Operators over the long haul. How do we do this? Based on the July 2018 signing of a Joint Requirements Oversight Council Memo (JROC) making Total Force Fitness (TFF) a required framework for taking care of our military Servicemembers, we propose three solutions for further optimizing the performance of SOF. The proposed solutions are human performance optimization (HPO)/TFF capability-based blueprinting (CBB), HPO integrator profession (HPO-I), and HPO-centric education and training across the total force. These solutions would potentiate the Preservation of the Force and Family (POTFF) concept by improving the targeting of resources and support of Operator and unit operational readiness. These solutions, the knowledge, skills, abilities, and experiences in HPO from a holistic perspective and the opportunity to obtain college credits through the Uniformed Services University of the Health Sciences (USU) College of Allied Health Sciences (CAHS) are described here.

Keywords: capability-based blueprinting; human performance education; human performance integrator

PMID: 31201760

DOI: 8KWD-FDSP

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Oral Steroids for Dermatitis

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Fisher AD, Clarke J, Williams TK. 15(2). 8 - 11. (Journal Article)

Abstract

Contact/allergic dermatitis is frequently treated inappropriately with lower-than-recommended doses or inadequate duration of treatment with oral and intramuscular glucocorticoids. This article highlights a case of dermatitis in a Ranger Assessment and Selection Program student who was improperly treated over 2 weeks with oral steroids after being bit by Cimex lectularius, commonly known as bed bugs. The article also highlights the pitfalls of improper oral steroid dosing and provides reasoning for longer-duration oral steroid treatment.

Keywords: dermatitis; steroids; bed bugs; military; Cimex lectularis

PMID: 26125159

DOI: 6JHH-CIDT

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Osteoarthritis: Pathophysiology, Prevalence, Risk Factors, and Exercise for Reducing Pain and Disability

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Knapik JJ, Pope R, Orr R, Schram B. 18(3). 94 - 102. (Journal Article)

Abstract

Osteoarthritis (OA) is a disorder involving deterioration of articular cartilage and underlying bone and is associated with symptoms of pain and disability. The incidence of OA in the military increased over the period 2000 to 2012 and was the first or second leading cause of medical separations in this period. Risk factors for OA include older age, black race, genetics, higher body mass index, prior knee injury, and excessive joint loading. Animal studies indicate that moderate exercise can assist in maintaining normal cartilage, and individuals performing moderate levels of exercise show little evidence of OA. There is considerable evidence that among individuals who develop OA, moderate and regular exercise can reduce pain and disability. There is no firm evidence that any particular mode of exercise (e.g., aerobic training, resistance exercise) is more effective than another for reducing OA-related pain and disability, but limited research suggests that exercise should be lifelong and conducted at least three times per week for optimal effects.

Keywords: osteoarthritis; exercise; pain; disability

PMID: 30222846

DOI: V9VN-I71T

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Overview Of Combat Trauma In Military Working Dogs In Iraq And Afghanistan

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Baker JL, Truesdale CA, Schlanser JR. 09(2). 105 - 108. (Previously Published)

Previously published in The United States Army Medical Department Journal / The Unites States Army Veterinary Corps January - March 2009.

Keywords:

PMID: 19813524

DOI: X30F-D8EZ

Pain as a Barrier to Human Performance: A Focus on Function for Self-Reporting Pain With the Defense Veterans Pain Rating Scale

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Buckenmaier CC, Galloway KT, Polomano RC, Deuster PA. 16(2). 82 - 87. (Journal Article)

Abstract

The intense physical demands and dangerous operational environments common to Special Operations Forces (SOF) result in a variety of painful conditions, including musculoskeletal pain, headaches, and acute and chronic pain from combat injuries. Pain is a wellaccepted barrier to human performance. The Pain Management Task Force and the development of the Defense Veterans Pain Rating Scale (DVPRS) are discussed to provide a framework for changing the culture of pain management away from intensity of pain to interference with function and performance. The emergence of complementary and integrative pain management (CIM) practices is briefly reviewed as viable alternatives to the traditional reliance on opioids and other prescription medications. The SOF community can be the change agent for the DVPRS and CIM approaches to pain management, which will in the end serve to accelerate recovery and return SOF operators to duty faster and with an enhanced ability to perform with less pain.

Keywords:

PMID: 27450608

DOI: S27H-8173

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Pain Control and Point-of-Care Ultrasound: An Approach to Rib Fractures for the Austere Provider

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Snyder R, Brillhart DB. 23(3). 70 - 73. (Journal Article)

Abstract

Rib fractures are common injuries that cause significant discomfort and can lead to severe pulmonary complications. Rib injury most often results from high-velocity traumatic mechanisms, while rarely representing underlying metastatic disease or secondary injury due to pulmonary illness. Because most rib fractures are caused by obvious trauma, algorithms are focused on treatment rather than investigating the exact mechanism of rib fractures. Chest radiographs are often the initial imaging performed but have proven to be unreliable in identification of rib fracture. Computed tomography (CT) is a diagnostic option as it is more sensitive and specific than simple radiographs. However, both modalities are generally unavailable to Special Operations Forces (SOF) medical personnel working in austere locations. These medical providers could potentially diagnose and treat rib fractures in any environment using a standardized approach that includes clarity of mechanism, pain relief, and point-of-care ultrasound (POCUS). This case demonstrates an approach to the diagnosis and treatment of a rib fracture in a 47-year-old male who presented to a military treatment facility with unlocalized flank and back pain, but the methods employed have applicability to the austere provider working far from the resources of a medical center.

Keywords: POCUS; rib fracture; perineural block; prolotherapy; musculoskeletal ultrasound

PMID: 37253154

DOI: 5EY1-GPAM

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Pain Management In Current Combat Operations

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Black IH, McManus JG. 10(1). 75 - 79. (Previously Published)

Permission granted to republish. Reproduced from Prehospital Emergency Care 2009, Vol. 13, No. 2, Pages 223-227

Abstract

Pain management in the U.S. military, particularly in combat, shares many of the same principles found in civilian heathcare organizations and institutions. Pain is one of the most common reasons for which Soldiers seek medical attention in the combat environment, which mirrors the civilian experience. However, the combat environment exacerbates the typical challenges found in treating acute pain and has the additional obstacles of a lack of supplies and equipment, delayed or prolonged evacuation times and distances, devastating injuries, provider inexperience, and dangerous tactical situations. These factors contribute to the difficulty in controlling a Soldier's pain in combat. Furthermore, civilian healthcare providers have also learned the importance of practicing pain management principles in austere and tactical environments because of recent natural and man-made domestic disasters. Pain management research, education, and treatment strategies have been created to try to achieve adequate battlefield analgesia, and these lessons learned may aid civilian healthcare providers if the circumstances arise. This article presents a brief history and current overview of pain management for combat casualties on today's battlefield. Recent natural disasters and increased threats for terrorist acts have proven the need for civilian healthcare providers to be properly trained in pain management principles in an austere or tactical environment.

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DOI:

Pain Management In The Prehospital Environment

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McManus JG, Sallee DR. 08(1). 111 - 119. (Previously Published)

Previously published in Emerg Med Clin N Am 23 (2005) 415 - 431. Permission granted to republish in the JSOM.

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DOI:

Painful Scalp Nodules on an Active-Duty Sailor

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Schmidgal EC, Wright KT. 19(1). 128 - 129. (Journal Article)

Abstract

Lesions of the scalp can present a challenging differential diagnosis to the primary care provider, especially in remote military settings where specialist care is not immediately available. Scalp lesions can be painful and disfiguring, and cause duty limitations if they interfere with the donning of personal protective equipment such as helmets, hardhats, or firefighting gear. We present a case of dissecting scalp cellulitis on an active- duty Navy Sailor who was leaving on an extended underway period on his ship the next day.

Keywords:

PMID: 30859540

DOI: 9M37-YL61

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Parasitology Results From A Medcap In Africa

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Franklin B, Swierczewski B. 11(4). 48 - 51. (Journal Article)

Abstract

The Medical Civil Action Program (MEDCAP) is an important tool that is utilized to support the larger missions in all areas of current operations. In Ethiopia, MEDCAPs are one of many tools commanders use to earn the trust and confidence of the local population. There are many ways to implement a MEDCAP and this paper will highlight one such successful engagement. This mission was intended in increase the medical capacity of host nation (HN) medical personnel and increase HN confidence in their government to provide for essential services. The mission was broken into four phases similar to traditional MEDCAPs, but with a significant difference.

Keywords:

PMID: 22173596

DOI: R59Q-31GX

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Patella Fracture in US Servicemember in an Austere Location

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Schermerhorn SM, Auchincloss PJ, Kraft K, Nelson KJ, Pamplin JC. 18(1). 142 - 144. (Journal Article)

Abstract

Objective: Review the management of a patient with acute patella fracture supported by telemedical consultation. Clinical Context: Regionally Aligned Forces (RAF) supporting US Army Africa/Southern European Task Force (USARAF/ SETAF) in Africa Command area of responsibility. Care was provided by a Role I facility on the compound. Organic Expertise: Three 68W combat medics; one Special Operations Combat Medic (SOCM). Closest Medical Support: Organic battalion physician assistant (PA) located in the United States; USARAF PA located in a European country; French Role II located in nearby West African country; telemedical consults via e-mail, phone, or videoteleconsultation. Earliest Evacuation: Estimated at 12 to 24 hours with appropriate clearances.

Keywords: critical care; telemedicine; military personnel; emergency treatment; patient transfer; prolonged field care

PMID: 29533450

DOI: 9LEW-DBMR

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Pathophysiology and Treatment of Burns

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Payne R, Glassman E, Turman ML, Cancio LC. 22(2). 87 - 92. (Journal Article)

Abstract

Management of burn patients in the prehospital and prolonged field care environments presents complex patient care and logistical challenges. The authors discuss the pathophysiology, diagnostics, longitudinal concerns, and treatment involved in the care of such patients.

Keywords: burns; prehospital; critical care; military medicine; Special Operations Medicine

PMID: 35639900

DOI: BGGY-2LFL

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Pectoralis Major Injury During Basic Airborne Training

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McIntire S, Boujie L, Leasiolagi J. 16(3). 11 - 14. (Journal Article)

Abstract

Injuries involving rupture of the pectoralis major are relatively rare. When they do occur, it is mostly frequently in a young, athletic man. The most common cause is weight lifting that results in eccentric muscle contraction (muscle contraction against an overbearing force, leading to muscle lengthening)-specifically, the bench press. Other mechanisms for this injury include forceful abduction and external rotation of the arm. Injury can occur anywhere along the pectoralis major from its medial origin on the sternum and clavicle to its lateral tendinous insertion on the humerus. At the time of injury, patients may report feeling a tearing sensation or hearing a pop, with immediate onset of pain. Physical examination findings can include a deformed appearance of the chest, ecchymosis of the chest and upper arm, pain and weakness with arm adduction and internal rotation, or noticeable asymmetry of the anterior axilla with arm abduction. Magnetic resonance imaging is the imaging study of choice to aid diagnosis. In a young and active population, such as the Special Operations community, appropriate and timely diagnosis is important because surgical intervention often is recommended. This report presents the case of an active-duty Servicemember who sustained a pectoralis major injury while exiting an aircraft during the Basic Airborne Course.

Keywords: pectoralis major; rupture; avulsion; tear; airborne; parachute; static line

PMID: 27734436

DOI: NADD-RXLM

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Pediatric Trauma: Management From an Austere Prospective

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Gray J, Linklater DR, Johnston J, Donham B. 17(1). 46 - 53. (Journal Article)

Abstract

Pediatric trauma represents a notable proportion of casualties encountered by Combat medics, physician assistants, and physicians while in the deployed setting. Most of these resuscitation teams receive limited pediatric- specific training and suffer subsequent emotional stress due the perceived high-stakes nature of caring for gravely wounded children. Even when children survive long enough to arrive at combat support hospitals, there remain high risks for morbidity and mortality for many of them. There are numerous reports of the epidemiological characteristics of these pediatric patients, the common mechanisms of injury, the hospital lengths of stay, and calls for pediatric-specific equipment and specialist presence in-theatre. There is scant literature, however, on child-specific battlefield resuscitation and training for initial providers, and we believe that, with appropriately tailored pediatric resuscitation education and training strategies, there is some potential for a reduction in the morbidity and mortality associated with childhood combat injury.

Keywords: pediatrics; combat injury; battlefield resuscitation

PMID: 28285480

DOI: HLUN-WK20

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Performance Characteristics of Fluid Warming Technology in Austere Environments

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Blakeman T, Fowler J, Branson R, Petro M, Rodriquez D. 21(1). 18 - 24. (Journal Article)

Abstract

Resuscitation of the critically ill or injured is a significant and complex task in any setting, often complicated by environmental influences. Hypothermia is one of the components of the "Triad of Death" in trauma patients. Devices for warming IV fluids in the austere environment must be small and portable, able to operate on battery power, warm fluids to normal body temperature (37°C), and perform under various conditions, including at altitude. The authors evaluated four portable fluid warmers that are currently fielded or have potential for use in military environments.

Keywords: intravenous fluids; fluid warning; resuscitation; hypothermia

PMID: 33721301

DOI: 0C2R-LNPH

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Performance Enhancement Assessment and Coaching in US Army Special Operations: Rapidly Enhancing Performance Through Targeted, Tailored Feedback

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Barry DM, DeVries M. 19(4). 66 - 73. (Journal Article)

Abstract

Background: Performance enhancement coaching poses significant benefits to individuals and organizations, such as improved job satisfaction and goal achievement. Given their training and experience in assessment and feedback, operational psychologists assigned to Special Operations units are uniquely positioned to provide performance enhancement coaching tailored to Operators and enablers. A preliminary program evaluation was conducted of the Performance Enhancement Assessment and Coaching (PEAC) Program. Methods: A sample of 32 Operators and enablers assigned to a US Army Special Operations Forces (ARSOF) unit voluntarily participated in the PEAC Program and completed one 90-minute coaching session. Following their coaching session, Soldiers provided qualitative and quantitative feedback on their coaching experience. Results: Soldiers overwhelmingly agreed that the PEAC Program was worth their time and helpful towards achieving their goals. Results indicate the PEAC Program enhanced Soldiers' perceived self-awareness, self-efficacy, and job performance. Results also suggest performance enhancement coaching may improve pass rates on interpersonally demanding Special Operations courses. Conclusion: Performance enhancement coaching delivers considerable value for Special Operations personnel and their organizations in relatively minimal time. Operational psychologist coaches (OPCs) assigned to Special Operations units can leverage their assessment skills to provide targeted, tailored performance enhancement coaching and increase value to their organizations.

Keywords: coaching; performance enhancement; operational psychology; assessment

PMID: 31910474

DOI: 15MT-BBCI

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Performance Evaluation of the Solo-T and the Combat Application Tourniquet in a Perfused Cadaver Model

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Holinga GJ, Foor JS, Van Horn SL, McGuire JE. 22(3). 49 - 55. (Journal Article)

Abstract

Purpose: We evaluated a 10.2-cm-wide, minimally elastic, adhesive wrap-based tourniquet (Solo-T or ST) alongside a 3.8-cm-wide windlass-based tourniquet (Combat Application Tourniquet Generation 7, or CAT) to determine if the tension wrap-tightened ST could deliver hemorrhage control equivalent to the windlass-tightened CAT. Methods: A cadaver model was used to simulate lower-thigh femoral arterial hemorrhage at "normal" (146 ± 5mmHg) and "elevated" (471 ± 3mmHg) perfusion pressures (mean ± standard error). Three study participants used the ST and CAT to control hemorrhage during 48 timed trials. Arterial occlusion was established by Doppler ultrasound and tourniquet performance was quantified by under-tourniquet pressure cuffs. Results: Participants achieved 100% (24/24) occlusion success rates and reported similar ease of use for both tourniquets. Occlusion and application times (mean ± standard error) were similar (p > .05) for the ST and CAT under "normal" (occlusion, ST: 25 ± 2 seconds, CAT: 22 ± 2 seconds; application, ST: 27 ± 2 seconds, CAT: 26 ± 2 seconds) and "elevated" (occlusion, ST: 24 ± 7 seconds, CAT: 24 ± 7 seconds; application, ST: 25 ± 7 seconds, CAT: 25 ± 7 seconds) perfusion alike. The ST mean completion pressures (mean ± standard error) were > 40% lower than the CAT under both "normal" perfusion (ST: 110 ± 20mmHg; CAT: 210 ± 30mmHg; p = 0.009) and "elevated" perfusion (ST: 190 ± 50mmHg; CAT: 340 ± 30mmHg; p = 0.03). Conclusion: The adhesive wrap-based ST tourniquet delivered equivalent hemorrhage control performance at significantly lower completion pressures than the CAT.

Keywords: first aid; hemorrhage control; perfused cadaver; tourniquet; tourniquet pressure; trauma care

PMID: 35862840

DOI: 24E1-MJ5S

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Performance Psychology as a Key Component of Human Performance Optimization

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Herzog TP, Deuster PA. 14(4). 99 - 105. (Journal Article)

Abstract

The degree of psychological fitness will ultimately impact mission outcomes, so approaches to enhancing it are critical. Performance psychology is one important aspect of psychological fitness that fits into the holistic model of human performance optimization. This article delves into one component of performance psychology: how mental skill training can be applied to improve performance on mission-related tasks. Mental skills training provides added internal resources to help meet the extraordinary external demands that Special Operations Forces personnel can face. Relevance in terms of the demand-resource model and the positive psychology concept of flow are explained. The application of two specific mental skills-executing a goal-setting process and using mental imagery to rehearse technical, tactical, and strategic tasks-will be discussed by using the example of how to enhance performance when entering and clearing rooms.

Keywords: human performance optimization; psychological fitness; performance psychology

PMID: 25399377

DOI: ZQ7B-8ZJE

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Pertussis

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Burnett MW. 13(4). 113 - 114. (Journal Article)

Abstract

Background: Pertussis, a disease that has been well described since the Middle Ages, has a worldwide distribution and can infect all ages. It is caused by the gram-negative, pleomorphic bacillus Bordetella pertussis, which is transmitted from human to human via aerosolized droplets at close range. Descriptions such as the one-hundred day cough in Chinese and whooping cough in English, describe the severity of this disease seen in both the developed and the developing world.

Keywords:

PMID: 24227570

DOI: NB14-JH4H

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Pharmacokinetics of Tranexamic Acid via Intravenous, Intraosseous, and Intramuscular Routes in a Porcine (Sus scrofa) Hemorrhagic Shock Model

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DeSoucy ES, Davidson AJ, Hoareau GL, Simon MA, Tibbits EM, Ferencz SE, Grayson JK, Galante JM. 19(4). 80 - 84. (Journal Article)

Abstract

Background: Intravenous (IV) tranexamic acid (TXA) is an adjunct for resuscitation in hemorrhagic shock; however, IV access in these patients may be difficult or impossible. Intraosseous (IO) or intramuscular (IM) administration could be quickly performed with minimal training. We investigated the pharmacokinetics of TXA via IV, IO, and IM routes in a swine model of controlled hemorrhagic shock. Methods: Fifteen swine were anesthetized and bled of 35% of their blood volume before randomization to a single 1g/10mL dose of IV, IO, or IM TXA. Serial serum samples were obtained after TXA administration. These were analyzed with high-pressure liquid chromatography-mass spectrometry to determine drug concentration at each time point and define the pharmacokinetics of each route. Results: There were no significant differences in baseline hemodynamics or blood loss between the groups. Peak concentration (Cmax) was significantly higher in IV and IO routes compared with IM (p = .005); however, the half-life of TXA was similar across all routes (p = .275). Conclusion: TXA administration via IO and IM routes during hemorrhagic shock achieves serum concentrations necessary for inhibition of fibrinolysis and may be practical alternatives when IV access is not available.

Keywords: shock; hemorrhagic; tranexamic acid; intravenous access

PMID: 31910476

DOI: COGQ-2CY1

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Phosphorus Burn Management with Multimodal Analgesia

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Saint-jean L, Corcostegui S, Galant J, Derkenne C. 23(3). 82 - 84. (Case Reports)

Abstract

We report the case of a patient suffering from a chemical burn caused by white phosphorus, for whom initial management required decontamination using multimodal analgesia. This case report should be familiar to other military emergency physicians and Tactical Emergency Medical Support for two reasons: 1) A phosphorus burn occurs from a chemical agent rarely encountered, with minimal research available in the medical literature, despite the use of this weapon in the recent Ukrainian conflict, and 2) We discuss the use of multimodal analgesia, combining loco-regional anesthesia (LRA) and an intranasal pathway, which can be used in a remote and austere environment.

Keywords: phosphorus burn; analgesia; intranasal

PMID: 37302143

DOI: N0QE-PCTE

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Physical Therapy Treatment Of Chronic Neck Pain A Discussion And Case Study: Using Dry Needling And Battlefield Acupuncture

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Guthrie RM, Chorba R. 16(1). 1 - 5. (Case Reports)

Abstract

Purpose: Chronic mechanical neck pain can have a complex clinical presentation and is often difficult to treat. This case study illustrates a successful physical therapy treatment approach using dry needling and auricular acupuncture techniques. Case Report: A 51-year-old active-duty, male US Marine was treated by a physical therapist in a direct-access military clinic for chronic neck pain poorly responsive to previous physical therapy, pharmacologic, and surgical interventions. Needling techniques were combined with standard physical therapy interventions to address the comprehensive needs of the patient. Within five treatments, the patient reported reduced pain levels from 8-9/10 to 0-2/10, improved sleep quality, and increased function with daily activities. Over several months, the patient reduced multiple medication use by greater than 85%. The effects of treatment were lasting, and the patient accomplished a successful transition to an independent maintenance program. Conclusion: Needling techniques have the potential to expedite favorable physical therapy outcomes for active-duty service members suffering from chronic mechanical and degenerative neck pain. The dramatic improvements observed in this case warrant additional exploration of treatment efficacy and delineation of best practices in the delivery of these techniques.

Keywords: pain, neck; physical therapy; dry needling; acupuncture; acupuncture, battlefield; pain management

PMID: 27045487

DOI: XC27-JWT2

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Physiological And Psychological Characteristics Of Successful Combat Controller Trainees

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Walker TB, Lennemann LM, McGregor JN, Mauzy C, Zupan MF. 11(2). 37 - 47. (Journal Article)

Abstract

Objectives: The United States Air Force (USAF) Combat Controller (CCT) training pipeline is extremely arduous and historically has an attrition rate of 70-80%. The primary objective of this study was to identify the physiological, psychological, or demographical characteristics associated with successful progression through the CCT pipeline program. Methods: A battery of physiological measurements, biographical information, and psychological tests were used to determine the profile of a successful CCT trainee. These measures were chosen on the basis of being standard physical fitness parameters, CCT-specific physical attribute indicators or validated psychological surveys. A multiple of physical tests served as measurements for cardiovascular endurance (VO2max and running economy), "anaerobic" capacity (Wingate power and loaded anaerobic endurance treadmill tests), body composition skinfolds measurements, power (Wingate and vertical jump), and reaction time (Makoto eye-hand test.) Each test was conducted using a standardized protocol. Psychological characteristics were explored through use of the International Personality Item Pool (IPIP-NEO) and the Mental Toughness Questionnaire 48 (MTQ 48). Results: Our findings revealed the following mean characteristics of 109 CCTs who completed Phase I of the pipeline and achieved their 3-level rating: 23 years old, 1.8m tall, 81kg, 12% body fat, VO2max of 59ml/kg/min, vertical jump of 62cm, able to generate 11.4W/kg peak power and 9.3W/Kg mean power during Wingate tests, overall mental toughness rating of 8 (out of 10) with high levels of extraversion and conscientiousness and low levels of neuroticism. The most popular competitive sport played in high school was football, followed by track, wrestling, and baseball. Conclusions: The results of the investigation confirm that CCT trainees who have achieved a 3-level rating possess much higher than average levels of aerobic and anaerobic fitness, power, mental toughness, extraversion and conscientiousness. They possess lower than average levels of neuroticism and openness to experience. These results may prove useful in refining the selection criteria and in designing training for CCT trainees.

Keywords:

PMID: 21455909

DOI: 7ZRU-MW0D

Physiological and Psychological Stressors Affecting Performance, Health, and Recovery in Special Forces Operators: Challenges and Solutions. A Scoping Review

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O'Hara R, Sussman LR, Tiede JM, Sheehan R, Keizer B. 22(2). 139 - 148. (Journal Article)

Abstract

Introduction: Special Operations Forces (SOF) Operators (SOs) are exposed to high levels of physiological and cognitive stressors early in their career, starting with the rigors of training, combined with years of recurring deployments. Over time, these stressors may degrade SOs' performance, health, and recovery. Objectives: (1) To evaluate sources identifying and describing physiological and psychological stressors affecting performance, health, and recovery in SOs, and (2) to explore interventions and phenomena of interest, such as the biological mechanisms of overtraining syndrome (OTS). Methods: This review followed the recommendations and methodology of the Joanna Briggs Institute and the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) guidelines. A database search from December 1993 to December 2021 was performed in PubMed, the Cochrane Library, and the Defense Technical Information Center (DTIC). Potential articles were identified using search terms from their titles, abstracts, and full texts. Articles effectively addressing the review questions and objectives were eligible. Results: After 19 articles were excluded for not meeting established inclusion criteria, a total of 92 full-text articles were assessed for eligibility. After the final analysis, 72 articles were included. Conclusions: Allostatic imbalance may occur when supra-maximal demands are prolonged and repeated. Without adequate recovery, health and performance may decline, leading to nonfunctional overreaching (NFO) and OTS, resulting in harmful psychological and hormonal disruptions. The recurring demands placed on SOs may result in a chronically high burden of physical and mental stress known as allostatic overload. Future investigation, especially in the purview of longitudinal implementation, health, and recovery monitoring, is necessary for the health and readiness of the SOF population.

Keywords: humans; cognition; overtraining syndrome; allostatic load; military personnel; sports

PMID: 35649409

DOI: 904J-601A

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Physiological Response in a Specialist Paramedic During Helicopter Winch Rescue in Remote Wilderness and Extreme Heat

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Meadley BN, Horton E, Perraton L, Smith K, Bowles K. 21(3). 41 - 44. (Journal Article)

Abstract

Tasks performed by search and rescue (SAR) teams can be physically demanding. SAR organizations are faced with mounting challenges due to increased participation in recreation in remote locations and more frequent extreme weather. We sought to describe the physiological response and the methods for data collection during helicopter emergency medical service (HEMS) winch rescue from remote wilderness in extreme heat. A flight paramedic sustained 81% of maximum heart rate (VO₂ ~44.8 mL/kg/min) for ~10 minutes at a rate of perceived exertion of 19/20, and a relative heart rate of 77.5% in 37.1°C. Maximal acceptable work time for this task was calculated at 37.7 minutes. Our data collection methods were feasible, and the data captured demonstrated the level of physiological strain that may be encountered during HEMS SAR operations in austere environments and hot climate. It is essential that SAR teams that perform physically demanding tasks use a scientific approach to adapt and evolve. This is necessary to ensure personnel are appropriately selected, trained, and equipped to respond in an era of increasing demand and extreme environments.

Keywords: search and rescue; helicopter emergency medical services; paramedic; eerobic capacity; human performance

PMID: 34529803

DOI: U2QG-2FVD

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Picture This: Management of Canine Pyotraumatic Dermatitis (a.k.a., Hot Spot)

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Palmer LE. 18(2). 105 - 109. (Journal Article)

Abstract

Pyotraumatic dermatitis (a.k.a., hot spot) is a rapidly developing, superficial, moist, exudative dermatitis commonly induced by self-inflicted trauma. Although not acutely life threatening, these lesions are extremely pruritic and distracting and significantly interfere with the canine's operational effectiveness and ability to stay on task. The review discusses a case, including clinical presentation, diagnosis, treatment, and prognosis.

Keywords: Operational K9s; dog keepers; pyotraumatic dermatitis; hot spot; acute moist dermatitis

PMID: 29889965

DOI: XCG6-N1DJ

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Pilot Ejection, Parachute, and Helicopter Crash Injuries

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McBratney CM, Rush SC, Kharod C. 14(4). 92 - 94. (Journal Article)

Abstract

USAF Pararescuemen (PJs) respond to downed aircrew as a fundamental mission for personnel recovery (PR), one of the Air Force's core functions. In addition to responding to these in Military settings, the PJs from the 212 Rescue Squadron routinely respond to small plane crashes in remote regions of Alaska. While there is a paucity of information on the latter, there have been articles detailing injuries sustained from helicopter crashes and while ejecting or parachuting from fixed wing aircraft. The following represents a new chapter added to the Pararescue Medical Operations Handbook, Sixth Edition (2014, editors Matt Wolf, MD, and Stephen Rush, MD, in press). It was designed to be a quick reference for PJs and their Special Operations flight surgeons to help with understanding of mechanism of injury with regard to pilot ejection, parachute, and helicopter accident injuries. It outlines the nature of the injuries sustained in such mishaps and provides an epidemiologic framework from which to approach the problem.

Keywords: Pararescuemen; helicopters; parachutes; fixed wing aircraft; injury prevention

PMID: 25399374

DOI: KN2Q-5G43

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Planning And Operational Consideration For Units Utilizing Military Working Dogs

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Royal J, Taylor JF. 09(1). 5 - 9. (Journal Article)

Abstract

Military working dogs are rapidly becoming integral to military operations. While they bring many valuable capabilities to the battlefield, it is important that Special Operations leaders consider canine team capabilities and requirements when planning missions. Careful logistical and operational planning can optimize the health, performance, and readiness of the working dog while protecting the safety and well-being of the team members working with them. We also offer recommendations for medical treatment of dog bites.

Keywords:

PMID: 19813342

DOI: B9WW-5CG8

Planning for Success: Desired Characteristics of Special Operations Surgeons, A Pilot Study

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Campbell BH, Alderman SM. 12(3). 8 - 13. (Journal Article)

Abstract

Background: Selection criteria for Special Operations Forces (SOF) physicians are often unclear to potential candidates without prior SOF experience. To date, no published career resource exists to guide the careers of physicians interested in becoming a SOF surgeon. Using a survey tool, desirable characteristics and personal attributes were identified that can be used to inform candidate career decisions and better prepare them for a future position in Special Operations. Methods: A descriptive, cross-sectional survey instrument was developed and distributed to current Army SOF Command Surgeons for further distribution to subordinate surgeons. Results were analyzed as a cohort and by subordinate command. Results: Respondents consisted of current SOF Surgeons. Uniformly, the individual characteristics most strongly desired are professionalism, being a team player, and leadership. Possessing or obtaining Airborne and Flight Surgeon qualifications prior to consideration for a surgeon position was highly desired. Residency training within Family Medicine or Emergency Medicine constituted the vast majority of specialty preference. Conclusions: Understanding which characteristics and attributes are desirable to current surgeons and commanders can aid physicians interested in SOF surgeon positions. Using this study and future studies can guide career planning and foster the selection of ideally trained physicians who will operate at the tip of the spear. The views expressed are those of the author(s) and do not reflect the official policy of the Department of the Army, the Department of Defense or the U.S. Government.

Keywords:

PMID: 23032314

DOI: YEF6-XR1D

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Pleuritic Chest Pain: This Can't Be Happening!

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Farrell R, Dare C, Hampton K. 17(4). 127 - 127. (Journal Article)

Keywords:

PMID: 29256210

DOI: IZCK-S7ID

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Pneumonitis and Respiratory Failure Secondary to Civilian Exposure to a Smoke Bomb in a Partially Enclosed Space

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Murray BP, Ralston SA, Dunkley CA, Carpenter JE, Geller RJ, Kazzi Z. 18(4). 24 - 26. (Case Reports)

Abstract

Smoke grenades are used during drills, police and military exercises, and crowd control. We report on a 25-year-old man who was exposed to a Superior 3C smoke bomb. He was initially stable but developed respiratory distress after 3 days and ultimately developed pulmonary fibrosis with marked loss in pulmonary function. The Superior 3C smoke bomb is similar in composition to the British Military's L83A1/2 and L132A1 and the US M18 smoke grenades, all commonly used as multipurpose smoke-producing devices for combat and training. They are primarily composed of zinc oxide and hexachlorethane, the combustion of which produces zinc chloride. These devices are safe when used properly in open air but can cause significant morbidity in an enclosed space. This case emphasizes the potential hazards of using smoke bombs even in semienclosed spaces and the potential delay in the development of significant pulmonary complications.

Keywords:

PMID: 30566719

DOI: UD9X-AUXA

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Point Prevalence Survey for Tick-Borne Pathogens in Military Working Dogs, Shelter Animals, and Pet Populations in Northern Colombia

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Mccown M, Alleman A, Sayler KA, Chandrashekar R, Thatcher B, Tyrrell P, Stillman B, Beall M, Barbet AF. 14(4). 81 - 85. (Journal Article)

Abstract

Background: Based on the high tick-borne pathogen results from a 2011 surveillance study in three Colombian cities, an in-depth point prevalence survey was conducted to determine the seroprevalence of tick-borne pathogens at a specific point in time in 70 working dogs, 101 shelter dogs, and 47 client-owned dogs in Barranquilla, Colombia. Results: Of the 218 serum samples, 163 (74%) were positive for Ehrlichia canis and 116 (53%) for Anaplasma platys. Exposure to tick-borne pathogens was highest in shelter and working dogs where more than 90% of the samples were seropositive or positive on polymerase chain reaction for one or more organisms as compared to 51% in client-owned animals. Conclusion: Surveillance for exposure to tickborne pathogens provides vital information necessary to protect and conserve the health of local humans and animals, deployed military service members, and working dogs in various parts of the world. This study and resultant data demonstrate the value of following a broadbased surveillance study with a more specific, focused analysis in an area of concern. This area's high levels of exposure warrant emphasis by medical planners and advisors on precautionary measures for military dogs, Special Operations Forces personnel, and the local public.

Keywords: tick-borne pathogens; point prevalence; surveillance; US Military SOF; military working dogs; Colombia

PMID: 25399372

DOI: 1VBK-JXC7

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Point-of-Care Coagulation Testing for Trauma Patients in a Military Setting: A Prospective Study

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Cotte J, d'Aranda E, Chauvin V, Kaiser E, Meaudre E. 13(4). 59 - 62. (Journal Article)

Abstract

Background and Objective: Almost 50% of military trauma patients who need transfusions develop a coagulopathy. Immediately treating this coagulopathy improves the patient's prognosis. Field military hospitals often lack laboratory devices needed to diagnose a clinically significant coagulopathy and have limited blood product resources such as plasma. Point-of-care (POC) devices for the measurement of prothrombin time (PT) are available and have been tested in a variety of situations, including hemorrhagic surgery. The authors compared a POC device, the Coaguchek XS Pro (F. Hoffmann-La Roche Ltd., Basel, Switzerland), with laboratory measures for determining the PT in military trauma patients in a field hospital. Methods: This single-center prospective study was designed to compare POC coagulation monitoring with traditional laboratory testing. It was conducted at the French military hospital located at Kabul International Airport. All patients with trauma injuries resulting from war operations were included. A blood sample was drawn immediately on admission. PT was determined both in the laboratory and with use of the Coaguchek XS pro. Results: Forty patients with war trauma were enrolled during a 3-month period. The authors recorded 69 measurements. The two methods were correlated with a correlation coefficient of 0.78 (ρ < .001). The Bland- Altman plot showed a mean difference of 5.8% (95% confidence interval -14.9% to 26.6%). Using a PT cutoff of 60%, POC had a sensitivity of 77.1% and a specificity of 94.1%. Results from POC PT measurement were available within a mean of 25.8 minutes before laboratory measures. Conclusions: The Coaguchek XS Pro device can be used successfully in an austere environment without compromising its performance.

Keywords: point-of-care; coagulation; prothrombin time; military trauma

PMID: 24227563

DOI: 6OJ3-UGS5

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Portable Ultrasound Empowers Special Forces Medics

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Crisp JD. 10(1). 59 - 62. (Journal Article)

Keywords:

PMID: 20306417

DOI: 4BZD-1GNH

Portuguese 2nd Parachute Battalion

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Ferreira B. 16(4). 122 - 124. (Journal Article)

Keywords:

PMID: 28088833

DOI: UKLU-Y625

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Postural Stability of Special Warfare Combatant-Craft Crewmen With Tactical Gear

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Morgan PM, Williams VJ, Sell TC. 16(4). 27 - 31. (Journal Article)

Abstract

Background: The US Naval Special Warfare's Special Warfare Combatant-Craft Crewmen (SWCC) operate on small, high-speed boats while wearing tactical gear (TG). The TG increases mission safety and success but may affect postural stability, potentially increasing risk for musculoskeletal injury. Therefore, the purpose of this study was to examine the effects of TG on postural stability during the Sensory Organization Test (SOT). Methods: Eight SWCC performed the SOT on NeuroCom's Balance Manager with TG and with no tactical gear (NTG). The status of gear was performed in randomized order. The SOT consisted of six different conditions that challenge sensory systems responsible for postural stability. Each condition was performed for three trials, resulting in a total of 18 trials. Results: Overall performance, each individual condition, and sensory system analysis (somatosensory, visual, vestibular, preference) were scored. Data were not normally distributed therefore Wilcoxon signed-rank tests were used to compare each variable (ρ = .05). No significant differences were found between NTG and TG tests. No statistically significant differences were detected under the two TG conditions. This may be due to low statistical power, or potentially insensitivity of the assessment. Also, the amount and distribution of weight worn during the TG conditions, and the SWCC's unstable occupational platform, may have contributed to the findings. The data from this sample will be used in future research to better understand how TG affects SWCC. Conclusion: The data show that the addition of TG used in our study did not affect postural stability of SWCC during the SOT. Although no statistically significant differences were observed, there are clinical reasons for continued study of the effect of increased load on postural stability, using more challenging conditions, greater surface perturbations, dynamic tasks, and heavier loads.

Keywords: postural stability; tactical gear; sensory organization test; Navy; SWCC

PMID: 28088814

DOI: ALNS-5X82

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Potential of Visual Sensory Screening, Diagnostic Evaluation, and Training for Treatment of Postconcussive Symptoms and Performance Enhancement for Special Forces Qualified Personnel

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Suttles ST. 15(2). 54 - 63. (Journal Article)

Abstract

Mild traumatic brain injury (mTBI) or concussive injuries remain a challenge for both athletes and clinicians, given high incidence rates and heterogeneous clinical trajectories. Moreover, exposure to blast in combat is compounded by chronic, frequent exposure to a variety of subclinical impacts and overpressure, in some cases annually over many years. Subsequent injuries are often more severe than the original and lead to higher incidence of chronic symptoms in combat units, particularly Special Operations Forces (SOF), which is compounded by a propensity to underreport or avoid Army medical systems altogether. The unique nature and psychological makeup of SOF Soldiers suggest that new guidelines for progressive return-to-activity and return-to-duty decision-making within the traditional medical setting may not be generalizable to this population. Further, the traditional criteria for return to duty and return to play in sport may be insensitive to persistent deficits, resulting in premature return. There is presidential and Department of Defense mandates for continued research in the areas of diagnostics, treatment, and assessments for return to duty. With recent shift toward understanding clinical trajectories, particularly visual and vestibular trajectories, promising new technology from the field of sports vision may prove useful toward that endeavor. Since the advent of performance programs within SOF units, these Soldiers build trust with performance personnel, which include rehabilitative personnel, through consistent and regular shared experience. Implementation of comprehensive vision and visual performance screening in conjunction with the study of sports vision technology within the performance setting, in conjunction with unit medical personnel, may yield important findings for diagnosis and treatment of mTBI; to include the chronically symptomatic postconcussive Soldiers. Last, with a wealth of literature supporting visual skills training for athlete populations, to include competitive shooters, the implementation of visual skills training will likely be a useful adjunct to performance training of SOF personnel.

Keywords: traumatic brain injury, mild; concussion; sensory station; rehabilitation; visual skills; return to duty; Special Operations; human performance

PMID: 26125165

DOI: Q0UK-S9SI

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POW and Detainee Operations: Lessons Unlearned

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Caci JB. 15(2). 139 - 143. (Journal Article)

Abstract

Throughout the history of modern warfare, tales of atrocities have repeatedly surfaced that depict active and passive aggression toward prisoners of war (POWs). Yet, with each conflict, new tales are born and an undeniable reality of warfare inflicts fresh scars for aggressors to bear. It is understandable, based on human nature and the goals of war, that a government (or its representatives) will feel malice toward enemy prisoners captured during a conflict. It is unquestionably a challenge to overcome that human nature, despite the statutes that outline lawful treatment of POWs. While most aspects of warfare have been revolutionized throughout history, the means by which a military deals with its POWs remains somewhat mired in the reticence of leaders to acknowledge that it will factor into every conflict-that it will, in fact, become a source of controversy as long as it is handled as an afterthought. As shown in accounts dating back to the Revolutionary War, the law can only influence human nature to a point, especially when resources are limited, ignorance is a reality, and no one is watching.

Keywords: prisoners of war; history of warfare; POW camps

PMID: 26125179

DOI: UQQQ-LLK1

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Powassan Virus: Centers for Disease Control and Prevention

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Anonymous A. 19(4). 108 - 108. (Journal Article)

Keywords:

PMID: 31910483

DOI: 4GS0-FVTC

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Power To The People

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Schauer SG, Cunningham CW, DeLorenzo RA. 16(1). 69 - 71. (Editorial)

Keywords:

PMID: 27045499

DOI: B1XI-SGJ1

Practical Recommendations for Prehospital Selection of Pediatric Pelvic Circumferential Compression Devices

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Reyes J, Kelly J, Badaki-Makun O, Anders J. 23(2). 40 - 43. (Journal Article)

Abstract

Introduction: Although the instances of Special Operations Forces (SOF) medical providers treating pediatric pelvic fractures are rare, such fractures are notable injuries in terror attacks and are at high risk for morbidity and mortality for the patient as well as stress for the provider. Presently, guidelines for pediatric-sized pelvic stabilization device application are limited to measured pelvic circumference. This study aims to inform more practical sizing guidelines. Methods: Subjects aged 1 year to 14 years were enrolled. Subject height, weight, pelvic circumference, and fit on the Broselow Pediatric Emergency Tape® (Armstrong Medical Industries), fit with the Pediatric PelvicBinder® (PelvicBinder), and fit with the small SAM Pelvic Sling® (SAM® Medical) were collected. The primary outcome was the proportion of subjects fitting each device. Results: Sixty-five subjects were recruited; median age was 5 years (interquartile range, 1-8 years); 40 (62%) subjects were male. Ninety-one percent of subjects fit within the scale of the Broselow Tape (height <143-cm). One hundred percent of subjects with a height <143-cm had an appropriate fit with the Pediatric PelvicBinder (95% confidence level [CI], 91.8-100%), while 91.7% of subjects with a height >143-cm fit the SAM Pelvic Sling (95%CI, 61.5-99.8%). Conclusions: Providers should attempt to fit the Pediatric PelvicBinder for children >1 year old with suspected unstable pelvic fracture who fall on the Broselow Tape (<143-cm). The small SAM Pelvic Sling should be used for those taller than 143-cm.

Keywords: pediatrics; pelvic fractures; pelvic stabilizer; terrorist attacks

PMID: 37083895

DOI: FAJK-XG81

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Precision Performance Nutrition What Can Special Operations Forces Communities Expect?

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Conkright W, Deuster PA. 19(1). 107 - 112. (Journal Article)

Abstract

Modern-day warfare and operational tempo require Special Operations Forces (SOF) personnel to be ready and able to perform optimally on the battlefield at all times. To do this, US Special Operations Command has invested in high-performance training centers and human performance staff, including performance dietitians. Performance dietitians are critical, because it is widely recognized that nutrition affects all aspects of health and performance, particularly for the SOF Operator. These aspects include everything from physical and sensory to psychosocial and cognitive factors, as well as environmental exposures and genetic predispositions. The impact of nutrition on performance has been well established, with specific recommendations and position stands on fueling for athletics from multiple international organizations. However, sports nutrition guidelines are based on outcomes from sample means rather than individual changes in performance. Precision performance nutrition solutions must include a systems-based approach and consider the individuality of the Operator along with their interactions with their environment. The purpose of this article is to summarize what is known about performance nutrition and outline what can be done to move toward personalized precision nutrition. We discuss pitfalls and challenges with regard to mission-specific goals, optimization versus adaptation, and longitudinal tracking; and present our view of the future.

Keywords: adaptation; fueling; longitudinal tracking; metabolomics; microbiome; military; nutrigenomics; personalized nutrition

PMID: 30859537

DOI: ECZV-HCCY

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Pre-Deployment Training Recommendations for Special Forces Medical Sergeants Based on Recent Operation Enduring Freedom Experiences

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Hughes JR, Hughes T. 09(4). 16 - 19. (Journal Article)

Abstract

Retrospective analysis of patient records from two 1st Battalion, 7th Special Forces Group combat rotations in Operation Enduring Freedom reveals a high volume of medical activity over a wide range of medical issues managed by Special Forces Medical Sergeants (MOS 18Ds). The initial training curriculum for 18Ds has been modified to provide graduating 18Ds with a refresher course and updated credentialing before reporting to their first unit. However, due to the high operational tempo, subsequent biannual refresher training has proven difficult for at least one Special Forces unit. Units must plan ahead between deployments to balance medic recredentialing with unit pre-mission training and individual non-medical training.

Keywords:

PMID: 20112643

DOI: HMD2-9TNB

Predicting When to Administer Blood Products During Tactical Aeromedical Evacuation: Evaluation of a US Model

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Le Clerc S, McLennan J, Kyle A, Mann-Salinas EA, Russell RJ. 14(4). 48 - 52. (Journal Article)

Abstract

The administration of blood products to battlefield casualties in the prehospital arena has contributed significantly to the survival of critically injured patients in Afghanistan over the past 5 years. Given as part of an established military "chain of survival," blood product administration has represented a step-change improvement in capability for both UK and US tactical aeromedical evacuation (TACEVAC) platforms. The authors explore current concepts, analyzing and exploring themes associated with early use of blood products (fresh frozen plasma [FFP] and red blood cells [RBCs]), and they compare and evaluate a US/UK study analyzing the differences and recommending future strategy. The subject matter expert (SME) consensus guidelines developed for use by the US Army Air Ambulance units commonly known as call sign "DUSTOFF." These TACEVAC assets in Afghanistan were validated in this retrospective study. Using statistical analysis, the authors were able to ascertain that the current DUSTOFF SME-derived guidelines offer a sensitivity of 63.04% and a specificity of 89.07%. By adjusting the indicators to include a single above-ankle amputation with a systolic blood pressure (SBP) less than 90mmHg and pulse greater than 120/min, the sensitivity could be increased to 67.39% while maintaining the specificity at 89.07%. In our data set, a single amputation above the ankle, in combination with an SBP of less than 100mmHg and a pulse of greater than 120/min, increased the sensitivity to 76% but with a slight drop in specificity to 86%. Further study of military prehospital casualty data is under way to identify additional physiological parameters that will allow simple scoring tools in the remote setting to guide the administration of prehospital blood products.

Keywords: trauma; prehospital; blood products; military; scoring tool; tactical; aeromedical evacuation

PMID: 25399368

DOI: HSMR-SMBF

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Prehospital Administration of Antibiotic Prophylaxis for Open Combat Wounds in Afghanistan: 2013-2014

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Schauer SG, Fisher AD, April MD, Stolper KA, Cunningham CW, Carter R, Fernandez JD, Pfaff JA. 18(2). 53 - 56. (Journal Article)

Abstract

Background: Military operations place injured Servicemembers at high risk for open wounds. Austere environments and initial wound contamination increase the risk for infection. Wound infections continue to cause significant morbidity among injured Servicemembers. Limited evidence suggests that early antibiotic therapy for open wounds reduces infection rates. Methods: We obtained data from the Prehospital Trauma Registry (PHTR) from January 2013 through September 2014. This database includes data from Tactical Combat Casualty Care (TCCC) cards, Department of Defense 1380 forms, and after-action reports to provide near-real-time feedback to units on prehospital medical care. We evaluated whether patients with open wounds received antibiotics in accordance with TCCC guidelines. Low adherence was defined at less than 80%. Results: In this data set, overall, prefixed facility providers administered antibiotics to 54.0% of patients with an open combat wound. Of the antibiotics given, 11.1% were within TCCC guidelines. The relatively low administration and adherence rates persisted across subgroup analyses. Conclusion: Overall, relatively few patients with open combat wounds receive antibiotic administration as recommended by TCCC guidelines. In the group that received antibiotics, few received the specific antibiotics recommended by TCCC guidelines. The development of strategies to improve adherence to these TCCC recommendations is a research priority.

Keywords: prehospital; antibiotics; wound; prophylaxis; combat; emergency; tactical; casualty

PMID: 29889956

DOI: ZRIK-EOE3

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Prehospital Administration of Tranexamic Acid by Ground Forces in Afghanistan: The Prehospital Trauma Registry Experience

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Schauer SG, April MD, Naylor JF, Wiese J, Ryan KL, Fisher AD, Cunningham CW, Mitchell N, Antonacci MA. 17(3). 55 - 58. (Journal Article)

Abstract

Background: Tranexamic acid (TXA) was shown to reduce overall mortality and death secondary to hemorrhage in a large prospective study. This intervention is time sensitive. As such, the Tactical Combat Casualty Care (TCCC) guidelines recommend use of this low-cost, safe intervention among patients with possible hemorrhagic shock, penetrating trauma to the thorax or trunk, or extremity amputation. Objective: Prehospital administration of TXA by ground forces in the Afghanistan combat theater is described. Methods: We obtained data from the Prehospital Trauma Registry. We searched for all patients with documented hypotension, amputation, or penetrating trauma to the torso. Results: From January 2013 to September 2014, there were 272 patients who met inclusion criteria. Most injuries (97.8%; n = 266) were battle injuries. Of the 272 patients who met criteria to receive prehospital TXA, 51 (18.8%) received TXA, whereas the remaining 221 (81.2%) did not. Higher proportions of patients receiving TXA versus patients not receiving TXA received hemostatic dressings, pressure dressings, and tourniquet placement. Conversely, the proportion of patients receiving intravenous fluids was higher in the no-TXA group. Conclusion: Overall, proportions of eligible patients receiving TXA were low despite emphasis in the guidelines. The reasons for this low adherence to TCCC guidelines are likely multifactorial. Future research should seek to identify reasons TXA is not given when indicated and to develop training and technology to increase prehospital TXA administration.

Keywords: tranexamic acid; prehospital; trauma; combat; military; TXA

PMID: 28910469

DOI: 7U98-J4HL

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Prehospital Advances In The Management Of Severe Penetrating Trauma

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Mabry RL, McManus JG. 09(2). 93 - 101. (Previously Published)

Previously published in Critical Care Medicine 2008; 36[Suppl.]:S258 - S266. Republished in JSOM with permission of LippincottWilliams &Wilkins

Abstract

Background: Historic advances in combat prehospital care have been made in the last decade. Unlike other areas of critical care, most of these innovations are not the result of significant improvements in technology, but by conceptual changes in how care is delivered in a tactical setting. The new concept of Tactical Combat Casualty Care has revolutionized the management of combat casualties in the prehospital tactical setting. Discussion: The Tactical Combat Casualty Care concept recognizes the unique epidemiologic and tactical considerations of combat care and that simply extrapolating civilian care concepts to the battlefield are insufficient. Summary: This article examines the most recent and salient advances that have occurred in battlefield prehospital care driven by our ongoing combat experience in the Iraq and Afghanistan and the evolution around the Tactical Combat Casualty Care concept.

Keywords:

PMID: 19813522

DOI: EMG7-N9N5

Prehospital Analgesia With Ketamine for Combat Wounds: A Case Series

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Fisher AD, Rippee B, Shehan H, Conklin CC, Mabry RL. 14(4). 11 - 17. (Journal Article)

Abstract

Background: No data have been published on the use of ketamine at the point of injury in combat. Objective: To provide adequate pain management for severely injured Rangers, ketamine was chosen for its analgesic and dissociative properties. Ketamine was first used in the 75th Ranger Regiment in 2005 but fell out of favor because medical providers had limited experience with its use. In 2009, with new providers and change in medic training at the battalion level, the Regiment implemented a protocol using doses of ketamine that exceed the current Tactical Combat Casualty Care recommendations. Methods: Medical after-action reports were reviewed for all Ranger casualties who received ketamine at the point of injury for combat wounds from January 2009 to October 2014. Patients and medics were also interviewed. Results: Unit medical protocols authorize ketamine for tourniquet pain, amputations, long-bone fractures, and pain refractory to other agents. Nine of the 11 patients were US Forces; two were local nationals (one female, one male). The average initial dose given intramuscularly was 183mg, about 2 to 3mg/kg and intravenously 65mg, about 1mg/kg. The patients also received an opioid, a benzodiazepine, or both. There was one episode of apnea that was corrected quickly with stimulus. Eight of the 11 patients required the application of at least one tourniquet; four patients needed between two and four tourniquets to control hemorrhage. Pain was assessed with a subjective 1-10 scale. Before ketamine, the pain was rated as 9-10, with one patient claiming a pain level of 8. Of the US Forces, seven of the nine had no pain after receiving ketamine and two had a pain level of four. Two of the eight had posttraumatic stress disorder. Conclusions: In this small, retrospective sample of combat casualties, ketamine appeared to be a safe and effective battlefield analgesic.

Keywords: ketamine; midazolam; pain management; TCCC; tourniquet; PTSD

PMID: 25399363

DOI: BO8F-KYQT

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Prehospital and En Route Cricothyrotomy Performed in the Combat Setting: A Prospective, Multicenter, Observational Study

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Barnard EB, Ervin AT, Mabry RL, Bebarta VS. 14(4). 35 - 39. (Journal Article)

Abstract

Introduction: Airway compromise is the third most common cause of potentially preventable combat death. Surgical cricothyrotomy is an infrequently performed but lifesaving airway intervention. There are limited published data on prehospital cricothyrotomy in civilian or military settings. Our aim was to prospectively describe the survival rate and complications associated with cricothyrotomy performed in the military prehospital and en route setting. Methods: The Life-Saving Intervention (LSI) study is a prospective, institutional review boardapproved, multicenter trial examining LSIs performed in the prehospital combat setting. We prospectively recorded LSIs performed on patients in theater who were transported to six combat hospitals. Trained site investigators evaluated patients on arrival and recorded demographics, vital signs, and LSIs performed. LSIs were predefined and include cricothyrotomies, chest tubes, intubations, tourniquets, and other procedures. From the large dataset, we analyzed patients who had a cricothyrotomy performed. Hospital outcomes were cross-referenced from the Department of Defense Trauma Registry. Descriptive statistics or Wilcoxon test (nonparametric) were used for data comparisons; statistical significance was set at ρ < .05. The primary outcome was success of prehospital and en route cricothyrotomy. Results: Of the 1,927 patients enrolled, 34 patients had a cricothyrotomy performed (1.8%). Median age was 24 years (interquartile range [IQR]: 22.5-25 years), 97% were men. Mechanisms of injury were blast (79%), penetrating (18%), and blunt force (3%), and 83% had major head, face, or neck injuries. Median Glasgow Coma Scale score (GCS) was 3 (IQR: 3-7.5) and four patients had GCS higher than 8. Cricothyrotomy was successful in 82% of cases. Reasons for failure included left main stem intubation (n = 1), subcutaneous passage (n = 1), and unsuccessful attempt (n = 4). Five patients had a prehospital basic airway intervention. Unsuccessful endotracheal intubation preceded 15% of cricothyrotomies. Of the 24 patients who had the provider type recorded, six had a cricothyrotomy by a combat medic (pre-evacuation), and 18 by an evacuation helicopter medic. Combat-hospital outcome data were available for 26 patients, 13 (50%) of whom survived to discharge. The cricothyrotomy patients had more LSIs than noncricothyrotomy patients (four versus two LSIs per patient; ρ < .0011). Conclusion: In our prospective, multicenter study evaluating cricothyrotomy in combat, procedural success was higher than previously reported. In addition, the majority of cricothyrotomies were performed by the evacuation helicopter medic rather than the prehospital combat medic. Prehospital military medics should receive training in decision making and be provided with adjuncts to facilitate this lifesaving procedure.

Keywords: airway management; airway obstruction; military medicine; war; emergency medical services; cricothyrotomy; airway

PMID: 25399366

DOI: 62V1-UIZC

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Prehospital Anemia Care A Review of Symptoms, Evaluation, and Management

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Rankin CJ, Fetherston T, Ballentine CD, Adams B, Long B, Carius BM. 22(2). 69 - 74. (Journal Article)

Abstract

The ongoing evolution of prehospital medical care continues to advance beyond immediate triage care. Prehospital care is even more important to consider in theaters with extended evacuation times and limited local medical assets. Although blood loss is often associated with settings of acute traumatic hemorrhage in military medicine, the possibility for other hematologic compromise necessitating urgent action requires medics operating in these environments to have a fundamental knowledge of the pathophysiology, manifestations, and stabilization measures of anemia to aid their patients prior to, or in lieu of, evacuation. Continued development of and access to point-of-care testing in increasingly forward-deployed settings further enable medics to perform these tasks. Here, we provide a brief review of hemoglobin function and composition, and presentation and management considerations of anemia, to assist medics in their treatment efforts. We also address specific concerns for battlefield and atraumatic presentations.

Keywords: hemoglobin; anemia; prehospital care; blood loss, hemorrhage; military; laboratory; malaria; hemolysis; bleeding; transfusion

PMID: 35639897

DOI: 6H4H-TYVO

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Prehospital Care of Canine Gastric Dilatation and Volvulus

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Palmer LE. 18(1). 91 - 98. (Journal Article)

Abstract

The intent of the Operational K9 (OpK9) ongoing series is to provide the Special Operations Medical Association community with clinical concepts and scientific information on preventive and prehospital emergency care relevant to the OpK9. Often the only medical support immediately available for an injured or ill OpK9 in the field is their handler or the human Special Operations Combat Medic or civilian tactical medic attached to the team (e.g., Pararescueman, 18D, SWAT medic). The information is applicable to personnel operating within the US Special Operations Command as well as civilian Tactical Emergency Medical Services communities that may have the responsibility of supporting an OpK9.

Keywords: Operational K9s; gastic dilation and volvulus; bloat; gastric decompression; trocarization; dogs

PMID: 29533441

DOI: 8JGH-VRJV

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Prehospital Combat Wound Medication Pack Administration in Iraq and Afghanistan: A Department of Defense Trauma Registry Analysis

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Schauer SG, Naylor JF, Ahmed YM, Maddry JK, April MD. 20(3). 76 - 80. (Journal Article)

Abstract

Background: The United States (US) military utilizes combat wound medication packs (CWMP) to provide analgesia and wound prophylaxis in casualties who are still able to fight. We compared characteristics of combat casualties receiving CWMP to those not receiving CWMP. We also describe the proportions of casualties with injury patterns consistent with Tactical Combat Casualty Care (TCCC) guideline indications for CWMP use who received this intervention. Methods: This is a secondary analysis of Department of a Defense Trauma Registry (DODTR) dataset of US military personnel from January 2007 to August 2016. We searched for all subjects with documented use of at least one medication from the CWMP (acetaminophen, meloxicam, moxifloxacin). Results: Within our dataset, 11,665 casualties were US military Servicemembers. Overall, <1% (84) of our study population received the CWMP. The median age and mechanism of injuries were similar between CWMP nonrecipients versus recipients. Median composite injury scores were higher for nonrecipients than recipients (6 versus 4, P < .001). Proportions of casualties with injury patterns meeting TCCC guideline CWMP indications who received this intervention were low: gunshot wound, <1% (14 of 1805), tourniquet applied, <1% (11 of 1912), major amputation, <1% (5 of 803), and open fracture, <1% (10 of 2425). Based on serious injuries by body region, we had similar findings for the thorax (<1%; 3 of 1122), abdomen (<1%; 1 of 736), and extremities (<1%; 11 of 2699). Conclusions: Subjects receiving the CWMP were less severely injured compared to those who did not receive this intervention. The CWMP had very infrequent use among those casualties with injury patterns meeting indications specified in the TCCC Guidelines for use of this intervention.

Keywords: combat; pill; pack; military; pain; antibiotics

PMID: 32969008

DOI: X4E8-NNXE

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Prehospital Cricothyrotomy Kits Used in Combat

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Schauer SG, April MD, Cunningham CW, Long AN, Carter R. 17(3). 18 - 20. (Case Reports)

Abstract

Background: Surgical cricothyrotomy remains the only definitive airway management modality for the tactical setting recommended by Tactical Combat Casualty Care guidelines. Some units have fielded commercial cricothyrotomy kits to assist Combat Medics with surgical cricothyrotomy. To our knowledge, no previous publications report data on the use of these kits in combat settings. This series reports the the use of two kits in four patients in the prehospital combat setting. Methods: Using the Department of Defense Trauma Registry and the Prehospital Trauma Registry, we identified four cases of patients who underwent prehospital cricothyrotomy with the use of commercial kits. In the first two cases, a Medic successfully used a North American Rescue CricKit (NARCK) to obtain a surgical airway in a Servicemember with multiple amputations from an improvised explosive device explosion. In case 3, the Medic unsuccessfully used an H&H Medical kit to attempt placement of a surgical airway in a Servicemember shot in the head by small arms fire. A second attempt to place a surgical airway using a NARCK was successful. In case 4, a Soldier sustained a gunshot wound to the chest. A Medic described fluid in the airway precluding bag-valve-mask ventilation; the Medic attempted to place a surgical airway with the H&H kit without success. Conclusion: Four cases of prehospital surgical airway cannulation on the battlefield demonstrated three successful uses of prehospital cricothyrotomy kits. Further research should focus on determining which kits may be most useful in the combat setting.

Keywords: airway, surgical; cricothyrotomy; cricothyroidotomy; combat; prehospital; Medic, Afghanistan

PMID: 28910462

DOI: MTTO-UKNJ

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Prehospital Electrolyte Care: A Review of Symptoms, Evaluation, and Management

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Painter A, Carius BM. 22(2). 80 - 86. (Journal Article)

Abstract

Ongoing evolution of prehospital medical care continues to advance beyond tactical field care scenarios in the consideration of prolonged field care. This is even more important to consider in theaters with extended evacuation times and limited local medical assets. The critical regulatory functions of electrolytes such as sodium, potassium, calcium, and glucose require medics operating in these environments to have a strong, fundamental knowledge of the principles, manifestations, and initial stabilization measures to aid their patients prior to, or in lieu of evacuation. Continued development and access to point of care testing in increasingly forward deployed settings further enables medics to perform these tasks. Here, we provide a brief review of these vital electrolytes, as well as additional kidney function evaluation considerations, to assist medics in their treatment efforts. Specific concerns for battlefield and atraumatic presentations are addressed.

Keywords: military; laboratory; sodium; potassium; calcium; glucose; electrolytes; creatinine

PMID: 35639899

DOI: X436-FKVQ

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Prehospital Emergency Care: Evaluation of the Junctional Emergency Tourniquet Tool With a Perfused Cadaver Model

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Gates K, Baer L, Holcomb JB. 14(1). 40 - 44. (Journal Article)

Abstract

Objective: Junctional bleeding from the groin is a leading cause of potentially preventable death on the battlefield. To address this problem, a novel device called the Junctional Emergency Treatment Tool (JETT™) was developed. The JETT was designed to stabilize pelvic ring fractures while controlling lower extremity bleeding sustained during high-energy traumatic events on the battlefield and in the civilian environment. Our purpose was to assess the effectiveness of the JETT in the control of simulated life threatening hemorrhage from proximal injuries in the groin of a perfused cadaver. Methods: The JETT was compared with the standard issue combat tourniquet and a Food and Drug Administration (FDA)-cleared junctional hemorrhage control clamp (CRoC™) in a perfused human cadaver model. The JETT's ability to stop pulsatile flow at the common femoral artery was assessed through proximal aorta and distal measurements of arterial flow rates and pressures. Results: In three cadavers, when the JETT or the CRoC was applied in the groin, there was an immediate cessation of fluid flow from the common femoral artery while the inlet flow aortic pulsatile pressure was maintained. However, the time to bilateral application of the JETT was faster (10 seconds vs. 68 seconds) than bilateral sequential application of two CRoC devices. Conclusions: The JETT is a single device capable of effectively and quickly controlling bilateral lower extremity junctional hemorrhage at normal physiological blood pressures.

Keywords: hemorrhage; tourniquet; wounds and injuries; junctional hemorrhage; combat casualty care; femoral artery

PMID: 24604437

DOI: 385H-XCYJ

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Prehospital Iliac Crest Intraosseous Whole Blood Infusion

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Fulghum GH, Gravano B, Foudrait A, Rush SC, Paladino L. 21(4). 90 - 93. (Case Reports)

Abstract

Low-titer cold-stored O-positive whole blood (LTCSO+WB) resuscitation therapy is the cornerstone of military hemorrhagic shock resuscitation. During the past 19 years, improved patient outcomes have shown the importance of this intervention in shock treatment. Iliac crest intraosseous (IO) placement is an alternative when peripheral sites such as the humeral head and tibia are not available options. To date, no study has explored the administration of LTCSO+WB through an iliac crest IO in the military prehospital setting. Contingency procedures for vascular access are necessary for casualties with severe trauma to all four extremities, and the iliac crest is a viable option. The literature supports situational advantages over other peripheral IO sites.

Keywords: whole blood transfusion; vascular access; pararescue; trauma; intraosseous; iliac crest

PMID: 34969134

DOI: Q9CZ-YKF4

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Prehospital Medicine and the Future Will ECMO Ever Play a Role?

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Macku D, Hedvicak P, Quinn JM, Bencko V. 18(1). 133 - 138. (Journal Article)

Abstract

Due to the hybrid warfare currently experienced by multiple NATO coalition and NATO partner nations, the tactical combat casualty care (TCCC) paradigm is greatly challenged. One of the major challenges to TCCC is the ad hoc extension phase in resource-poor environments, referred to as prolonged field care (PFC) and forward resuscitative care (FRC). The nuanced clinical skills with limited resources required by warfighters and auxiliary health care professionals to mitigate death on the battlefield and prevent morbidity and mortality in the PFC phase represent a balance that is still under review. The aim of our article is to describe the connection between extracorporeal membrane oxygenation (ECMO) or the extracorporeal life support (ECLS) treatment and its possible improvement in prehospital trauma care, at a Role 1 or 2 facility and, more provocatively, in the PFC phase of care in the future through innovative technology and how it connects with FRC. We report and describe here the primary components of ECMO/ECLS and present the main concept of a human extracorporeal circulation cocoon as a transitional living form for the cardiopulmonary stabilization of wounded combatants on the battlefield and their transportation to higher echelons of care and treatment facilities (to include damage control resuscitation [DCR] and damage control surgery [DCS]). As clinical governance, these matters would fall within the remit of the Committee on Surgical Combat Casualty Care (CoSCCC) and the Committee on Enroute Combat Casualty Care (CoERCCC), and it is within this framework that we propose this concept piece of ECMO in the prehospital space. We caution that this report is a proposed innovation to TCCC but also serves to push the envelope of the PFC and FRC paradigm. What we propose will not change the practice this year, but as ECMO technology progresses, it may change our practice within the next decade. We conclude with proposed novel future research to save life on the battlefield with ECMO as a major challenge and one worth the focus of further research. Medicine is controversial and constantly changing; for those who work in prehospital and battlefield medicine, change is the only constant on which we rely, and without provocative discussion that makes our systems and practice more robust, we will fail.

Keywords: NATO; TCCC; prolonged field care; forward resuscitative care; extracorporeal membrane oxygenation; extracorporeal life support

PMID: 29533448

DOI: T6PM-V4F3

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Prehospital Needle Decompression Improves Clinical Outcomes in Helicopter Evacuation Patients With Multisystem Trauma: A Multicenter Study

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Henry R, Ghafil C, Golden A, Matsushima K, Eckstein M, Foran CP, Theeuwen H, Bentley DE, Inaba K, Strumwasser A. 21(1). 49 - 54. (Journal Article)

Abstract

Background: The utility of prehospital thoracic needle decompression (ND) for tension physiology in the civilian setting continues to be debated. We attempted to provide objective evidence for clinical improvement when ND is performed and determine whether technical success is associated with provider factors. We also attempted to determine whether certain clinical scenarios are more predictive than others of successful improvement in symptoms when ND is performed. Methods: Prehospital ND data acquired from one air ambulance service serving 79 trauma centers consisted of 143 patients (n = 143; ND attempts = 172). Demographic and clinical outcome data were retrospectively reviewed. Patients were stratified by prehospital characteristics and indications. Objective outcomes were measured as improvement in vital signs, subjective patient assessment, and physical examination findings. Univariate analysis was performed using chi-square for variable proportions and unpaired Student's t-test for variable means; p < .05 was considered statistically significant. Results: The success rate of ND performed for hypoxia (70.5%) was notably higher than ND performed for hemodynamic instability (20.3%; p < .01) or cardiac arrest (0%; p < .01). Compared to vital sign parameters, clinical examination findings as part of the indication for ND did not reliably predict technical success (p > .52 for all indications). No difference was observed comparing registered nurse versus paramedic (p = .23), diameter of catheter (p < .13 for all), or length of catheter (p = .12). Conclusion: Prehospital ND should be considered in the appropriate clinical setting. Outcomes are less reliable in cases of cardiopulmonary arrest or hypotension with respiratory symptoms; however, this should not deter prehospital providers from attempting ND when clinically indicated. Additionally, the success rate of prehospital ND does not appear to be related to catheter type or the role of the performing provider.

Keywords: needle decompression; prehospital emergency care; tension physiology; cardiopulmonary arrest

PMID: 33721307

DOI: XDCK-IY9J

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Prehospital Traumatic Brain Injury Management Clinical Pearls and Pathophysiology

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Ditzel RM, Hwang BY, Schmid JH, Ling GS. 22(2). 55 - 61. (Journal Article)

Abstract

Traumatic brain injury (TBI) management is complex. The brain is a sensitive, high-maintenance organ that loses its ability to take care of itself upon injury, and our primary mission is to achieve and maintain optimal levels of cerebral blood flow (CBF) from the moment of injury until recovery. The authors provide a case and discuss prehospital patient management, including adequate oxygen saturation and blood pressure, early recognition of TBI, frequent exams, detailed charting and hand-off, and fast transport to the next echelon of care.

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

PMID: 35639895

DOI: 8AMI-B6SP

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Prehospital Use of Hemostatic Bandages and Tourniquets: Translation From Military Experience to Implementation in Civilian Trauma Care

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Zietlow JM, Zietlow SP, Morris DS, Berns KS, Jenkins DH. 15(2). 48 - 53. (Journal Article)

Abstract

Background: While the military use of tourniquets and hemostatic gauze is well established, few data exist regarding civilian emergency medical services (EMS) systems experience. Methods: A retrospective review was performed of consecutive patients with prehospital tourniquet and hemostatic gauze application in a single ground and rotor-wing rural medical transport service. Standard EMS registry data were reviewed for each case. Results: During the study period, which included 203,301 Gold Cross Ambulance and 8,987 Mayo One Transport records, 125 patients were treated with tourniquets and/or hemostatic gauze in the prehospital setting. Specifically, 77 tourniquets were used for 73 patients and 62 hemostatic dressings were applied to 52 patients. Seven patients required both interventions. Mechanisms of injury (MOIs) for tourniquet use were blunt trauma (50%), penetrating wounds (43%), and uncontrolled hemodialysis fistula bleeding (7%). Tourniquet placement was equitably distributed between upper and lower extremities, as well as proximal and distal locations. Mean tourniquet time was 27 minutes, with 98.7% success. Hemostatic bandage MOIs were blunt trauma (50%), penetrating wounds (35%), and other MOIs (15%). Hemostatic bandage application was head and neck (50%), extremities (36%), and torso (14%), with a 95% success rate. Training for both interventions was computer-based and hands-on, with maintained proficiency of > 95% after 2 years. Conclusion: Civilian prehospital use of tourniquets and hemostatic gauze is feasible and effective at achieving hemostasis. Online and practical training programs result in proficiency of skills, which can be maintained despite infrequent use.

Keywords: dressing, hemostatic; tourniquet; trauma care; prehospital civilian

PMID: 26125164

DOI: 1P70-3H9D

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Prehospital Whole Blood in SOF: Current Use and Future Directions

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Jones TB, Moore VL, Shishido AA. 19(4). 88 - 90. (Journal Article)

Abstract

The US Joint Trauma System (JTS) recommends stored whole blood (SWB) as the preferred product for prehospital resuscitation of battlefield casualties in both their Tactical Combat Casualty Care (TCCC) guidelines and their clinical practice guidelines (CPGs). Clinical data from nearly 2 decades of war during Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF) suggest that whole blood (WB) is safe, effective, and far superior to crystalloid and colloid resuscitation fluids. The JTS CPG for whole blood transfusion reflects the most recent clinical evidence but poses unique challenges for execution by Special Operations Forces (SOF) operating in austere environments. Given the limited shelf-life of 35 days, WB requires a constant steady pool of donors. Additionally, the cold-chain requirement for storage poses challenges for SOF on long missions without access to blood refrigerators. SOF operating in less-developed theaters face additional logistical challenges. To mitigate the challenges of WB delivery, US SOF have implemented various protocols to ensure optimal donor pool, awareness/education among medics and specialized equipment for tactical methods of blood-carry and delivery. In general, steps taken include the following: (1) Prior to deployment, soldiers are screened for blood type and titers in order to establish a large donor pool. Support soldiers have been found to be particularly beneficial donors as they typically are in closer proximity to the blood support detachment. (2) In units that operate in smaller teams, such as ODAs, medics are outfitted with "blood kits" to carry blood on missions for point of injury transfusion. In units with larger teams, LTOWB donors are identified on missions and deliver fresh WB in the event of casualties. (3) Medics receive a WB transfusion refresher tabletop exercise and review after action reviews from previous rotations. Additionally, prehospital WB delivery is a required component of scenario-based premission training. The expectation is that medics will administer WB on missions when tactically feasible. Using the prolonged field care framework (ruck, truck, house) as a template, medics now use different methods to store and transport the SWB depending on phase. Medic "truck" and "house" kits include the Dometic CFX™ powered coolers that run on AC, DC, or solar power and allow for constant temperature monitoring. When on foot, medics have been outfitted with tactical blood coolers including the Pelican Biomedical Medic 4™ or Combat Medical Blood Box™ along with a Belmont Buddy-Lite™ intravenous (IV) infusion warmer and IV administration kit with standard micron filter. Presently, SOF medics have the donor support, logistical framework, training, and equipment to deliver WB at the point of injury. However, widespread implementation will require expanded distribution and standardization of "blood kits." Additionally, SOF medical planners must put greater emphasis on education and the importance of WB over crystalloids or colloids-as many medics continue to carry only these products out of convenience. As SOF strive to establish tactics, techniques, and procedures (TTPs) and streamline prehospital WB delivery, we must constantly reassess and refine our procedures, incorporate the latest evidence and technology, and adapt to an evolving battlefield.

Keywords:

PMID: 31910478

DOI: Q12Y-6Y8I

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Preliminary Comparison of New and Established Tactical Tourniquets in a Manikin Hemorrhage Model

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Gibson R, Housler GJ, Rush SC, Aden JK, Kragh JF, Dubick MA. 16(1). 29 - 35. (Journal Article)

Abstract

Background: Emergency tourniquet use has been associated with hemorrhage control and improved survival during the wars since 2001. The purpose of the present study is to compare the differential performance of two new tactical tourniquets with the standard-issue tourniquet to provide preliminary evidence to guide decisions on device development. Methods: A laboratory experiment was designed to test the effectiveness of tourniquets on a manikin thigh. Three models of tourniquets were assessed. The Rapid Application Tourniquet System (RATS) and the Tactical Mechanical Tourniquet (TMT) were compared with the standard-issue Combat Application Tourniquet® (C-A-T). Two users conducted 30 tests each. Results: Percentages for effectiveness (hemorrhage control, yes/no) and distal pulse cessation did not differ significantly by model. When compared with the RATS, the C-A-T performed better (ρ < .001) for time to hemorrhage control and fluid loss. The C-A-T and TMT had comparable responses for most measures, but the C-A-T applied more pressure (ρ = .04) than did the TMT for hemorrhage control. Conclusion: All three tactical tourniquets showed substantial capacity for hemorrhage control. However, the two new tourniquet models (RATS and TMT) did not offer any improvement over the C-A-T, which is currently issued to military services. Indeed, one of the new models, the RATS, was inferior to the C-A-T in terms of speed of application and simulated loss of blood. Opportunities were detected for refinements in design of the two new tourniquets that may offer future improvements in their performance.

Keywords: first aid; damage control; hemorrhage; shock; tourniquet; resuscitation

PMID: 27045491

DOI: OMIE-ELVB

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Preliminary Comparison of Pneumatic Models of Tourniquet for Prehospital Control of Limb Bleeding in a Manikin Model

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Gibson R, Aden JK, Dubick MA, Kragh JF. 16(2). 21 - 27. (Journal Article)

Abstract

Background: Emergency tourniquet use has been associated with hemorrhage control and improved survival during the wars since 2001, but little is known of the differential performance of pneumatic tourniquet models. The purpose of this study was to compare the performance of three models of pneumatic tourniquets in a laboratory setting to aid a possible decision to field test suitable models for medic preference. Methods: A laboratory experiment was designed to test the effectiveness of tourniquets on a manikin thigh. Three models (one Emergency and Military Tourniquet [EMT] and two Tactical Pneumatic Tourniquets differing in width: 2 in. and 3 in. [TPT3]) were compared with the standard-issue Combat Application Tourniquet of a strap-and-windlass design. Two users conducted 40 tests each on a right-thigh manikin (HapMed Leg Tourniquet Trainer) with a simulated above-knee amputation injury. Measurements included effectiveness in hemorrhage control, pulse stoppage distal to the tourniquet, time to stop bleeding, blood loss, and pressure. Results: All four models were 100% effective in both hemorrhage control and pulse stoppage distal to the tourniquet. The TPT3 had the slowest mean time to stop bleeding and the highest mean blood loss. The EMT had the least mean pressure. An interuser difference was found only for mean pressure. Conclusions: All models of tourniquet performed equally well for both the critical outcome of effectiveness and the important outcome of pulse stoppage, whereas results for secondary outcomes (time, pressure, and blood loss) differed by model. The EMT had best performance for every type of measurement.

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

PMID: 27450599

DOI: TKBM-GS8O

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Preliminary Measures of Instructor Learning in Teaching Junctional Tourniquet Users

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Kragh JF, Aden JK, Shackelford S, Dubick MA. 16(2). 13 - 15. (Journal Article)

Abstract

Background: The objective of the present study was to assess the effect of instructor learning on student performance in use of junctional tourniquets. Methods: From a convenience sample of data available after another study, we used a manikin for assessment of control of bleeding from a right groin gunshot wound. Blood loss was measured by the instructor while training users. The data set represented a group of 30 persons taught one at a time. The first measure was a plot of mean blood loss volumes for the sequential users. The second measure was a plot of the cumulative sum (CUSUM) of mean blood loss (BL) volumes for users. Results: Mean blood loss trended down as the instructor gained experience with each newly instructed user. User performance continually improved as the instructor gained more experience with teaching. No plateau effect was observed within the 30 users. The CUSUM plot illustrated a turning point or cusp at the seventh user. The prior portion of the plot (users 1-7) had the greatest improvement; performance did not improve as much thereafter. The improvement after the seventh user was the only change detected in the instructor's trend of performance. Conclusions: The instructor's teaching experience appeared to directly affect user performance; in a model of junctional hemorrhage, the volume of blood loss from the manikin during junctional tourniquet placement was a useful metric of instructor learning. The CUSUM technique detected a small but meaningful change in trend where the instructor learning curve was greatest while working with the first seven users.

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

PMID: 27450597

DOI: TLZM-T3WM

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Preparations for a Controversial Speaker and Anticipated Volatility in a College Town

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Slish J, Hwang C, Holtsman L, Jones J, Stout D, Abo BN, Ryan M. 20(2). 104 - 109. (Journal Article)

Abstract

In summer of 2017 in Charlottesville, Virginia, white nationalists clashed with counterprotestors, ultimately leading to the death of three people and leaving 34 more injured. Soon after, the same group was granted permission to speak on the campus of the University of Florida in Gainesville, Florida. Despite our college town having limited resources and personnel, the comprehensive and extensive preparation preceding the event ensured a peaceful resolution for such a large and potentially volatile situation. The preparatory steps required joint efforts from local and state partners in law enforcement, emergency medical services, and emergency departments. We describe here the situation we faced, the pre-event preparations, the response in the field and in our emergency department, and the outcomes from an emergency and tactical medicine perspective. We hope our successful experience will impart knowledge for similar events.

Keywords: TCCC; TECC; mass-casualty event; event medicine; tactical medicine; National Incident Management System

PMID: 32573745

DOI: K96J-UQTA

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Preparedness for Resuscitation at a Geographically Isolated Army Troop Medical Clinic: Lessons From Camp Blanding, Florida

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Studer NM, Horsley GW, Godbee DC. 14(2). 14 - 19. (Journal Article)

Abstract

Introduction: Many Servicemembers rely on nondeployed Role 1 facilities, such as troop medical clinics, as their primary source of healthcare. At geographically isolated military installations, these facilities are the "only game in town" for medical care. Servicemembers may present to these facilities with emergent conditions, regardless of designed intent of the facility or the wishes of staff. The U.S. Army Troop Medical Clinic, Camp Blanding is such a facility. Methods: The clinic was reorganized with a 5S approach, streamlining supply, equipment, and workflow processes. This was accomplished to allow the facility to not only improve its general delivery of care but also ensure capability to handle at least one medical or trauma resuscitation. Equipment, disposable supplies, documentation, and staff training were addressed.Results/ Discussion/ Conclusion: Despite facility intention, lack of supplies/equipment, or staff inexperience with emergency care, an acute ill or injured Servicemember must be stabilized at the nondeployed Role 1 facility while awaiting transport to a higher level of care. This expectation is the same as that of deployed Role 1 facilities. A cost-savings can also be realized when minor "emergencies" are handled in-house.

Keywords: aid station; troop medical clinic; sick bay; resuscitation; emergency medicine; primary care; National Guard; rural medicine; sick call

PMID: 24952035

DOI: MMPH-JPR5

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Preparing for Operations in a Resource-Depleted and/or Extended Evacuation Environment

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Corey G, Lafayette T. 13(3). 74 - 80. (Journal Article)

Abstract

The wars in Afghanistan and Iraq are the only conflicts to which many medics have ever been exposed. These mature theaters have robust medical systems that ensure rapid access to full-spectrum medical care for all combat-wounded and medically injured personnel. As current conflicts draw to a close, U.S. medics may be deployed to environments that will require the ability to stabilize casualties for longer than 1 hour. Historical mission analysis reveals the need to review skills that have not been emphasized during upgrade and predeployment training. This unit's preparation for the extended care environment can be accomplished using a 4-point approach: (1) review of specific long-term skills training, (2) an extended care lab that reviews extended care skills and then lets the medic practice in a real-time scenario, (3) introduction to the HITMAN mnemonic tool, which helps identify and address patient needs, and (4) teleconsultation.

Keywords: extended care; austere environments; long-term skills training; teleconsultation

PMID: 24048994

DOI: 2FOF-XV80

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Preparing Soldiers for the Stress of Combat

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Flanagan SC, Kotwal RS, Forsten RD. 12(2). 33 - 41. (Journal Article)

Abstract

Protracted use of stressors during military training courses does not necessarily enhance a Soldier's ability to regulate stress on the battlefield. Extensive stress during training can be a contributing factor to suboptimal neurologic and overall long-term health. Prolonged high-stress military training programs, as well as extended duration combat deployments, should be comprehensively scrutinized for opportunities to preserve health and increase combat effectiveness. Contemporary research in neuroscience and psychology can provide insight into training techniques that can be used to control stress and optimize performance in combat. Physical fitness training programs can elevate the stress threshold. Extensive situational training can also inoculate Soldiers to specific combat stressors. Training methods such as these will enable Soldiers to achieve higher levels of performance while under enemy fire and are encouraged for units deploying to combat.

Keywords: combat stress; military training; military deployment; physical training; posttraumatic stress disorder; sleep deprivation; stress inoculation training

PMID: 22707023

DOI: RPAT-ESAK

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Prescreened Whole O Blood Group Walking Blood Bank Capabilities for Nontraditional Maritime Medical Receiving Platforms: A Case Series

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Chang R, Boyle BP, Udoh MO, Maestas JM, Gehrz JA, Ruano E, Banker L, Cap AP, Bitterman JW, Deaton TG, Auten JD. Ahead of Print. (Journal Article)

Abstract

Background: Tactical Combat Casualty Care (TCCC) guidelines recognize low-titer group O whole blood (LTOWB) as the resuscitative fluid of choice for combat wounded. Utilization of prescreened LTOWB in a walking blood bank (WBB) format has been well described by the Ranger O low-titer blood (ROLO) and the United States Marine Corps Valkyrie programs, but it has not been applied to the maritime setting. Methods: We describe three WBB experiences of an expeditionary resuscitative surgical system (ERSS) team, attached to three nontraditional maritime medical receiving platforms, over 6 months. Results: Significant variations were identified in the number of screened eligible donors, the number of LTOWB donors, and the timely arrival at WBB activation sites between the platforms. Overall, 95% and 84% of the screened eligible group O blood donors on the Arleigh Burke Class Destroyer (DDG) and Nimitz Class Aircraft Carrier (CVN), respectively, were determined to be LTOWB. However, only 37% of the eligible screened group O blood donors aboard the Harper's Ferry Class Dock Landing Ship (LSD) were found to be LTOWB. Of the eligible donors, 66% did not complete screening, with 52% citing a correctable reason for nonparticipation. Conclusion: LTOWB attained through WBBs may be the only practical resuscitative fluid on maritime platforms without inherent blood product storage capabilities to perform remote damage control resuscitation. Future efforts should focus on optimizing WBBs through capability development, education, and training efforts.

Keywords: Low titer O; whole blood transfusion; damage control resuscitation; distributed maritime operations; walking blood bank

PMID: 38408045

DOI: PC7T-LML9

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Pressure Responses of Tourniquet Practice Models to Calibrated Force Applications

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Wall PL, Hingtgen E, Buising CM. 21(2). 11 - 17. (Journal Article)

Abstract

Background: Tourniquet training sometimes involves models, and a certification process is expected to use something other than human limbs; therefore, investigating model- and limb-pressure responses to force application is important. Methods: Pressure response to force was collected for a 3.8cm-wide nonelastic strap and a 10.1cm-wide elastic strap placed over 14 objects. Each object was suspended; an inflated neonatal blood pressure cuff was placed atop the object with the strap over the bladder; and strap ends were connected below with 4.54kg weights attached at 20-second intervals to 27.24kg. Results: Pressure-response curves differed by strap, thigh aspect (medial, lateral, ventral, dorsal; n = 2 subjects; p < .0001); subject (medial thigh; n = 3 subjects; p < .0001); and object (thighs; small and large pool noodles ± central metal rod, foam yoga roller, coffee can, 20% ballistic gel cylinder [Gel; Clear Ballistics; clearballistics.com] with central metal tubing, rolled pair of 5mm yoga mats ± central metal rod, hemorrhage-control training thigh [Z-Medica], sand-filled training manikin limb [Drumm Emergency Solutions]; p < .0001). Compliance, circumference, support techniques, and surface interactions, especially with the 10.1cm-wide elastic strap, affected pressure responses: smaller circumference, lower compliance, and lower surface coefficient of friction were associated with higher pressure/force applied. Conclusions: Different objects have different pressure-response curves. This may be important to acquisition and retention of limb tourniquet skills and is important for systems for certifying tourniquets.

Keywords: pressure; reference standards; tourniquet; hemorrhage; first aid; emergency treatment

PMID: 34105115

DOI: Z0NY-MPPL

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Pressures Under 3.8cm, 5.1cm, and Side-by-Side 3.8cm-Wide Tourniquets

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Wall PL, Weasel J, Rometti MR, Birkholz S, Gildemaster Y, Grulke L, Sahr SM, Buising CM. 16(2). 28 - 35. (Journal Article)

Abstract

Background: Applications of wider tourniquet are expected to occlude arterial flow at lower pressures. We examined pressures under 3.8cm-wide, 5.1cm-wide, and side-by-side-3.8cm-wide nonelastic strap-based tourniquets. Methods: Ratcheting Medical Tourniquets (RMT) were applied mid-thigh and mid-arm for 120 seconds with Doppler-indicated occlusion. The RMTs were a Single Tactical RMT (3.8cm-wide), a Wide RMT (5.1cm-wide), and Paired Tactical RMTs (7.6cm-total width). Tightening completion was measured at one-tooth advance past arterial occlusion, and paired applications involved alternating tourniquet tightening. Results: All 96 applications on the 16 recipients reached occlusion. Paired tourniquets had the lowest occlusion pressures (ρ < .05). All pressures are given as median mmHg, minimum-maximum mmHg. Thigh application occlusion pressures were Single 256, 219-299; Wide 259, 203-287; Distal of Pair 222, 183-256; and Proximal of Pair 184, 160-236. Arm application occlusion pressures were Single 230, 189-294; Wide 212, 161-258; Distal of Pair 204, 193-254, and Proximal of Pair 168, 148-227. Pressure increases with the final tooth advance were greater for the 2 teeth/cm Wide than for the 2.5 teeth/cm Tacticals (ρ < .05). Thigh final tooth advance pressure increases were Single 40, 33-49; Wide 51, 37-65; Distal of Pair 13, 1-35; and Proximal of Pair 15, 0-30. Arm final tooth advance pressure increases were Single 49, 41-71; Wide 63, 48-77; Distal of Pair 3, 0-14; and Proximal of Pair 23, 2-35. Pressure decreases occurred under all tourniquets over 120 seconds. Thigh pressure decreases were Single 41, 32-75; Wide 43, 28-62; Distal of Pair 25, 16-37; and Proximal of Pair 22, 15-37. Arm pressure decreases were Single 28, 21-43; Wide 26, 16-36; Distal of Pair 16, 12-35; and Proximal of Pair 12, 5-24. Occlusion losses before 120 seconds occurred predominantly on the thigh and with paired applications (ρ < .05). Occlusion losses occurred in six Paired thigh applications, two Single thigh applications, and one Paired arm application. Conclusions: Side-by-side tourniquets achieve occlusion at lower pressures than single tourniquets. Additionally, pressure decreases under tourniquets over time; so all tourniquet applications require reassessments for continued effectiveness.

Keywords: tourniquet; hemorrhage; first aid; emergency treatment

PMID: 27450600

DOI: XIBN-XPNT

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Pretrauma Interventions in Force Health Protection: Introducing the "Left of Bang" Paradigm

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Eisenstein NM, Naumann DN, Bowley DM, Midwinter MJ. 16(4). 59 - 63. (Editorial)

Keywords: trauma, prevention and control; wounds and injuries; prehospital emergency care; organizational innovation; Editorials

PMID: 28088819

DOI: KMMA-SV9L

Prevalence of Low Back and Cervical Back Pain in Military Helicopter Crews: An Underestimated Italian Problem

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Marchesini M, Ippolito C, Ambrosini L, Bignami EG, Fasani M, Abbenante D. 21(2). 67 - 71. (Journal Article)

Abstract

Background: Studies have highlighted the incidence and prevalence of chronic pain, which is an epidemic problem in all career sectors, as well as estimated the economic loss that follows its pathology. Several studies have indicated a high incidence of chronic osteoarticular pain in military service members, particularly in flight personnel. To date, no studies have estimated the incidence of pain pathology in the Italian military population, despite the implications related to flight qualification. Methods: A survey was conducted on helicopter flight personnel undergoing periodic annual evaluation. Results: A statistically significantly higher incidence of pain pathology than that reported in the global civilian population was demonstrated. More than 80% of the interviewed population reported moderate-to-severe back pain (45% in the lumbar tract and 38% in the cervical tract). Further, it was found that most staff with chronic pain do not use drugs or other treatments for severe pain because of concerns that such treatment approaches may compromise flight qualifications. Discussion: The present study observed a high incidence of pain in Italian military flight personnel and examined the degree to which this problem is undertreated in these individuals. To address this problem, further in-depth and larger investigations that include therapeutic protocols to resolve such pain pathologies should be conducted. Such investigations could help to reduce pain experienced by flight personnel and enhance the productivity of the Italian military forces while considering the pharmacologic limitations related to the task. Conclusion: Chronic lumbar and neck pain is more common in military helicopter crews than in the civilian population. The true figure is frequently underestimated because of staff concerns regarding the potential influence of therapies on work activity.

Keywords: pain, low back; pain, cervical back; helicopter crew, military; helicopter crew, Italian

PMID: 34105124

DOI: MQZT-YXMK

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Prevalence of Posttraumatic Stress Disorder in Special Operations Forces

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Neller DJ, Butcher JJ. 13(1). 91 - 91. (Letter)

Keywords:

DOI:

Prevalence of Trauma-Induced Hypocalcemia in the Prehospital Setting

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Brandt M, Liccardi C, Heidle J, Woods TD, White C, Mullins JR, Blackwell J, Le L, Brantley K. 23(2). 44 - 48. (Journal Article)

Abstract

Background: Recent data published by the Special Operations community suggest the Lethal Triad of Trauma should be changed to the Lethal Diamond, to include coagulopathy, acidosis, hypothermia, and hypocalcemia. The purpose of this study is to determine the prevalence of trauma-induced hypocalcemia in level I and II trauma patients. Methods: This is a retrospective cohort study conducted at a level I trauma center and Special Operations Combat Medic (SOCM) training site. Adult patients were identified via trauma services registry from September 2021 to April 2022. Patients who received blood products prior to emergency department (ED) arrival were excluded from the study. Ionized calcium levels were utilized in this study. Results: Of the 408 patients screened, 370 were included in the final analysis of this cohort. Hypocalcemia was noted in 189 (51%) patients, with severe hypocalcemia identified in two (<1%) patients. Thirty-two (11.2%) patients had elevated international normalized ratio (INR), 34 (23%) patients had pH <7.36, 21 (8%) patients had elevated lactic acid, and 9 (2.5%) patients had a temperature of <35°C. Conclusion: Hypocalcemia was prevalent in half of the trauma patients in this cohort. The administration of a calcium supplement empirically in trauma patients from the prehospital environment and prior to blood transfusion is not recommended until further data prove it beneficial.

Keywords: hypocalcemia; trauma; ionized calcium; Diamond of Death; lethal triad

PMID: 37094288

DOI: WYEJ-1M3J

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Preventing Ring Associated Injuries: Think Twice About Wearing That Ring

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Levy MJ, Gerold KB. 14(1). 93 - 95. (Journal Article)

Keywords:

PMID: 24604445

DOI: DCIA-Z71N

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Prevention of Foot Blisters

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Knapik JJ. 14(2). 95 - 97. (Journal Article)

Abstract

Foot blisters are the most common medical problem faced by Soldiers during foot march operations and, if untreated, they can lead to infection. Foot blisters are caused by boots rubbing on the foot (frictional forces), which separates skin layers and allows fluid to seep in. Blisters can be prevented by wearing properly sized boots, conditioning feet through regular road marching, wearing socks that reduce reduce friction and moisture, and possibly applying antiperspirants to the feet.

Keywords: blisters; injury prevention; foot blisters; road marching; footwear; load carriage; socks; antipersprants

PMID: 24952049

DOI: LU12-P967

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Preventive Medicine and Its Role in the Special Operation Forces Medical Team

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Agudelo JJ. 15(2). 136 - 138. (Journal Article)

Abstract

Throughout history, Soldiers in wartime have been especially vulnerable to infectious diseases, which have devastated and decimated entire armies, causing suspension and, in some cases, complete cancellation of military operations. Dr William Foege, a renowned Harvard epidemiologist, and his colleagues claim that throughout history, infectious diseases have killed more Soldiers than have weapons. Reality shows that it does not matter if your Soldiers had the best training available with the best equipment and top of the world intelligence: if your personnel get sick, they become more of a liability than an asset for a combat operation. This article presents some of the key findings that continue to affect our Special Operations Forces (SOF) and how the use of specifically designed new products can help in controlling short- and long-term consequences of infectious diseases.

Keywords: preventive medicine; diseases, infectious

PMID: 26125178

DOI: LVHB-AB7H

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Principles and Considerations in the Early Identification and Prehospital Treatment of Thrombocytopenia

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Nietsch KS, Roach TM, Wilson ZD, Kelly SM. 22(2). 75 - 79. (Journal Article)

Abstract

Thrombocytopenia is a common condition characterized by a low platelet count, typically less than 150,000/µL. This article outlines key considerations for field medical providers to effectively identify the early signs of thrombocytopenia and treat different etiologies in the prehospital environment. Following a representative case study, we present a review of basic pathophysiology to include different manifestations of thrombocytopenia as well as diagnostic methods, treatments, and other necessary interventions in this unique setting. With an adequate understanding of typical patient histories and physical presentations leading to this diagnosis, field medics and physicians can be armed with useful information to potentially improve patient outcomes.

Keywords: thrombocytopenia; platelets; bleeding; bruising

PMID: 35639898

DOI: 333T-XIYF

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Priorities for a 21st-Century Defense: Aligning U.S. Army Environmental Science and Engineering Officer Resources with the Department of Defense Strategic Guidance

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Licina D, Rufolo D, Story M. 13(2). 38 - 43. (Journal Article)

Abstract

The recently published Department of Defense (DoD) strategic guidance highlights the need to "shape a joint force for the future." Supporting requirements to shape the joint force while the overall DoD force structure is reduced will be challenging. Fortunately, based on its unique training and experience, the Army Environmental Science and Engineering Officer (ESEO) profession is positioned today to fill anticipated joint public health requirements. Obtaining the U.S. Army Medical Department (AMEDD) approval to meet these requirements will have near-term consequences for the ESEO profession as some existing (albeit antiquated) authorizations may go unfilled. However, long-term dividends for the Medical Service Corps (MSC), AMEDD, Army, and DoD will be achieved by realigning critical resources to future joint and interagency requirements. Assigning ESEOs now to organizations such as the Theater Special Operations Commands (TSOCs), U.S. Agency for International Development (USAID), and the North Atlantic Treaty Organization (NATO) with perceived and real joint force health protection/public health requirements through unique means will ensure our profession remains relevant today and supports the joint force of tomorrow.

Keywords: environmental science; public health; global health; defense strategic guidance

PMID: 23817877

DOI: UW5H-KUL1

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Prisoner of War Medical Ingenuity in Far East Captivity

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Parkes M, Gill G. 22(4). 117 - 121. (Journal Article)

Abstract

Research into British perspectives of the medical history of Far East prisoners of war (FEPOWs) has been conducted by the Liverpool School of Tropical Medicine (United Kingdom), resulting from decades of treating FEPOW veterans that began after their repatriation in late 1945. This paper examines some of the ingenious ways that British medical officers, medical orderlies, and volunteers fought to save the lives of thousands of FEPOWs during captivity in the Second World War. It highlights some of the key medical challenges, together with the resourcefulness of a "citizen's army" of conscripts and volunteers who used their civilian knowledge, skills, and ingenuity in many ways to support Allied medical staff. Using the most basic of materials, they were able to produce a vast array of medical support equipment and even drugs, undoubtedly saving many lives.

Keywords: World War II; prisoners of war; Medical Support

PMID: 36525024

DOI: E1MR-82OF

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Proceedings From the 2016 Mid-Year Meeting of the Committee for Tactical Emergency Casualty Care (C-TECC) and Committee Updates

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Shapiro G, Tang N, Kamin R, Smith R. 17(1). 149 - 151. (Classical Conference)

Keywords:

PMID: 28285494

DOI: ZS4E-8IDC

Proceedings from the 2017 Mid-Year Meeting of the Committee for Tactical Emergency Casualty Care (C-TECC) and Committee Updates

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Hartford B, Shapiro G, Marino MJ, Smith R, Tang N. 18(1). 160 - 161. (Classical Conference)

Keywords:

PMID: 29533454

DOI: 03XN-6DPH

Proceedings of the 2016 Spring/Summer Meeting of the Committee for Tactical Emergency Casualty Care

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Tang N, Shapiro G, Smith ER, Kamin R, Callaway DW. 16(2). 148 - 150. (Classical Conference)

Keywords:

PMID: 27689384

DOI: FRNX-T2HP

Proceedings of the 2023 Spring/Summer Meeting of the Committee for Tactical Emergency Casualty Care (C-TECC) and Committee Updates

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Shapiro GL, Marino MJ, Callaway DW, Kamin R, Yee A, Cunningham C, Schwartz J, Park C, Smith R, Tang N. 23(3). 102 - 104. (Classical Conference)

Keywords: Tactical Emergency Casualty Care; TECC; Special Operations; SOF; trauma

PMID: 37699260

DOI: APZU-5IKO

Proficiency in Improvised Tourniquets for Extremities: A Review

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Rohrich C, Plackett TP, Scholz BM, Hetzler MR. 19(3). 123 - 127. (Journal Article)

Abstract

Tourniquets have become ubiquitous tools for controlling hemorrhage in the modern prehospital environment, and while commercial products are preferable, improvised tourniquets play an important role when commercial options are not available. A properly constructed improvised tourniquet can be highly effective provided the user adheres to certain principles. This review article identifies key skills in the construction and application of improvised tourniquets on an extremity. An improvised tourniquet design for an extremity should include three components: a strap, a rod, and a securing mechanism. The strap can be made from a variety of materials, but cravat- like fabric has been shown to work well. Optimal strap dimensions should be at least 2cm in width and a continuous segment long enough to extend around the extremity while still offering ends to accommodate and secure the rod. The rod should be constructed from a material that is hard, strong, and capable of withstanding the torque placed on it without bending or breaking. After torque is applied, the rod must be secured into position to maintain the constricting force and survive patient transport. Finally, the need for an improvised tourniquet is a contingency that all first responders should anticipate. Hands-on training should be conducted routinely in conjunction with other first responder tasks.

Keywords: tourniquets; improvised tourniquets; hemorrhage; military medicine; emergency medical services; unconventional medicine

PMID: 31539448

DOI: 5XTW-C355

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Progress Of Tactical Emergency Medical Support In Japan

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Fuse A, Schwartz RB, Saitoh D, Agawa S, Ohnishi M, Okumura T. 16(1). 140 - 141. (Journal Article)

Keywords:

PMID: 27045510

DOI: CEYB-GQNS

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Project Reach: A Pilot Cross-Sectional Study of the Telemedical Capabilities of Special Operations Medical Personnel

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Carlton DM, Lowery D, Woodard C, Lugo-Robles R, Charny G. 21(2). 54 - 60. (Journal Article)

Abstract

Background: While the US military has relied on the "Golden Hour" for casualty evacuation in Iraq and Afghanistan during most of the last two decades, Special Operations Forces (SOF) personnel have found themselves operating further outside of this established medical infrastructure. This has required prolonged casualty care beyond doctrinal timelines. Telemedicine is increasingly used by medical personnel to bridge this gap, augmenting the local staff with the expertise of a distant consultant. This pilot study was launched to establish a baseline of current SOF telemedical capabilities. Methods: This is a cross-sectional study of a 292 Department of Defense (DoD) SOF medical personnel via an online questionnaire during the period of October 2018-May 2019. Results: Approximately 16.1% of the 292 respondents stated they received telemedicine equipment, 51.1% of respondents who received telemedicine equipment reported also receiving training on their equipment. Overall, 40.6% of respondents were "actively looking to add telemedicine to their practice," with prolonged field care as the primary intended use. Ideal characteristics of telemedicine equipment were described as a device weighing 6 lb or less, with real-time video and ultrasound transmission capabilities. Discussion: The data demonstrated a gap between provider demand for telemedicine capabilities and their comfort to employ these capabilities downrange. Conclusions: This study suggests a need to increase the self-reported telemedicine competency of deployed local providers. Authors believe that this is best accomplished through incorporation of early integration of teleconsulting systems into mission rehearsals and unit exercises. Further study should be considered to investigate the efficacy of ongoing acquisition and training programs, along with how telemedicine is being incorporated in the unit during the predeployment training period.

Keywords: telemedicine; telehealth; communication; military; prolonged field care; Special Operations Force; austere; project research

PMID: 34105122

DOI: T8U3-GQG3

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Prolonged Casualty Care Guidelines 21 December 2021

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Remley MA, Loos PE, Riesberg JC. 22(1). 18 - 47. (Classical Conference)

Keywords:

PMID: 35278313

DOI: 8IUQ-907J

Prolonged Field Care for the Summer 2017 Edition

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Keenan S. 17(2). 131 - 131. (Journal Article)

Keywords:

PMID: 28599046

DOI: O4PX-H3I9

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Prolonged Field Care for the Winter 2016 Edition

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Keenan S. 16(4). 86 - 86. (Classical Conference)

Keywords:

PMID: 28088825

DOI: TUU1-F2KO

Prolonged Field Care for the Winter 2017 Edition

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Riesberg JC. 17(4). 114 - 114. (Journal Article)

Keywords:

PMID: 29256208

DOI: ICDT-119O

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Prolonged Field Care in Support of Operation Inherent Resolve, 2016

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Blaine C, Abbott M, Jacobson E. 18(3). 120 - 123. (Journal Article)

Abstract

The authors present their experience in emergency and longterm medical care by Special Operations Forces (SOF) medical providers in an austere environment. In this case, a Special Forces Operational Detachment-Alpha (SFOD-A) was deployed in support of Operation Inherent Resolve, partnered with indigenous combat forces.

Keywords: prolonged field care; indigenous combat forces; austere environments

PMID: 30222849

DOI: IKCL-Q0PN

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Prolonged Field Care of a Casualty With Penetrating Chest Trauma

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Barnhart G, Cullinan W, Pickett JR. 16(4). 99 - 101. (Case Reports)

Abstract

As Special Operations mission sets shift to regions with less coalition medical infrastructure, the need for quality long-term field care has increased. More and more, Special Operations Medics will be expected to maintain casualties in the field well past the "golden hour" with limited resources and other tactical limitations. This case report describes an extended-care scenario (>12 hours) of a casualty with a chest wound, from point of injury to eventual casualty evacuation and hand off at a Role II facility. This case demonstrates the importance of long-term tactical medical considerations and the effectiveness of minimal fluid resuscitation in treating penetrating thoracic trauma.

Keywords: prolonged field care; chest trauma, penetrating; resuscitation, fluid

PMID: 28088827

DOI: VR0V-CYS2

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Prolonged Field Care Working Group Fluid Therapy Recommendations

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Baker BL, Powell D, Riesberg JC, Keenan S. 16(1). 112 - 117. (Journal Article)

Abstract

The Prolonged Field Care Working Group concurs that fresh whole blood (FWB) is the fluid of choice for patients in hemorrhagic shock, and the capability to transfuse FWB should be a basic skill set for Special Operations Forces (SOF) Medics. Prolonged field care (PFC) must also address resuscitative and maintenance fluid requirements in nonhemorrhagic conditions.

Keywords: prolonged field care; blood, fresh whole; shock, hemorrhagic; transfusion

PMID: 27045508

DOI: MKQL-04OU

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Prolonged Field Care Working Group Position Paper: Operational Context for Prolonged Field Care

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Mohr CJ, Keenan S. 15(3). 78 - 80. (Journal Article)

Keywords:

PMID: 26360359

DOI: 1T85-6NB9

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Prolonged Field Care Working Group Position Paper: Prolonged Field Care Capabilities

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Ball JA, Keenan S. 15(3). 76 - 77. (Journal Article)

Keywords:

PMID: 26360358

DOI: B3NN-SY8Y

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Prolonged Field Care Working Group Update

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Keenan S. 16(2). 105 - 106. (Journal Article)

Keywords:

PMID: 27450613

DOI: H0VS-2AXL

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Providers Face Challenges Maintaining Deployment-Ready Skills at Garrison Hospitals

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Schauer SG, Varney SM. 15(4). 79 - 80. (Editorial)

Keywords:

PMID: 27280217

DOI: DUNC-539E

Psoriasis

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Yetto T. 15(2). 132 - 135. (Journal Article)

Abstract

An active duty Sailor has a long history of skin lesions on his scalp, chest, back, and legs. He was evaluated and treated previously but could not recall the specific details. He is diagnosed with plaque psoriasis, an immune-mediated chronic disease. This article reviews the etiology, morphology, diagnosis, and treatment of psoriasis.

Keywords: psoriasis; plaques; pustules; arthritis, psoriatic; nails

PMID: 26125177

DOI: 5U7D-YUYC

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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(4). 63 - 64. (Editorial)

Keywords:

PMID: 20112650

DOI: 9QFJ-9PGU

Psychological Reslilence and Postdeployment Social Support Protect against Traumatic Stress and Depressive Symptoms In Soldiers Returning From Operation Enduring Freedom and Iraqi Freedom

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Pietrzak RH, Johnson DC, Goldstein MB, Malley JC, Southwick SM. 09(3). 67 - 73. (Previously Published)

Previously Published in Depression and Anxiety 0 : 1–7 (2009). Permission granted to republish in the JSOM.

Abstract

Background: A number of studies have examined the prevalence and correlates of posttraumatic stress disorder (PTSD), depression, and related psychiatric conditions in Soldiers returning from Operations Enduring Freedom and Iraqi Freedom (OEF/OIF), but none have examined whether factors such as psychological resilience and social support may protect against these conditions in this population. Methods:Atotal of 272 predominantly older reserve/National Guard OEF/OIF veterans completed a mail survey assessing traumatic stress and depressive symptoms, resilience, and social support. Results: Resilience scores in the full sample were comparable to those observed in civilian outpatient primary-care patients. Respondents with PTSD, however, scored significantly lower on this measure and on measures of unit support and postdeployment social support. Ahierarchical regression analysis in the full sample suggested that resilience (specifically, increased personal control and positive acceptance of change) and postdeployment social support were negatively associated with traumatic stress and depressive symptoms, even after adjusting for demographic characteristics and combat exposure. Conclusions: These results suggest that interventions to bolster psychological resilience and postdeployment social support may help reduce the severity of traumatic stress and depressive symptoms in OEF/OIF veterans.

Keywords:

PMID: 19739479

DOI: LANU-HRWC

Psychological Strategies During Military Training Are Linked to Resilience in US Navy Explosive Ordnance Disposal Operators

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Taylor MK, Rolo C, Stump J, Mayo J, Hernandez LM, Gould DR. 19(1). 61 - 65. (Journal Article)

Abstract

Purpose: We describe the psychological strategies (PS) used by a specialized military population, US Navy explosive ordnance disposal (EOD), during training and military operations. We also aim to establish the relationship between PS and resilience. Methods: The Test of Performance Strategies was adapted to the military environment and subsequently was administered to 58 EOD Operators in conjunction with the 10-item Connor- Davidson Resilience Scale. Differences between high- and low-resilience Operators for PS were evaluated with discriminant models. Results: The PS of EOD Operators were comparable to those of Olympic athletes described in our prior study. The most frequently used strategies during training and military operations were goal setting and emotional control. Discriminant analysis indicated an overall difference between high- and low-resilience Operators with respect to the six training subscales (ρ < .05), with goal setting, emotional control, and attentional control contributing most to the discriminant function. Conclusion: EOD Operators' use of PS was comparable to that of elite athletes. We provide evidence that more-resilient EOD Operators differ from their less resilient counterparts in the strategies they use. These findings have implications for mental preparation strategies used during military training and operations.

Keywords: stress; military; psychological strategies; explosive ordnance disposal; Special Operations

PMID: 30859529

DOI: JAEQ-3MJZ

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Psychosocial 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 Postdeployment Social Support

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Pietrzak RH, Johnson DC, Goldstein MB, Malley JC, Rivers AJ, Morgan CA, Southwick SM. 09(3). 74 - 78. (Previously Published)

Previously published in the Journal ofAffective Disorders, (2009), doi:10.1016/j.jad.2009.04.015. Permission granted to republish in the JSOM.

Abstract

Background: Little research has examined the role of protective factors such as psychological resilience, unit support, and postdeployment social support in buffering against PTSD and depressive symptoms, and psychosocial difficulties in veterans of Operations Enduring Freedom (OEF) and Iraqi Freedom (OIF). Materials and Methods:Atotal of 272 OEF/OIF veterans completed a survey containing PTSD and depression screening measures, and questionnaires assessing resilience, social support, and psychosocial functioning. Results: Lower unit support and postdeployment social support were associated with increased PTSD and depressive symptoms, and decreased resilience and psychosocial functioning. Path analyses suggested that resilience fully mediated the association between unit support and PTSD and depressive symptoms, and that postdeployment social support partially mediated the association between PTSD and depressive symptoms and psychosocial functioning. Limitations: Generalizability of results is limited by the relatively low response rate and predominantly older and reserve/National Guard sample. Conclusions: These results suggest that interventions designed to bolster unit support, resilience, and postdeployment support may help protect against traumatic stress and depressive symptoms, and improve psychosocial functioning in veterans.

Keywords:

PMID: 19739480

DOI: 1K29-WT93

PTSD: An Elusive Definition

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Kirkbride JF. 12(2). 42 - 47. (Journal Article)

Abstract

The Global War on Terrorism became the longest standing conflict in United States military history on June 7, 2010. It is estimated that 1.64 million U.S. troops have been deployed in support of Operation Enduring Freedom and Operation Iraqi Freedom (ρ xix).1 Both conflicts have produced high numbers of casualties as the result of ground combat. The amount of casualties though has been relatively low compared to other conflicts. Some of this can be attributed to the advances in body armor and emergency medicine that allow many servicemembers to survive conditions that previously led to death. Conversely, surviving these situations leaves those same members with memories that are psychologically difficult to live with and cause chronic difficulties. Unlike an amputee, or the victim of severe burns where the signs and symptoms of their injuries are obvious, patients with psychological disorders can have a range of signs and symptoms common in many other mental disorders, making it difficult to diagnose and treat Soldiers suffering from Post-traumatic Stress Disorder (PTSD).

Keywords:

PMID: 22707024

DOI: PE5N-2FRH

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Public Access Hemorrhage Control and the Stop the Bleeding Coalition

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Levy MJ. 15(3). 126 - 128. (Journal Article)

Keywords:

PMID: 26360367

DOI: OZXY-ZKW5

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Public Health Foodborne Illness Case Study During A Special Operations Forces Deployment To South America

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McCown ME, Grzeszak B. 10(4). 45 - 47. (Journal Article)

Abstract

Although many public health articles have been published detailing foodborne illness outbreaks, a medical literature search revealed no articles that detail a case study or a specific response of a deployed U.S. military unit to a potential foodborne illness. This article describes a recent public health case study of a U.S. Special Operations Forces (SOF) team sickened while deployed to South America. It highlights public health factors which may affect U.S. personnel deployed or serving overseas and may serve as a guide for a deployed SOF medic to reference in response to a potential food- or waterborne illness outbreak. Methods: Eight food samples and five water samples were collected. The food samples were obtained from the host nation kitchen that provided food to the SOF team. The water samples were collected from the kitchen as well as from multiple sites on the host nation base. These samples were packaged in sterile containers, stored at appropriate temperatures, and submitted to a U.S. Army diagnostic laboratory for analysis. Results: Laboratory results confirmed the presence of elevated aerobic plate counts (APCs) in the food prepared by the host nation and consumed by the SOF team. Discussion: High APCs in food are the primary indicator of improper sanitation of food preparation surfaces and utensils. Conclusion: This case study concluded that poor kitchen sanitation, improper food storage, preparation, and/or holding were the probable conditions that led to the team's symptoms. These results emphasize the importance of ensuring safe food and water for U.S. personnel serving overseas, especially in a deployment or combat setting. Contaminated food and/or water will negatively impact the health and availability of forces, which may lead to mission failure. The SOF medic must respond to potential outbreaks and be able to (1) critically inspect food preparation areas and accurately advise commanders in order to correct deficiencies and (2) perform food/water surveillance testing consistently throughout a deployment and at any time in response to a potential outbreak.

Keywords:

PMID: 21442591

DOI: FVEV-P2ND

Public Health Operations In The JSOTF-P

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Rufolo D, Facciolla C. 11(2). 4 - 7. (Journal Article)

Abstract

Medical personnel have a proven operational and strategic role as part of Counterinsurgency (COIN) and Foreign Internal Defense (FID) operations. In addition to the traditional employment of medical assets in Medical Civic Action Programs, commanders can utilize their medical resources in a teaching and educational capacity to effectively target an entire village (men, women, and children), with minimal logistical support. In the Joint Special Operations Task Force- Philippines, Environmental Science Engineer Officers and veterinarians added additional capabilities and facilitated educational programs that stimulate the coordination of local, military, and government resources to improve public health infrastructure and make a sustainable, lasting impact.

Keywords:

PMID: 21455902

DOI: OAL1-R8FW

Pulseless Arrest After Rapid Sequence Intubation of the Massively Hemorrhaged Warfighter: A Case Series

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Schwarzkoph BW, Emerling AD, Iteen A, Deaton TG, Auten JD, Bianchi WD. 22(1). 104 - 107. (Case Reports)

Abstract

Management of hemorrhagic shock and airway stabilization are two pillars of trauma resuscitation which have a dependent, yet incompletely understood relationship. Patients presenting with traumatic hemorrhage may manifest shock physiology prior to intubation, conferring a higher risk of postintubation hypotension, pulseless arrest, and mortality. This case series describes of a group of seven US military members with combat-related trauma who experienced pulseless arrest after rapid sequence intubation in a role 2 or role 3 setting. All except one of the patients had hemodynamics suggesting hemorrhagic shock prior to intubation. This case series highlights the need for further research to define which trauma patients are at risk of postintubation pulseless arrest. It also focuses on the knowledge gap related to the role that delayed airway management and judicious blood product resuscitation may play in preventable death after injury.

Keywords: pulseless arrest; traumatic arrest; rapid sequence intubation; transfusion; TCCC

PMID: 35278324

DOI: ANSR-FR0P

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Q Fever

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Burnett MW. 15(2). 109 - 111. (Journal Article)

Abstract

Q fever is a zoonotic disease found throughout the world. It is caused by the intracellular gram-negative bacterium Coxiella burnetii. Infection by C. burnetii occurs primarily by inhalation of the aerosolized bacteria from birthing animals or contaminated dust. The bacterium is very resistant to drying and heat, and is considered highly endemic in the Middle East, where it is likely underdiagnosed. Special Operations Forces medical providers should be aware of this disease, which must be in the differential diagnosis of a patient who has a history of fever, elevated liver enzymes, pneumonia in its acute form, and endocarditis, especially in those with existing valvular heart disease in its chronic form.

Keywords: Q fever; disease, zoonotic

PMID: 26125173

DOI: Z76J-ESMB

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Quality Assurance in Tactical Combat Casualty Care for Medical Personnel Training 16 April 2020

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Greydanus DJ, Hassmann LL, Butler FK. 20(2). 95 - 103. (Journal Article)

Abstract

At present, however, there is no systematic, comprehensive quality assurance program for TCCC training throughout the DoD. Individual courses and instructors may or may not use all of the materials in the JTS-approved curriculum; they may or may not add content that is not part of the JTS curriculum; and they may or may not add additional training in the form of advanced simulation, hands-on training with moulaged casualties, graded trauma lanes, or live-tissue training. A recent pilot appraisal of four Tactical Combat Casualty Care for Medical Personnel (TCCC-MP) training courses found that TCCC-MP courses are not presenting all of the course material recommended by the Joint Trauma System (JTS), despite TCCC training having been mandated by the Department of Defense (DoD) for all US military personnel. Some of the omitted material is essential to ensuring that students are fully prepared to perform TCCC on the battlefield. Further, there was incorrect messaging presented in the TCCC-MP courses that were appraised, some of which, if actually reflected in the care provided on the battlefield, would likely result in adverse casualty outcomes. Other aspects of the TCCC messaging presented in the appraised courses that is not at present part of the JTS-approved curriculum might, however, be appropriate for inclusion into the TCCC Guidelines and the course curriculum. Examples of material that should be considered for incorporation into the TCCC curriculum include modifying the method of tranexamic acid (TXA) administration (slow IV push vs the currently recommended 10-minute infusion) and a better technique for securing of the new CAT Generation 7 tourniquets after application. The course appraiser also noted that there were a number of excellent videos of actual TCCC interventions being performed that are not part of the current JTS-approved TCCC-MP curriculum. These videos should be forwarded to CoTCCC staff and the Joint Trauma Education and Training (JTET) branch of the JTS for consideration as potential additions to the TCCC-MP curriculum. Consideration should also be given to the inclusion of additional TCCC training modalities such as advanced simulators, moulaged casualties, graded trauma lanes, autologous blood transfusion training, and the use of live-tissue training (when logistically feasible) for selected course items such as surgical airways. Further, the 16-hour training time currently allotted for TCCC-MP training was found to be insufficient to present all of academic material and testing contained in the existing TCCC-MP curriculum. A 5-day course should be considered to include the entire JTS-recommended curriculum and to add graded trauma lanes and autologous blood transfusion training to the core JTS TCCC-MP curriculum. The post-course written testing also needs to use the standardized TCCC fund of knowledge questions and the TCCC Critical Decision Case Study questions developed by the JTS. Finally, there is a need to establish a systematic and standardized quality assurance program to ensure that TCCC training programs are carried out in accordance with the JTS-recommended TCCC curriculum. This program would best be performed as a new function of the CoTCCC with dedicated TCCC course appraisers.

Keywords: Tactical Combat Casualty Care; TCCC; training; simulators; live tissue training; battlefield trauma care

PMID: 32573744

DOI: T63H-3OXX

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Quality of Care Assessment in Forward Detection of Extremity Compartment Syndrome in War

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King DR, Kragh JF, Blackbourne LH. 13(2). 20 - 24. (Journal Article)

Abstract

Background: Recent efforts to improve the quality of care in the Afghanistan theater have focused on extremity compartment syndrome, a common, disabling, and costly problem. To identify opportunities to improve care, the present survey was undertaken to observe the use of two standard methods-the traditional, improvised method and the common, off-the-shelf method-for determining intracompartmental pressures in the lower extremities of combat casualties. Methods: As part of a quality of care improvement effort during Operation Enduring Freedom, all combat casualties presenting to a forward surgical team at Forward Operating Base Shank from August to November 2011 with lower-extremity major trauma were evaluated for signs and symptoms of compartment syndrome. Results: Ten casualties had pressure measurement surveyed simultaneously using both methods. A two one-sided test analysis demonstrated a mean difference of -0.13 (90% confidence interval, -0.36 to 0.096), which indicated that the methods were similar. A repeated-measures analysis yielded a p value of .72, indicating no statistical difference between the methods. The receiver operating characteristic curve demonstrated excellent agreement within the prespecified limits (±2mm Hg, area under the curve 1.0), which indicated that the methods were similar. Conclusion: The main finding of the quality of care effort was that clinicians received similar information from use of two standard methods for far forward measurement of pressures to detect extremity compartment syndrome. This finding may help clinicians improve the quality of care in the theater in detecting, diagnosing, and monitoring compartment syndrome.

Keywords: fascia wounds; injuries; emergency medical services; Afghan Campaign 2001-present; military medicine

PMID: 23817874

DOI: DMC9-73ID

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QuikClot® Combat Gauze® Use by Ground Forces in Afghanistan The Prehospital Trauma Registry Experience

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Schauer SG, April MD, Naylor JF, Fisher AD, Cunningham CW, Ryan KL, Thomas KC, Brillhart DB, Fernandez JD, Antonacci MA. 17(2). 101 - 106. (Journal Article)

Abstract

Background: QuikClot® Combat Gauze® (QCCG) was fielded in 2008 to replace previous generations of hemostatic products. To the best of our knowledge, despite nearly a decade of use, there are no published data on use among US combatant forces. We describe the use of QCCG by ground forces in Afghanistan and compare patients who received QCCG compared with the remaining population in the database who did not receive QCCG. Methods: Data were obtained from the Prehospital Trauma Registry (PHTR). Joint Trauma System personnel linked patients to the Department of Defense Trauma Registry (DODTR) for outcome data, when available, upon reaching a fixed facility. Results: Of the 705 patients within the entire PHTR, 118 (16.7%) had documented use of QCCG. Most patients (69.5%) were Afghan; all were male. Lower extremities accounted for the most common site of application (39.7%). Hemorrhage control occurred in 88.3% of encounters with hemorrhage control status documented. Patients receiving QCCG generally had higher rates of concomitant interventions. Of the 705 patients, 190 were linkable to the DODTR for outcome data; 25 of the 28 (89.3%) in the QCCG group were discharged alive compared with 153 of the 162 (94.4%) in the non-QCCG group (ρ = .300). Conclusion: QCCG appears to have common use on the battlefield as a concomitant intervention for obtaining hemorrhage control. Patients receiving QCCG had higher rates of gunshot wounds compared with the baseline population and were generally sicker. Hemorrhage control success was like that reported in other military and civilian settings.

Keywords: hemorrhage; gauze; combat; military; QuikClot®; hemostatic; combat

PMID: 28599041

DOI: MJDI-7NPA

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Rabies

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Burnett MW. 13(3). 102 - 104. (Journal Article)

Abstract

Rabies has been a scourge of mankind since antiquity. The name itself, "rabies" is derived from the ancient Sanskrit rabhas meaning "to do violence" and has been found described in medical writings several thousand years old. The rabies virus is an RNA virus of the family Rhabdoviridae (Greek for "rod-shaped virus"), genus Lyssavirus (Lyssa being the Greek God of frenzy and rage). Rabies infections have a worldwide spread, with only a few, mostly island nations laying claim to being "rabies free."

Keywords:

PMID: 24049000

DOI: 365J-W4Y7

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Rabies: 2015 Update

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Burnett MW. 15(3). 105 - 107. (Journal Article)

Abstract

Rabies is an almost universally fatal viral disease transmitted to humans primarily by bites and scratches from infected animals, and less commonly through other routes, including transplantation of infected organs, exposure to infected neural tissue, and possibly through airborne and aerosolized routes. This disease is endemic to all continents worldwide except Antarctica, and only a few islands elsewhere can be considered "rabies free." Special Operations Forces medical providers should be aware of this disease. Prevention and recognition of risk are key due to its extreme lethality.

Keywords: rabies, vaccine

PMID: 26360364

DOI: IIHR-6LUD

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Ranger Athlete Warrior Assessment Performance in a Reserve Officer Training Corps Training Environment

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Meckley DP, Hulbert K, Stewart D, O'Brien N, Barringer N, Hornsby JH. 19(1). 96 - 98. (Journal Article)

Abstract

Muscular strength, power, and aerobic capacity are vital to Army Reserve Officer Training Corps (AROTC) Cadets as well as active-duty Soldiers, especially when lifting heavy objects, traveling long distances, or moving with maximum speed and agility. The purpose of this study was to examine the change (after a pre/post intervention) of 5 weeks of resistance strength training and aerobic capacity training on a Ranger Athlete Warrior (RAW) assessment. Twelve (males, n = 10; females, n = 2) college-aged AROTC Cadets volunteered for this study during their train-up for the annual Ranger Challenge Competition. Each training week consisted of two resistance, two aerobic, and one tactical training session lasting about 90 minutes. The RAW assessment consisted of the following: 5-10-5 shuttle, standing broad jump, 3-repetition maximum (RM) trap bar deadlift, pull-ups, metronome pushups, heel claps, and two 300-yard shuttles. Paired samples t tests produced statistically significant differences (pre vs post): 5-10-5 (p = .04), 3-RM trap bar deadlift (p = .01), and metronome push-ups (p = .01). The results suggest that combining resistance strength and endurance and aerobic capacity training at a set volume with a self-selected intensity improved the Cadets' agility, lower-body strength, and upper-body muscular endurance. Implementing a program similar to this in other AROTC programs could also improve Cadet performance in the field. This study also showed the benefit of an AROTC program collaborating with human performance professionals to optimize Cadets' human performance capabilities.

Keywords:

PMID: 30859535

DOI: GDSW-TAQZ

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Ranger First Responder And The Evolution Of Tactical Combat Casualty Care

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Veliz C, Montgomery HR, Kotwal RS. 10(3). 90 - 91. (Journal Article)

Keywords:

PMID: 21049436

DOI: 04TL-ET5E

Rapid Ketamine Infusion at an Analgesic Dose Resulting in Transient Hypotension and Bradycardia in the Emergency Department

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Emerling AD, Fisher J, Walrath B, Drew B. 20(1). 31 - 33. (Case Reports)

Abstract

Ketamine's favorable hemodynamic and safety profile is motivating increasing use in the prehospital environment. Despite these advantages, certain side effects require advanced planning and training. We present a case of rapid intravenous administration of ketamine causing bradycardia and hypotension. A 46-year-old man presented to the emergency department for an exacerbation of chronic shoulder pain. Given the chronicity of the pain and multiple failed treatment attempts, ketamine at an analgesic dose was used. Despite the local protocol directing administration over several minutes, it was pushed rapidly, resulting in malaise, nausea, pallor, bradycardia, and hypotension. The patient returned to his baseline without intervention. This and other known side effects of ketamine, such as behavioral disturbances, altered sense of reality, and elevated heart rate and blood pressure, are well documented in the literature. With this report, the authors aim to raise awareness of transient bradycardia and hypotension associated with the rapid administration of ketamine at an analgesic dose.

Keywords: ketamine; rapid infusion; vasovagal; bradycardia; hypotension; prehospital; emergency department

PMID: 32203601

DOI: N455-UKW4

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Rapid Reversal Ofwarfarin Toxicity Using Recombinant Factor Viia In A Deteriorating Patient With Left Hemothorax

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Samir H, Owens GP, Masud F. 07(3). 1 - 3. (Case Reports)

Keywords:

DOI:

Rapid Vision Correction by Special Operations Forces

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Reynolds ME. 17(2). 60 - 64. (Journal Article)

Abstract

Background: This report describes a rapid method of vision correction used by Special Operations Medics in multiple operational engagements. Methods: Between 2011 and 2015, Special Operations Medics used an algorithm- driven refraction technique. A standard block of instruction was provided to the medics, along with a packaged kit. The technique was used in multiple operational engagements with host nation military and civilians. Data collected for program evaluation were later analyzed to assess the utility of the technique. Results: Glasses were distributed to 230 patients with complaints of either decreased distance or near (reading). Most patients (84%) with distance complaints achieved corrected binocular vision of 20/40 or better, and 97% of patients with near-vision complaints achieved corrected near-binocular vision of 20/40 or better. There was no statistically significant difference between the percentages of patients achieving 20/40 when medics used the technique under direct supervision versus independent use. Conclusion: A basic refraction technique using a designed kit allows for meaningful improvement in distance and/or near vision at austere locations. Special Operations Medics can leverage this approach after specific training with minimal time commitment. It can serve as a rapid, effective intervention with multiple applications in diverse operational environments.

Keywords: visual impariment; refractive error; vision; presbyopia

PMID: 28599035

DOI: LZEX-7YM3

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Rationale and Implementation of a Novel Special Operations Medical Officer Course

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Fedor PJ, Dorsch J, Kharod C, Paladino L, Rush SC. 21(1). 25 - 29. (Journal Article)

Abstract

Background: The Air Force Special Warfare Medical Officer Course was created to address the lack of operationally focused, job-specific clinical training for medical officers (MOs). This course addresses the gap in knowledge, skill, and application of operational medicine, as well as the behavioral health, human performance, education, and medical oversight of Operators. Methods: The course was designed around the senior author's decade of experience piecing together training for his own role as a pararescue flight surgeon and informed by 5 years of flight surgeon courses, lessons learned from case studies of ill-prepared deployed physicians, and input from prehospital medicine subject matter experts. Results: Air Force pararescue and special tactics flight surgeons, physician assistants, and an independent duty medical technician (IDMT) attended. The course consisted of 10 full weekdays of didactics and skills sessions covering theory and application of operational medicine, human performance optimization, behavioral health for Operators, adult education theory, principles of prehospital clinical oversight, and other expeditionary concepts. The course culminated with combat casualty care scenario-based exercises, in which the providers performed operational medicine in full kit with weapons and simulation rounds. Discussion: For many logistical and practical reasons, civilian medical experience, traditional military medical training, existing special operations medical courses, and "merit badge" card classes are not adequate preparation for this specialized role. Focused, job-specific training should be provided to Special Operations Forces Medical Officers (SOFMO) and, ultimately, to any MO deploying in support of medics or combatants. The goal is to maximize the success of military medical operations while reducing the morbidity and mortality of combat and training casualties. Conclusion: This operationally focused MO course can serve as a model for the future training of SOFMO and has stimulated discussion for consideration of a joint approach to prehospital medical training.

Keywords: Special Operations Forces; medical officer; physician; prehospital; training; education

PMID: 33721302

DOI: Y7JG-KP26

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Rationale for Use of Intravenous Acetaminophen in Special Operations Medicine

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Vokoun ES. 15(2). 71 - 73. (Journal Article)

Abstract

Use of intravenous acetaminophen has increased recently as an opioid-sparing strategy for patients undergoing major surgery. Its characteristics and efficacy suggest that it would a useful adjunct in combat trauma medicine. This article reviews those characteristics, which include rapid onset, high peak plasma concentration, and favorable side-effect profile. Also discussed is the hepatotoxicity risk of acetaminophen in a combat trauma patient. It concludes that intravenous acetaminophen should be considered as an addition to the US Special Operations Command Tactical Trauma Protocols and supplied to medics for use in field care.

Keywords: acetaminophen, intravenous; trauma, combat; prolonged field care

PMID: 26125167

DOI: XC14-M36Z

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Ray Banta's War: A Combat Surgeon in World War II China

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Farr WD. 19(2). 138 - 138. (Book Review)

Abstract

Clark JE Jr. Ray Banta's War: A Combat Surgeon in World War II China. Middletown, DE: CreateSpace Independent Publishing Platform; 2015. ISBN-10: 1515171256 and ISBN-13: 978-1515171256. Paperback: 264 pages.

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DOI:

Re: Tourniquet Effectiveness When Placed Over the Joint Service Lightweight Integrated Suit Technology

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Picard CT, Douma MJ. 18(2). 148 - 148. (Letter)

Keywords: letter; tourniquets; Joint Service Lightweight Integrated Suit Technology

PMID: 29889974

DOI: RK3E-18OQ

Real-World Experience With Three Point-of-Care Blood Analyzers in Deployed Environments

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Peffer J, Ley N, Wuelher J, d'Andrea P, Rittberg C, Losch J, Lynch JH. 15(4). 109 - 112. (Journal Article)

Abstract

Austere environments such as Africa pose clinical challenges, which are multiplied for Special Operations Forces (SOF) providers who must face these challenges with limited resources against the tyranny of distance. These limited resources apply not only to treatment tools but to diagnostic tools as well. Laboratory diagnostics may provide critical information in diagnosis, initial triage, and/or evacuation decisions, all of which may enhance a patient's survival. However, unlike in climatecontrolled, fixed-facility hospitals, the deployed SOF provider must have access to a simple, reliable device for point-of-care testing (POCT) to obtain clinically meaningful data in a practical manner given the surroundings.

Keywords: Africa; medicine, tactical; testing, laboratory; analyzers, blood, point-of-care; malaria; HIV; medicine, wilderness

PMID: 26630105

DOI: I2HN-VEXM

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Recent Considerations in Tactical Medicine

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Rush SC. 13(2). 54 - 58. (Journal Article)

Abstract

A philosophical approach to tactical and remote medicine should be reflected in the gear (e.g., equipment and technology) chosen as well as the protocols used. The gear needs to be lightweight and small volume. As much as possible, it should have multiple uses, and there should be no redundancy with other items. When modern technology (e.g., hemostatic gauze, pulse oximeters, etc.) allows it to have unique applications, it should be used. Otherwise, if simple basic gear works, it should remain a staple (e.g., cravats). Protocols should reflect the goal to provide thorough care in an efficient manner. They should be straightforward and scaleable and be capable of being trained in a fashion that will allow them to become automatic under duress. These guiding principles establish a basis from which the Special Operations Forces/Tactical Medic or PJ can operate to maximal effectiveness. This article will describe current thinking in Pararescue as it relates to gear and protocols.

Keywords: tactical medicine; remote medicine; pararescue

PMID: 23817879

DOI: NTNR-ENJW

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Recovery of Bacteria and Fungi From a Leg Wound

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Washington M, Barnhill JC, Duff MA, Griffin J. 15(4). 113 - 116. (Journal Article)

Abstract

Acute and chronic wound infections can both be encountered in the deployed setting. These wounds are often contaminated by bacteria and fungi derived from the external environment. In this article, we present the case of a wound infection simultaneously colonized by Enterobacter cloacae (a bacterial pathogen) and Trichosporon asahii (an unusual fungal pathogen). We describe the examination and treatment of the patient and review the distinguishing characteristics of each organism

Keywords: infection; bacteria; fungi; Enterobacter cloacae; Trichosporon asahii

PMID: 26630106

DOI: DW1G-SZNG

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Red Rash

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Banting J, Meriano T. 16(1). 76 - 80. (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: rash; rash, red; dermatology

PMID: 27045501

DOI: CYZD-R2IP

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Redefining Technical Rescue and Casualty Care for SOF: Part 1

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McKay SD, Johnston J, Callaway DW. 12(4). 86 - 93. (Journal Article)

Abstract

Trauma care in the tactical environment is complex; it requires a unique blend of situational awareness, foresight, medical skill, multitasking, and physical strength. Rescue is a critical, but often over-looked, component of nearly all tactical trauma casualty management. Successful fullspectrum casualty management requires proficiency in four areas: casualty access, assessment, stabilization, and extraction. When complex rescue situations arise (casualty removal from roof tops, mountain terrain, collapsed structures, wells, or a karez), casualty care often becomes further complicated. Special Operations units have historically looked to civilian technical rescue techniques and equipment to fill this "rescue gap." Similar to the evolution of pre-hospital military medicine from civilian guidelines (e.g. Advanced Trauma Life Support) (ATLS)) to an evidence-based, tactical-specific guideline (Tactical Combat Casualty Care (TCCC)), an evolution is required within the rescue paradigm. This shift from civilian-based technical rescue guidelines towards an Operational Rescue™ capability allows tactical variables such as minimal equipment, low light/night vision goggles (NVG) considerations, enemy threats, and variable evacuation times to permeate through the individual rescue skill set. Just as with TCCC, in which the principles of casualty care remain consistent, the practices must be adapted to end-users environment, so it is with rescue.

Keywords:

PMID: 23536462

DOI: YT1M-YHYX

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Red-Green Tactical Lighting Is Preferred for Suturing Wounds in a Simulated Night Environment

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Noyes BP, Mclean JB, Walchak AC, Zarow GJ, Gaspary MJ, Knoop KJ, Roszko PJ. 21(1). 65 - 69. (Journal Article)

Abstract

Background: Delivering medical care in nighttime conditions is challenging, as 25% of Special Operations medical Operators have reported that problems with lighting contributed to poor casualty outcomes. Red light is often used in nighttime operations but makes blood detection difficult and diminishes depth perception and visual acuity. Red-green combination lighting may be superior for differentiating blood from tissue and other fluids but had not been tested versus red-only or green-only lighting for combat-related medical procedures, such as wound suturing. Methods: Dark-adapted medical resident physicians (N = 24) sutured 6cm long, 3cm deep, full-thickness lacerations in deceased swine under red-only, green-only, and red-green lighting provided by a tactical flashlight using a randomized within-subjects design. Time to suture completion, suture quality, user ratings, and user preference data were contrasted at p < .05. This study was approved by Naval Medical Center Portsmouth IRB. Results: Suture completion time and suture quality were similar across all lighting conditions. Participants rated red-green lighting as significantly easier for identifying blood, identifying instruments, and performing suturing (p < .01). Red-green lighting was preferred by 83% of participants compared to 8% each for red-only and green-only (p < .001). Conclusions: Pending further study under tactical conditions, red-green lighting is tentatively recommended for treating battlefield wounds in low-light environments.

Keywords: First-Light; combat medicine; light discipline; combat lighting; tactical lighting

PMID: 33721309

DOI: KB62-0IBO

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Red-Green Versus Blue Tactical Light: A Direct, Objective Comparison

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Pedler M, Ruiz F, Lamari M, Hutchinson C, Noyes B, Petrash M, Calvano CJ, La Porta A, Enzenauer RW. 16(4). 54 - 58. (Journal Article)

Abstract

Background: Success in Special Operations Forces medicine (SOFMED) depends on maximizing visual capability without compromising the provider or casualty when under fire. There is no single light that has been deemed "ideal" for all SOFMED environments. Methods: We used the Farnsworth-Munsell (FM) hue test to determine color vision of normal subjects under white, red-green, and blue flashlights to determine color discrimination. Then we used a timed color-determination visual test to determine how quickly normal subjects can identify color correctly. We had subjects perform a simulated surgery illuminated by a normal white-light source, then by red-green or blue light-emitting diode (LED) tactical light. Results: The total error score for white light was 49.714, 272.923 for red/green light, and 531.4 for blue light. The subjective perception of simulated trauma wounds was not substantially different with red-green LED tactical light when compared with white LED light. However, simulated surgery under the blue LED was more difficult compared with simulated surgery under the red-green LED light. Conclusion: Red-green was a superior light source for SOFMED and military first responders in this study, especially, where light was required to allow accurate and efficient application of Tactical Combat Casualty Care to injured personnel.

Keywords:

PMID: 28088818

DOI: O7LR-1Z1H

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Regimented Techniques Facilitate a Rapid Ascent to Very High Altitude: A Controlled Study

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Anglim AM, Boyd DW. 12(2). 48 - 57. (Journal Article)

Abstract

Objective: For travel to high altitudes, most experts advise a gradual ascent regimen to prevent acute mountain sickness (AMS). Such standard recommendations are applied to the general public. It is generally thought, however, that those whose work requires frequent rapid ascents, such as military personnel, porters and guides, often make these ascents without adequate preventive measures and then, experience significant morbidity and potential mortality due to AMS. The aim of this study were to demonstrate that the risk of rapid ascents can be mitigated if performed with adherence to a structured nutrition and hydration plan, carrying controlled loads, and taking specific prescribed rest periods during the ascent. Methods: This study used a randomized controlled trial of a group of Nepali porters, guides, and a Westerner with similar characteristics, all participating in their first ascent of the early Himalayan season. Data collected each day included oxygen saturation (SpO(2)), heart rate (HR), weight, and blood pressure (BP). Data was collected every 300 meters(m) (1,000 feet [ft]) and at the same time and altitude at each days end. Ascent profiles, age, gender, ethnic origin, altitude of residence and experience at altitude were also obtained. In four days, a control group of Nepali porters and a Sherpa guide and an equal number of Nepali porters and a Sherpa guide in an intervention group, (led by a Westerner) went from Kathmandu (1,300m), to the summit of Kala Pattar (5,640m), and Everest Base Camp (5,380m), averaging approximately 1,000m (3,500ft) gain a day in altitude, with no acclimatization rest days. During the rapid ascent from 4,300ft to 18,500ft, a regimented program was followed by the intervention group, while the control group ascended using their traditional methods as Nepali porters and Sherpa guides. Values are given as mean ± SE. T-test, ANOVA, and Mann-Whitney tests were used to compare variables. Results: Based on mean SpO(2) measurements on the summit of Kala Pattar at 5,640m (18,500ft), the intervention group had a SpO(2) of 79.5% ± 3.209 and the control group's mean SpO(2) was 74.5% ± 3.109 (ρ = .076). Importantly, two participants dropped out of the control group at 4,900m with SpO(2) scores of 77 and 71. The ANOVA results between the groups SpO(2) at 5,640m was significant at p ≥ .04. Mann Whitney U test results demonstrate a significant (U = 21.5, p = .04) difference in median SpO(2) levels between the intervention and the control groups. This indicates that employing a regimented program is vital to the objective of sustaining adequate SpO(2) levels and yielding a successful climb. The intervention group that followed the regimented nutrition, hydration, and rest period program performed physiologically superior to the control group, especially on the longest (10 hours), highest (5,640m), and greatest altitude gain (1,090m) day-despite resting for five minutes every 25 minutes of hiking. This was achieved with no acclimatization days, and each participant residing at low altitude. Conclusions: Participants who followed a structured nutrition, hydration plan, and adhered to prescribed rest periods, performed physiologically superior to the control group who did not. Two control group participants dropped out with poor physiological measurements. This aggressive ascent profile mirrors encountered work demands on military personnel, professional porters, and guides. The beneficial effect was significant and could provide superior methods to those whose duties require aggressive ascent profiles. The implications of frequent rest periods (10 minutes an hour), a high-carbohydrate diet, and at least 3,000ml of fluid a day appear to factually present a physiologically superior method to trekking at high to very-high altitudes. The health implications for trekkers to the Himalaya (or to any place at high altitude) by using a similar regimented program are that it may allow for an AMS-free, more enjoyable experience at altitude.

Keywords: high altitude; prevention of AMS; rapid ascent; military; Nepal; Sherpa; Porter

PMID: 22707025

DOI: P704-6GXU

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Regional Anesthetic Blocks For The Cure Of Minor Upper Extremity Wounds: Part One

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Arne BC. 10(3). 120 - 122. (Journal Article)

Keywords:

PMID: 21140986

DOI: JT71-9G2E

Regional Anesthetic Blocks Fot The Cure Of Minor Lower Extremity Wounds: Part Two

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Arne BC. 10(3). 123 - 125. (Journal Article)

Keywords:

PMID: 21140987

DOI: ORO8-YKA2

Remote Dental Surgery as a Medical Civilian Assistance Program (MEDCAP): Helping Iraqi, Kurdish, and U.S. Forces Win Hearts and Minds in the Fight Against Daesh

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Ferreira B. 17(3). 148 - 150. (Journal Article)

Abstract

Dr Ferreira discusses the work of the Humanitarian Aid and Security Forces (HASF) in providing volunteer dental services to a local Christian militia in Mosul, Iraq.

Keywords: iraq; dentistry; Humanitarian Aid and Security Forces

PMID: 28910487

DOI: 6U1I-0SSE

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Remote Telementored Ultrasound-Directed Compression to Potentially Accelerate Hemostasis in Exsanguinating Junctional Vascular Injuries

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Kirkpatrick AW, McKee JL, McKee I, Panebianco NL, Ball CG. 15(4). 71 - 74. (Journal Article)

Abstract

Bleeding to death has been identified as the leading cause of potentially preventable injury-related death worldwide. Temporary hemorrhage control could allow the patient to be transported to a site capable of damage- control surgery. A novel device that may offer a fast and effective means of controlling nontruncal bleeding (junctional and extremity) is the iTClamp (Innovative Trauma Care; http://innovativetraumacare.com). This case study demonstrated that a motivated and intelligent, but untrained, first responder could successfully localize the actual anatomic site of an exsanguinating bleed and then could relatively easily compress this site to control the bleeding site by using ultrasound-guided manual-compression techniques.

Keywords: hemorrhage; iTClamp; ultrasound; bleeding; control

PMID: 26630098

DOI: DQZ8-G4IY

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Replacement of Promethazine With Ondansetron for Treatment of Opioid- and Trauma-Related Nausea and Vomiting in Tactical Combat Casualty Care

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Onifer DJ, Butler FK, Gross K, Otten EJ, Patton R, Russell RJ, Stockinger Z, Burrell E. 15(2). 17 - 24. (Journal Article)

Abstract

The current Tactical Combat Casualty Care (TCCC) Guidelines recommend parenteral promethazine as the single agent for the treatment of opioid-induced nausea and/or vomiting and give a secondary indication of "synergistic analgesic effect." Promethazine, however, has a well-documented history of undesired side effects relating to impairment and dysregulation of the central and autonomic nervous systems, such as sedation, extrapyramidal symptoms, dystonia, impairment of psychomotor function, neuroleptic malignant syndrome, and hypotension. These may be particularly worrisome in the combat casualty. Additionally, since 16 September 2009, there has been a US Food and Drug Administration (FDA) black box warning for the injectable form of promethazine, due to "the risk of serious tissue injury when this drug is administered incorrectly." Conversely, ondansetron, which is now available in generic form, has a well-established favorable safety profile and demonstrated efficacy in undifferentiated nausea and vomiting in the emergency department and prehospital settings. It has none of the central and autonomic nervous system side effects noted with promethazine and carries no FDA black box warning. Ondansetron is available in parenteral form and an orally disintegrating tablet, providing multiple safe and effective routes of administration. Despite the fact that it is an off-label use, ondansetron is being increasingly given for acute, undifferentiated nausea and vomiting and is presently being used in the field on combat casualties by some US and Allied Forces. Considering the risks involved with promethazine use, and the efficacy and safety of ondansetron and ondansetron's availability in a generic form, we recommend removing promethazine from the TCCC Guidelines and replacing it with ondansetron.

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PMID: 26125161

DOI: 23QE-HGO7

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Resilience and Suicide in Special Operations Forces: State of the Science via Integrative Review

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Rocklein Kemplin K, Paun O, Godbee DC, Brandon JW. 19(2). 57 - 66. (Journal Article)

Abstract

Background: Due to alarming rates of suicide in Special Operations Forces (SOF) and associated effects of traumatic stress in military populations writ large, resilience initiatives thought to influence Servicemembers' mitigation of traumatic stress and thus lower suicide risks have been implemented throughout the services. Since combat operations commenced in multiple theaters of war nearly two decades ago, resilience in conventional military populations became a topic of keen interest throughout departments of defense worldwide as well. Despite researchers' consistent assertions that SOF are highly resilient and at low risk for suicide, granular analysis of pertinent research and escalating suicide in SOF reveals no empirical basis for those beliefs. Methods: We report findings from an integrative review of resilience research in SOF and larger military populations to contextualize and augment understanding of the phenomenon. Results: Throughout the literature, conceptual and operational definitions of resilience varied based on country, context, investigators, and military populations studied. We identified critical gaps in resilience knowledge in the military, specifically: Resilience has not been studied in SOF; resilience is not concretely established to reduce suicide risk or proven to improve mental health outcomes; resilience differs when applied as a psychological construct; resilience research is based on specific assumptions of what composes resilience, depending on methods of measurement; resilience studies in this population lack rigor; research methodologies and conflicting interests invite potential bias. Conclusion: This integrative review highlights emergent issues and repetitive themes throughout military resilience research: resilience program inefficacy, potential investigator bias, perpetuated assumptions, and failure to capture and appropriately analyze germane data. Because of overall inconsistency in military resilience research, studies have limited external validity, and cannot be applied beyond sampled populations. Resilience cannot be responsibly offered as a solution to mitigating posttraumatic stress disorder nor suicide without detailed study of both in SOF.

Keywords: military; Special Operations Forces; resilience; suicide; traumatic stress; integrative review

PMID: 31201752

DOI: BQES-AM8H

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Resistance Operating Concept (ROC)

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Farr WD. 20(3). 158 - 158. (Book Review)

Abstract

Fiala OC. Resistance Operating Concept (ROC). MacDill Air Force Base, FL: The Joint Special Operations University Press; April 2020. 283 pages, softback. ISBN 978-1-941715-43-7.

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DOI:

Resourcing Interventions Enhance Psychology Support Capabilities in Special Operations Forces

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Myatt CA, Auzenne JW. 12(4). 54 - 59. (Journal Article)

Abstract

This study provides an examination of approaches to United States Government (USG) resourcing interventions on a national scale that enhance psychology support capabilities in the Special Operations Forces (SOF) community. A review of Congressional legislation and resourcing trends in the form of authorizations and appropriations since 2006 demonstrates how Congress supported enhanced psychology support capabilities throughout the Armed Forces and in SOF supporting innovative command interests that address adverse affects of operations tempo behavioral effects (OTBE). The formulation of meaningful metrics to address SOFspecific command interests led to a personnel tempo (PERSTEMPO) analysis in response to findings compiled by the Preservation of the Force and Families (POTFF) Task Force. The review of PERSTEMPO data at subordinate command and unit levels enhances the capability of SOF leaders to develop policy and guidance on training and operational planning that mitigates OTBE and maximizes resourcing authorizations. A major challenge faced by the DoD is in providing behavioral healthcare that meets public and legislative demands while proving suitable and sustainable at all levels of military operations: strategic, operational, and tactical. Current legislative authorizations offer a mechanism of command advocacy for resourced multi-functional program development that enhances psychology support capabilities while reinforcing SOF readiness and performance.

Keywords: resourcing interventions; psychology support capabilities; operations tempo behavioral effects (OTBE); personnel tempo (PERSTEMPO); Preservation of the Force and Families (POTFF)

PMID: 23536458

DOI: F2OE-PAGK

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ReSTART: A Novel Framework for Resource-Based Triage in Mass-Casualty Events

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Mills AF, Argon NT, Ziya S, Hiestand B, Winslow J. 14(1). 30 - 39. (Journal Article)

Abstract

Objective: Current guidelines for mass-casualty triage do not explicitly use information about resource availability. Even though this limitation has been widely recognized, how it should be addressed remains largely unexplored. The authors present a novel framework developed using operations research methods to account for resource limitations when determining priorities for transportation of critically injured patients. To illustrate how this framework can be used, they also develop two specific example methods, named ReSTART and Simple- ReSTART, both of which extend the widely adopted triage protocol Simple Triage and Rapid Treatment (START) by using a simple calculation to determine priorities based on the relative scarcity of transportation resources. Methods: The framework is supported by three techniques from operations research: mathematical analysis, optimization, and discrete-event simulation. The authors' algorithms were developed using mathematical analysis and optimization and then extensively tested using 9,000 discrete-event simulations on three distributions of patient severity (representing low, random, and high acuity). For each incident, the expected number of survivors was calculated under START, ReSTART, and Simple-ReSTART. A web-based decision support tool was constructed to help providers make prioritization decisions in the aftermath of mass-casualty incidents based on ReSTART. Results: In simulations, ReSTART resulted in significantly lower mortality than START regardless of which severity distribution was used (paired t test, ρ < .01). Mean decrease in critical mortality, the percentage of immediate and delayed patients who die, was 8.5% for low-acuity distribution (range -2.2% to 21.1%), 9.3% for random distribution (range -0.2% to 21.2%), and 9.1% for high-acuity distribution (range -0.7% to 21.1%). Although the critical mortality improvement due to ReSTART was different for each of the three severity distributions, the variation was less than 1 percentage point, indicating that the ReSTART policy is relatively robust to different severity distributions. Conclusions: Taking resource limitations into account in mass-casualty situations, triage has the potential to increase the expected number of survivors. Further validation is required before field implementation; however, the framework proposed in here can serve as the foundation for future work in this area.

Keywords: triage; mass-casualty event; prioritization

PMID: 24604436

DOI: CCCB-OGNO

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ReSTRAiN Yourself Before Diagnosing Strain

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Hampton K, Van Humbeeck L. 19(3). 122 - 122. (Journal Article)

Keywords:

PMID: 31539447

DOI: HNH1-QJCV

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Results Of Vietnamese Acupuncture Seen At The Second Surgical Hospital

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Rich NM, Dimond FC. 09(2). 102 - 104. (Previously Published)

Previously published in Military Medicine-October, 1967

Abstract

One of the rewards in the medical service in a foreign land is the exposure to exotic diseases and methods of therapy which are virtually unknown to many physicians in the western world. With the treatment of Vietnamese patients by medical personnel from the United States and other countries with a similar system of medical education, new experiences and challenges are presented daily. The use of acupuncture as a form of therapy is undoubtedly as unfamiliar to many physicians as it was to us. In addition to our treatment of American casualties at the Second Surgical Hospital in the Republic of Vietnam, we had the opportunity of treating some interesting problems in Vietnamese patients who had previously been treated with acupuncture. The majority of our own staff questioned, "What is acupuncture?"

Keywords:

PMID: 19813523

DOI: JWKL-SLE2

Resuscitation During Critical Care Transportation in Afghanistan

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Tobin JM, Nordmann GR, Kuncir EJ. 15(3). 72 - 75. (Journal Article)

Abstract

Objective: These data describe the critical care procedures performed on, and the resuscitation markers of, critically wounded personnel in Afghanistan following point of injury (POI) transports and intratheater transports. Providing this information may help inform discussion on the design of critical care transportation platforms for future conflicts. Methods: The Department of Defense Trauma Registry (DoDTR) was queried for descriptive data on combat casualties with Injury Severity Score (ISS) greater than 15 who were transported in Operation Enduring Freedom (OEF) from 1 January 2010 to 31 December 2010. Both POI transportation events and interfacility transportation events were reviewed. Base deficit (BD) was evaluated as a maker of resuscitation, and international normalized ratio (INR) was evaluated as a measure of coagulopathy. Results: There were 1198 transportation events that occurred during the study period - 634 (53%) transports from the POI and 564 (47%) intratheater transports. Critical care interventions were performed during 147 (12.3%) transportation events, including intubation, cricothyrotomy, double-lumen endotracheal tube placement, needle or tube thoracostomy, central venous access placement, and cardiopulmonary resuscitation. The mean BD on arrival in the emergency department was -5.4 mEq/L for POI transports and 0.68 mEq/L intratheater transports (ρ < .001). The mean INR on arrival in the emergency department was 1.48 for POI transports and 1.21 for intratheater transports (ρ < .001). Conclusions: Critical care interventions were needed frequently during evacuation of severely injured personnel. Furthermore, many troops arrived acidotic and coagulopathic following initial transport from POI. Together, these data suggest that a platform capable of damage control resuscitation and critical care interventions may be warranted on longer transports of more critically injured patients.

Keywords: transportation; critical care; resuscitation, trauma; damage control; emergency medical services; care, out-of-hospital

PMID: 26360357

DOI: V3ZO-RG71

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Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA): Introduction

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King DR. 18(1). 32 - 32. (Case Reports)

Keywords:

PMID: 29533430

DOI: W8DK-GCUA

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Resuscitative Endovascular Balloon Occlusion of the Aorta: Pushing Care Forward

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Teeter WA, Romagnoli AN, Glaser J, Fisher AD, Pasley JD, Scheele B, Hoehn M, Brenner ML. 17(1). 17 - 21. (Case Reports)

Abstract

Background: Resuscitative endovascular balloon occlusion of the aorta (REBOA), used to temporize noncompressible and junctional hemorrhage, may be deployable to the forward environment. Our hypothesis was that nonsurgeon physicians and high-level military medical technicians would be able to learn the theory and insertion of REBOA. Methods: US Army Special Operations Command medical personnel without prior endovascular experience were included. All participants received didactic instruction of the Basic Endovascular Skills for Trauma Course™ together, with individual evaluation of technical skills. A pretest and a posttest were administered to assess comprehension. Results: Four members of US Army Special Operations Command-two nonsurgeon physicians, one physician assistant, and one Special Operations Combat Medic-were included. REBOA procedural times moving from trial 1 to trial 6 decreased significantly from 186 ± 18.7 seconds to 83 ± 10.3 seconds (ρ < .0001). All participants demonstrated safe REBOA insertion and verbalized the indications for REBOA insertion and removal through all trials. All five procedural tasks were performed correctly by each participant. Comprehension and knowledge between the pretest and posttest improved significantly from 67.6 ± 7.3% to 81.3 ± 8.1% (ρ = .039). Conclusion: This study demonstrates that nonsurgeon and nonphysician providers can learn the steps required for REBOA after arterial access is established. Although insertion is relatively straightforward, the inability to gain arterial access percutaneously is prohibitive in providers without a surgical skillset and should be the focus of further training.

Keywords: REBOA; resuscitative endovascular balloon occlusion of the aorta; training; virtual reality simulation; junctional hemorrhage; noncompressable torso hemorrhage

PMID: 28285476

DOI: BQOR-ZQYJ

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Rethinking Heat Injury in the SOF Multipurpose Canine: A Critical Review

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Baker JL, Hollier PJ, Miller L, Lacy WA. 12(2). 8 - 15. (Journal Article)

Abstract

Heat injury is a significant concern of the Special Operations Forces Multipurpose Canine (SOF MPC). The unique athletic abilities and working environment of the SOF MPC differ from that of companion dogs or even conventional military working dogs. This should be considered in the prevention, diagnosis, and treatment of heat injury of the SOF MPC. A critical review of the literature on canine heat injury as it pertains to working dogs demonstrates limited scientific evidence on best practices for immediate clinical management of heat injury in SOF MPCs. A majority of management guidelines for heat injury in veterinary reference books and journals are based on review articles or professional opinion of the author vs. evidence from original research. In addition, guidelines are written primarily for companion animal populations vs. SOF MPCs and focus on measures to be undertaken in a clinical setting vs. point of injury. The phenomenon of "circular referencing" is also prevalent in the heat injury literature. Current guidelines supported by review articles and textbooks often provide no citation or cite other review articles for clinical standards such as normal temperature ranges, treatment methods, and recurrence of heat injury. This "circular referencing" phenomenon misrepresents anecdotal evidence and professional opinion as scientifically validated, reinforcing concepts and recommendations that are not truly supported by the evidence. Further study is needed to fully understand heat injury in SOF MPCs and how this applies to prevention, diagnosis and treatment guidelines. In order to provide SOF canine programs with best clinical advice and care, SOF Veterinarians must make clinical judgments based on evaluation of the most accurate and valid information possible. Clinical guidelines are fluid and should be reviewed regularly for relevance to the defined population in question. Clinical Guidelines should also be utilized as guiding principles in conjunction with clinical judgment vs. dictate a clinical protocol. SOF veterinarians as the veterinary support asset to SOF MPC programs should be clinically competent as well as versed in evidence based medicine practices to provide the cutting edge clinical support that is required to keep SOF MPCs operating in modern warfare environments.

Keywords:

PMID: 22707020

DOI: Y0AS-S4Y3

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Return to Duty After Severe Bilateral Lower Extremity Trauma

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Sheean AJ, Owens J, Suttles ST, Crossland BW, Stinner DJ. 15(1). 1 - 6. (Case Reports)

Abstract

Despite the preponderance of evidence demonstrating poor outcomes as a result of combat-related orthopaedic trauma, teams of medical professionals have remained undaunted in their pursuit of innovative techniques to maximize the functional capacity of Servicemembers with devastating extremity injuries. We present the case of an Active Duty Special Forces (SF) qualified senior noncommissioned officer (NCO) with severely injured extremities successfully salvaged with a multidisciplinary program involving cutting-edge prosthetic technology and a novel approach to physical rehabilitation.

Keywords: ankle fusion; outcomes; limb salvage; rehabilitation

PMID: 25770792

DOI: 1Y4T-447E

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Return to Full Duty After Anterior Cruciate Ligament Reconstruction: Is the Second Time More Difficult?

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Enad JG, Zehms CT. 13(1). 2 - 6. (Journal Article)

Abstract

Anterior cruciate ligament (ACL) injuries occur repeatedly in Special Operations Forces (SOF). In this study, we sought to determine whether military patients requiring a second (i.e., revision) ACL reconstruction in the same knee had a lower rate of return to full duty and greater chance of medical discharge versus those undergoing first-time (i.e., primary) ACL knee surgery. A sin-gle-institution, retrospective analysis of surgical records and medical board data of active duty members during a 4-year period identified 19 revision and 169 primary ACL cases, respectively. Measured end points were rate of return to full duty in each group and odds ratio (with 95% confidence interval) for medical discharge. Our results showed that 17 (90%) of 19 revision ACL patients returned to full duty at a mean of 7.5 ± 2.3 months. Two patients did not return to full duty and were medically discharged at 12 and 13 months, respectively. Meanwhile, 155 (92%) of 169 primary ACL patients returned to full duty (mean 7.3 ± 2.3 months), and 14 patients were medically discharged (mean 8.5 ± 2.8 months). Patients in the revision group were only 1.30 times (odds ratio) (95% confidence interval, 0.2726-6.2229) more likely to be medically discharged than patients in the primary group. Overall, the majority of revision ACL surgeries were successful. The period of limited duty was slightly longer after revision ACL surgery. Return to full duty was seen at a similar rate as primary ACL surgery, and the odds of medical discharge were statistically similar. The results are useful in counseling SOF members who might need to undergo revision ACL surgery.

Keywords:

PMID: 23526315

DOI: WB7Y-PJOF

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Review of 54 Cases of Prolonged Field Care

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DeSoucy ES, Shackelford S, DuBose JJ, Zweben S, Rush SC, Kotwal RS, Montgomery HR, Keenan S. 17(1). 121 - 129. (Journal Article)

Abstract

Background: Prolonged field care (PFC) is field medical care applied beyond doctrinal planning time-lines. As current and future medical operations must include deliberate and contingency planning for such events, data are lacking to support efforts. A case review was conducted to define the epidemiology, environment, and operational factors that affect PFC outcomes. Methods: A survey distributed to US military medical providers solicited details of PFC encounters lasting more than 4 hours and included patient demographics, environmental descriptors, provider training, modes of transportation, injuries, mechanism of injury, vital signs, treatments, equipment and resources used, duration of PFC, and morbidity and mortality status on delivery to the next level of care. Descriptive statistics were used to analyze survey responses. Results: Surveys from 54 patients treated during 41 missions were analyzed. The PFC provider was on scene at time of injury or illness for 40.7% (22/54) of cases. The environment was described as remote or austere for 96.3% (52/54) of cases. Enemy activity or weather also contributed to need for PFC in 37.0% (20/54) of cases. Care was provided primarily outdoors (37.0%; 20/54) and in hardened nonmedical structures (37.0%; 20/54) with 42.6% (23/54) of cases managed in two or more locations or transport platforms. Teleconsultation was obtained in 14.8% (8/54) of cases. The prehospital time of care ranged from 4 to 120 hours (median 10 hours), and five (9.3%) patients died prior to transport to next level of care. Conclusion: PFC in the prehospital setting is a vital area of military medicine about which data are sparse. This review was a novel initial analysis of recent US military PFC experiences, with descriptive findings that should prove helpful for future efforts to include defining unique skillsets and capabilities needed to effectively respond to a variety of PFC contingencies.

Keywords: prolonged field care; after action review; military medicine; prehospital; medical evacuation

PMID: 28285490

DOI: OAL4-CBRC

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Review of Canine Deaths While in Service in US Civilian Law Enforcement (2002-2012)

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Stojsih SE, Baker JL, Les CM, Bir CA. 14(4). 86 - 91. (Journal Article)

Abstract

Background: Working dogs have been proven effective in multiple military and law enforcement applications. Similar to their human counterparts, understanding mortality while still in service can help improve treatment of injuries, and improve equipment and training, to potentially reduce deaths. This is a retrospective study to characterize mortality of working dogs used in civilian law enforcement. Methods: Reported causes of death were gathered from two working dog and law enforcement officer memorial websites. Results: Of the 867 civilian law enforcement dogs reported to these memorial websites from 2002 to 2012 with reported causes of death while in service, the deaths of 318 were categorized as traumatic. The leading reported causes of traumatic death or euthanasia include trauma as a result of a vehicle strike, 25.8% (n = 82); heatstroke, 24.8% (n = 79); and penetrating ballistic trauma, 23.0% (n = 73). Conclusion: Although the information gathered was from online sources, this study casts some light on the risks that civilian law enforcement dogs undergo as part of the tasks to which they are assigned. These data underscore the need for a comprehensive database for this specialized population of working dogs to provide the robust, reliable data needed to develop prevention and treatment strategies for this valuable resource.

Keywords: canine; mortality; law enforcement; trauma

PMID: 25399373

DOI: 7R21-PW29

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Review of the Paris Special Operations Forces Combat Medical Care Conference, Fall 2022

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Pasquier P, Josse F, Mahe P. 23(1). 117 - 126. (Clinical Conference)

Abstract

For the first time in Europe, the Paris Special Operations Forces-Combat Medical Care (SOF-CMC) Conference, a satellite conference of the CMC-Conference in Ulm, Germany, took place on October 20-21, 2022, at the famous École du Val-de-Grâce in Paris, France, a historic and emblematic site for French military medicine (Figure 1). The Paris SOF-CMC Conference was organized by the French SOF Medical Command and the CMC Conference. Under the authority of COL Dr Pierre Mahé (French SOF Medical Command), the two scientific leaders of the conference (Figure 2), COL Prof. Pierre Pasquier (France) and LTC Dr Florent Josse (Germany), advanced a high scientific level around medical support in the field of Special Operations. This international symposium was dedicated to military physicians and paramedics as well as trauma and specialized surgeons involved in the medical support of Special Operations. International medical experts provided updates on current scientific data. They also presented the points of view of their respective nations on the evolution of war medicine during very high-level scientific sessions. The conference brought together nearly 300 participants (Figure 3), speakers, and industrial partners from more than 30 countries (Figure 4). This new Paris SOF-CMC Conference will be held every 2 years alternately with the CMC Conference in Ulm.

Keywords:

PMID: 36878849

DOI: 3WQ1-Z1Z8

Review, Clinical Update, and Practice Guidelines for Excited Delirium Syndrome

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Gerold KB, Gibbons ME, Fisette RE, Alves D. 15(1). 62 - 69. (Journal Article)

Abstract

Excited delirium syndrome (ExDS) is a term used to describe patients experiencing a clinical condition characterized by bizarre and aggressive behavior, often in association with the use of chronic sympathomimetic drug abuse. The agitated and disruptive behavior of persons with ExDS often results in a call to police resulting in an arrest for disorderly conduct. The suspect's inability to comply with police commands during the arrest frequently results in a struggle and the use of physical or chemical control measures, including the use of conductive energy weapons (CEWs). Deaths from this hypermetabolic syndrome are infrequent but potentially preventable with early identification, a coordinated aggressive police intervention, and prompt medical care. Preliminary experiences suggest that ExDS is a medical emergency treated most effectively using a coordinated response between police officers and emergency medical providers. Once the person suspected of experiencing ExDS is in custody, medical providers should rapidly sedate noncompliant patients with medications such as ketamine or an antipsychotic drug such as haloperidol in combination with a benzodiazepine drug such as midazolam or diazepam. Once sedated, patients should undergo a screening medical assessment and undergo initial treatment for conditions such as hyperthermia and dehydration. All patients exhibiting signs of ExDS should be transported rapidly to a medical treatment facility for further evaluation and treatment. This article reviews the epidemiology, clinical presentation, diagnosis, and treatment options for ExDS.

Keywords: excited delirium; excited delirium syndrome; delirium; sudden death; in-custody death; hyperthermia; sympathomimetic drug use; cocaine; phencyclidine; lysergic acid diethylamide; ketamine; haloperidol; taser; conductive energy weapon; Agitated Chaotic Event&tm;; ACE; medical emergency; emergency medical services; police

PMID: 25770800

DOI: 7NEE-ZX24

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Review: Getting Tourniquets Right = Getting Tourniquets Tight

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Wall PL, Buising CM, Sahr SM. 19(3). 52 - 63. (Journal Article)

Abstract

Tourniquet application to stop limb bleeding is conceptually simple, but optimal application technique matters, generally requires training, and is more likely with objective measures of correct application technique. Evidence of problems with application techniques, knowledge, and training can be ascertained from January 2007 to August 2018 PubMed peer-reviewed papers and in Stop The Bleed-related videos. Available data indicates optimal technique when not under fire involves application directly on skin. For nonelastic tourniquets, optimal application technique includes pulling the strap tangential to the limb at the redirect buckle (parallel to the limb-encircling strap entering the redirect buckle). Before engaging the mechanical advantage tightening system, the secured strap should exert at least 150mmHg inward, and skin indentation should be visible. For Combat Application Tourniquets, optimal technique includes the slot in the windlass rod parallel to the stabilization plate during the single 180° turn that should be sufficient for achieving arterial occlusion, which involves visible skin indentation and pressures of 250mmHg to 428mmHg on normotensive adult thighs. Appropriate pressures on manikins and isolated-limb simulations depend on how the under-tourniquet pressure response of each compares to the under-tourniquet pressure response of human limbs for matching tourniquet-force applications. Lack of such data is one of several concerns with manikin and isolated-limb simulation use. Regardless of model or human limb use, pictures and videos purporting to show proper tourniquet application techniques should show optimal tourniquet application techniques and properly applied, arterially occlusive limb tourniquets. Ideally, objective measures of correct tourniquet application technique would be included.

Keywords: tourniquet; tourniquet application; hemorrhage; first aid; emergency treatment

PMID: 31539434

DOI: RYU9-YZSV

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Rice-Based Electrolyte Drinks More Effective Than Water in Replacing Sweat Losses During Hot Weather Training and Operations

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Gerold KB, Greenough WB, Yasar S. 13(4). 12 - 14. (Journal Article)

Abstract

Heat-related injury presents significant threats to the health and operational effectiveness of Soldiers and military operations. In 2012, active component, U.S. Armed Forces experienced 365 incident cases of heat stroke and 2,257 incident cases of "other heat injury." Most of these occurred among recruit and enlisted personnel and most were under the age of 30. In conditioned military personnel, a rice-based oral rehydration solution was superior to water alone at maintaining body weight and, by inference, enabled Soldiers to better maintain their the state of hydration during prolonged exercise in high ambient temperatures. In view of the health risks associated with dehydration and their effects on training and operations, this study suggests that the consumption of beverages containing electrolytes and a rice-based carbohydrate is superior to the consumption of water alone in preventing dehydration and heat related illness.

Keywords: heat-related illness; dehydration; oral rehydration; water

PMID: 24227556

DOI: SE66-B7VN

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Rigid Eye Shields: A Critical Gap in the Individual First Aid Kit

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Brunstetter T, Diaz GY, Wasner C, Hart S, Burrows S. 13(3). 26 - 28. (Journal Article)

Abstract

From 5% to 22% of all U.S. Department of Defense combat casualties between 2001 and 2010 suffered some form of ocular trauma. Ocular injuries have an inordinately dramatic impact on return to duty, retention, and reintegration; only 25% of warfighters with severe ocular trauma return to duty. After a traumatic ocular event, the likelihood of saving an eye and preserving vision depends on several factors, especially the treatment quality at the point of injury. Every major organization associated with combat casualty care (e.g., the U.S. Army Institute of Surgical Research, the Committee on Tactical Combat Casualty Care, and the Department of Defense/VA Vision Center of Excellence) emphasizes the importance of placing a rigid eye shield on known/suspected eye injuries at point of injury. On the battlefield, there is no better way to protect an injured eye from further damage than with an eye shield, but shields are not readily available in individual first aid kits. Therefore, it is highly recommended that each Service rapidly integrate at least one rigid eye shield into every individual first aid kit, making them immediately available to every warfighter.

Keywords: rigid eye shield; ocular trauma; ballistic eye protection; eye injuries; open globe injuries; first aid kit

PMID: 24048984

DOI: L2NQ-GEBY

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Rigid Eye Shields: A Critical Gap in the Individual First Aid Kit Commentary

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Calvano CJ. 13(3). 29 - 30. (Journal Article)

Keywords:

PMID: 24048985

DOI: 2HPQ-ZK71

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Riot Medicine: Civil Disturbance Applications of the National Tactical Emergency Medical Support Competency Domains

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Pennardt A, West M. 20(4). 73 - 76. (Journal Article)

Abstract

The Portland, Oregon, Bureau of Fire & Rescue (PF&R) established a tactical emergency medical support team embedded within the Police Bureau's Rapid Response Team (RRT). The authors describe the team's training and their recent work.

Keywords: rapid response team; TEMS; teams; emergency medical support

PMID: 33320316

DOI: 3DP0-HYPT

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Rise and Kill First: The Secret History of Israel's Targeted Assassinations

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Farr WD. 19(1). 133 - 133. (Book Review)

Abstract

Bergman R. Rise and Kill First: The Secret History of Israel's Targeted Assassinations. New York, NY: Random House; 2018. Hardcover: 784 pages. ISBN-10: 1400069718, ISBN-13: 978-1400069712.

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DOI:

Rise of the Warrior Cop: The Militarization of America's Police Forces

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Farr WD. 15(2). 148 - 148. (Book Review)

Abstract

Balko, Radley. Rise of the Warrior Cop: The Militarization of America's Police Forces.
New York, NY: Public Affairs; 2013. Paperback 2014. ISBN 978-1-61039-457-4.

Keywords:

DOI:

Risk Associated With Autologous Fresh Whole Blood Training

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Donham B, Barbee GA, Deaton TG, Kerr W, Wier RP, Fisher AD. 19(3). 24 - 25. (Journal Article)

Abstract

Fresh whole blood (FWB) is increasingly being recognized as the ideal resuscitative fluid for hemorrhagic shock. Because of this, military units are working to establish the capability to give FWB from a walking blood bank donor in environments that are unsupported by conventional blood bank services. Therefore, many military units are performing autologous blood transfusion training. In this training, a volunteer has a unit of blood collected and then transfused back into the same donor. The authors report their experience performing an estimated 3408 autologous transfusions in training and report no instances of hemolytic transfusion reactions or other major complications. With appropriate control measures in place, autologous FWB training is low-risk training.

Keywords: military personnel; blood transfusion; autologous; simulation training

PMID: 31539430

DOI: 2708-3QM5

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Risk Factors for Injuries During Airborne Static Line Operations

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Knapik JJ, Steelman R. 14(3). 95 - 97. (Journal Article)

Abstract

US Army airborne operations began in World War II. Continuous improvements in parachute technology, aircraft exit procedures, and ground landing techniques have reduced the number of injuries over time from 27 per 1,000 descents to about 6 per 1,000 jumps. Studies have identified a number of factors that put parachutists at higher injury risk, including high wind speeds, night jumps, combat loads, higher temperatures, lower fitness, heavier body weight, and older age. Airborne injuries can be reduced by limiting risker training (higher wind speeds, night jumps, combat load) to the minimum necessary for tactical and operational proficiency. Wearing a parachute ankle brace (PAB) will reduce ankle injuries without increasing other injuries and should be considered by all parachutists, especially those with prior ankle problems. A high level of upper body muscular endurance and aerobic fitness is not only beneficial for general health but also associated with lower injury risk during airborne training.

Keywords: wind; night; combat load; temperature; fitness; parachute ankle brace

PMID: 25344715

DOI: AU63-1DVQ

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Risk of Harm Associated With Using Rapid Sequence Induction Intubation and Positive Pressure Ventilation in Patients With Hemorrhagic Shock

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Thompson P, Hudson AJ, Convertino VA, Bjerkvig C, Eliassen HS, Eastridge BJ, Irvine-Smith T, Braverman MA, Hellander S, Jenkins DH, Rappold JF, Gurney JM, Glassberg E, Cap AP, Aussett S, Apelseth TO, Williams S, Ward KR, Shackelford SA, Stroberg P, Vikeness BH, Pepe PE, Winckler CJ, Woolley T, Enbuske S, De Pasquale M, Boffard KD, Austlid I, Fosse TK, Asbjornsen H, Spinella PC, Strandenes G. 20(3). 97 - 102. (Editorial)

Abstract

Based on limited published evidence, physiological principles, clinical experience, and expertise, the author group has developed a consensus statement on the potential for iatrogenic harm with rapid sequence induction (RSI) intubation and positive-pressure ventilation (PPV) on patients in hemorrhagic shock. "In hemorrhagic shock, or any low flow (central hypovolemic) state, it should be noted that RSI and PPV are likely to cause iatrogenic harm by decreasing cardiac output." The use of RSI and PPV leads to an increased burden of shock due to a decreased cardiac output (CO)2 which is one of the primary determinants of oxygen delivery (DO2). The diminishing DO2 creates a state of systemic hypoxia, the severity of which will determine the magnitude of the shock (shock dose) and a growing deficit of oxygen, referred to as oxygen debt. Rapid accumulation of critical levels of oxygen debt results in coagulopathy and organ dysfunction and failure. Spontaneous respiration induced negative intrathoracic pressure (ITP) provides the pressure differential driving venous return. PPV subsequently increases ITP and thus right atrial pressure. The loss in pressure differential directly decreases CO and DO2 with a resultant increase in systemic hypoxia. If RSI and PPV are deemed necessary, prior or parallel resuscitation with blood products is required to mitigate post intervention reduction of DO2 and the potential for inducing cardiac arrest in the critically shocked patient.

Keywords:

PMID: 32969011

DOI: Q4G3-FEQR

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Risk of Harm in Needle Decompression for Tension Pneumothorax

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Thompson P, Ciaraglia A, Handspiker E, Bjerkvig C, Bynum JA, Glassberg E, Gurney J, Hudson AJ, Jenkins DH, Nicholson SE, Strandenes G, Braverman MA. 23(2). 9 - 12. (Journal Article)

Abstract

Introduction: Tension pneumothorax (TPX) is the third most common cause of preventable death in trauma. Needle decompression at the fifth intercostal space at anterior axillary line (5th ICS AAL) is recommended by Tactical Combat Casualty Care (TCCC) with an 83-mm needle catheter unit (NCU). We sought to determine the risk of cardiac injury at this site. Methods: Institutional data sets from two trauma centers were queried for 200 patients with CT chest. Inclusion criteria include body mass index of =30 and age 18-40 years. Measurements were taken at 2nd ICS mid clavicular line (MCL), 5th ICS AAL and distance from the skin to pericardium at 5th ICS AAL. Groups were compared using Mann-Whitney U and chi-squared tests. Results: The median age was 27 years with median BMI of 23.8 kg/m2. The cohort was 69.5% male. Mean chest wall thickness at 2nd ICS MCL was 38-mm (interquartile range (IQR) 32-45). At 5th ICS AAL, the median chest wall thickness was 30-mm (IQR 21-40) and the distance from skin to pericardium was 66-mm (IQR 54-79). Conclusion: The distance from skin to pericardium for 75% of patients falls within the length of the recommended needle catheter unit (83-mm). The current TCCC recommendation to "hub" the 83mm needle catheter unit has potential risk of cardiac injury.

Keywords: pneumothorax; needle thoracentesis; battlefield trauma

PMID: 37036785

DOI: ZU1D-3DL9

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Riverview Terrace Team: A Novel Special Operations Forces Medic Role Emerges at the Forefront of the Fight Against COVID-19

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Valenzuela J, Harrison C, Barajas J, Johnston EE. 20(4). 136 - 138. (Journal Article)

Abstract

During the Spring 2020 COVID surge, a team primarily composed of SOF medics coalesces in New York City, rapidly establishes a field hospital within a large academic teaching hospital, then transitions to step-down and ICU care as institutional needs evolve. Empowered to work as RNs, by emergency decree, the SOF medics, remarkable performance supports the need to define a novel role within the civilian healthcare system for these valuable, highly experienced, and underused providers.

Keywords: COVID-19; SOF medics; COVID surge; Special Operations; field hospital; RVT

PMID: 33320327

DOI: HC8T-LL75

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Rocky Mountain Spotted Fever

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Burnett MW. 16(3). 63 - 64. (Journal Article)

Keywords:

PMID: 27734445

DOI: 2HJB-7HXO

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Role Of Medicine In Supporting Special Forces Counter-insurgency Operations In Southern Afghanistan

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Keenan S. 07(1). 48 - 50. (Journal Article)

Abstract

The purpose of this article is to present the experiences of Task Force 31 during two rotations in support of Operation Enduring Freedom with the use of host nation (HN) medical care as a strategy to support our counter-insurgency plan in the Afghanistan theater. This policy, which consists of providing routine and basic preventive medical (sick call-type) HN care, is in direct contrast to the Rules of Eligibility, essentially only providing emergency care to local nationals. Our medical "rules of engagement" many times clash with the conventional methods of approaching medical care of local national patients, and this article seeks to explain why our strategy is valid in ourArea of Operations (AO).

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Role of NATO Special Operations Combat Medics in Special Operations Surgical Teams

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Konstantinos K. 20(1). 141 - 144. (Journal Article)

Abstract

Battlefield medicine is constantly evolving. Wound patterns, terrain, weapons, and medical evacuation change, so surgical capabilities must adapt. With the changing environment, we must evolve by adapting to offer the best practical care, closest to the frontline. The golden hour has never been a magical number, and the most successful care is provided by the most advanced practitioners as close to the point of injury as possible. The proper placement and access of surgical teams are a key factor in access to a casualty within minutes. NATO Special Operations combat medics (NSOCMs) are highly trained medical Operators who can work as a force multiplier, not only to the Special Operations elements in which they serve but also as members of a Special Operations surgical team (SOST), and these Soldiers can provide the essential skills necessary to best employ and support the surgical asset.

Keywords:

PMID: 32203619

DOI: 2PXF-EVA3

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Role of the Windlass in Improvised Tourniquet Use on a Manikin Hemorrhage Model

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Altamirano MP, Kragh JF, Aden JK, Dubick MA. 15(2). 42 - 46. (Journal Article)

Abstract

Background: In emergencies when commercially designed tourniquets are unavailable, hemorrhage may need to be controlled with improvised tourniquets. In the aftermath of the Boston Marathon bombing, no improvised strap-and-windlass tourniquets were used to treat casualties; tourniquets without windlasses were used. The purpose of the present study is to determine the effectiveness of improvised tourniquets with and without a windlass to better understand the role of the windlass in tightening the tourniquet strap. Methods: An experiment was designed to test the effectiveness of improvised strap-and-windlass tourniquets fashioned out of a tee shirt on a manikin thigh. Two users conducted 40 tests each with and without the use of a windlass. Results: Without a windlass, improvised tourniquets failed to stop bleeding in 99% of tests (79 of 80 tests). With a windlass, improvised tourniquets failed to stop bleeding in 32% of tests (ρ < .0001). In tests with no windlass, attempts to stop the pulse completely failed (100%, 80 of 80 tests). With a windlass, however, attempts to stop the pulse failed 31% of the time (25 of 80 tests); the difference in proportions was significant (ρ < .0001). Conclusions: Improvised strap-and-windlass tourniquets were more effective than those with no windlass, as a windlass allowed the user to gain mechanical advantage. However, improvised strap-and-windlass torniquets failed to control hemorrhage in 32% of tests.

Keywords: first aid; hemorrhage; tourniquet; shock; damage control; tourniquet, makeshift; tourniquet, homemade; strap-and-windlass

PMID: 26125163

DOI: DTPO-G5OG

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Routine Screening Laboratory Studies for Nonheat Stroke Field Heat Injuries Are Unnecessary: A Retrospective Review

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Schauer SG, Pfaff JA. 18(1). 88 - 90. (Journal Article)

Abstract

Background: Heat injuries are common in the military training environment. Base policies often mandate that heat causalities require evaluation at a higher level of care, which comes at significant use of resources. Laboratory studies are often ordered routinely, but their utility is unclear at this time. Methods: This project evaluated the use of screening laboratory studies for heat casualties brought to Bayne-Jones Army Community Hospital, Fort Polk, Louisiana. Casualties brought from the field directly to the emergency department (ED) were included. Abnormalities in laboratory study findings, admission/discharge rates, and length of stay were documented. Results: From May through September 2014, 104 casualties were seen in the ED because of heat injury. Laboratory tests were ordered for 101 patients. Of these, 11 patients were admitted to the hospital because of laboratory, history, and/or physical examination abnormalities. Nine were discharged in less than 24 hours. The remaining two were discharged within 48 hours; both had documented altered mental status on arrival to the ED. Laboratory test abnormalities were seen in most of the patients and appeared to have no impact on the decision to admit. Conclusion: Routine laboratory studies appeared to have low clinical utility in this patient population. A more targeted approach based on the history and physical examination may reduce military resource use.

Keywords: heat injury; heat exhaustion; heat stroke; climate; rhabdomyolysis; heat

PMID: 29533440

DOI: WK4W-2MYS

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Running A Local National Medical Clinic For Special Forces/special Operations Medical Personnel

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Blazier SJ, Leach RA, Perez G, Holmes BW, Blough RS, Keenan S. 07(1). 51 - 57. (Journal Article)

Abstract

The purpose of this article is to present a strategy for establishing and running a local national medical clinic in support of our counter-insurgency strategy, practiced by our Special Forces Task Force in support of Operation Enduring Freedom. In the course of multiple rotations to Afghanistan, we have acquired a feasible strategy to take advantage of the non-kinetic operations of a local national medical clinic. This article seeks to identify mission essential tasks and provides examples from Special Forces Teams (Operational Detachment -Alpha, or ODA) throughout our area of operations (AO) in different settings.

Keywords:

DOI:

Safety and Effectiveness Evidence of SAM® Junctional Tourniquet to Control Inguinal Hemorrhage in a Perfused Cadaver Model

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Johnson JE, Sims K, Hamilton DJ, Kragh JF. 14(2). 21 - 25. (Journal Article)

Abstract

Background: Hemorrhage from the trunk-appendage junctions is a common, preventable cause of death on the battlefield. The recently U.S. Food and Drug Administration (FDA)-cleared SAM® Junctional Tourniquet (SJT) was designed to control out-of-hospital inguinal and axillary hemorrhage. The purpose of the present study was to provide safety and effectiveness data associated with use of the SJT. Such data provided support for regulatory clearance. Methods: The SJT was tested in a perfused cadaver experiment simulating inguinal or axillary wound hemorrhage. Results: No safety problems or tissue damage occurred, and flow normalized promptly after tourniquet removal. During SJT use, an average of 107mmHg occluded the distal external iliac artery in an average of 7 seconds of inflation time; manual pressure as a control averaged 139mmHg. In SJT use, an average of 739mmHg occluded the axillary artery in an average of 5 seconds of inflation time; manual pressure as a control averaged 1237mmHg. The control was a referent that achieved results that were similar in one body area but different in the other; both findings indicate the device is as safe as, if not safer than, manual compression. Conclusion: The SJT was shown to be safe and effective in hemorrhage control in a cadaver model for both the axillary and inguinal areas. The SJT's Target Compression Devices required pressures approximately equal to or lower than manual pressure to achieve hemostasis in these junctional regions.

Keywords: hemorrhage; trauma; groin; wounds and injuries; first aid; damage control; emergency medical services; resuscitation; tourniquet

PMID: 24952036

DOI: D5PS-NYQA

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Salmon Thrombin-Fibrinogen Dressing Allows Greater Survival and Preserves Distal Blood Flow Compared to Standard Kaolin Gauze in Coagulopathic Swine with a Standardized Lethal Femoral Artery Injury

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Floyd CT, Rothwell SW, Risdahl J, Martin R, Olson CE, Rose N. 12(2). 16 - 26. (Journal Article)

Abstract

We have previously shown that lyophilized salmon thrombin and fibrinogen (STF) embedded in a dissolvable dextran dressing is as efficacious as Combat Gauze™ (CG) with regard to controlling hemorrhage and survival in non-coagulopathic swine with femoral artery lacerations. A major limitation of currently available advanced field dressings is the inability to control hemorrhage in coagulopathic casualties because of the exhaustion of host coagulation proteins. We tested the hypothesis that the STF dressing would be better able to control hemorrhage and prolong survival in coagulopathic swine compared to CG. Survival rate was 50% in CG-treated animals versus 90% in STF-treated animals. Survival time was significantly greater in STF-treated animals. Clots formed over the arterial injury in 100% of STF-treated animals compared to 0% in CG-treated animals (ρ < 0.001). STF-treated animals consumed less host coagulation factors, including platelets (ρ = 0.03). Survival after limb manipulation that simulated casualty evacuation was significantly higher with the STF dressing (ρ < 0.005). Angiographic observation of distal blood flow was seen twice as often with the STF dressing as with CG. The STF dressing allows a high survival rate, significantly greater survival time, and a significantly more stable dressing than CG in coagulopathic swine. The clot formed by the STF dressing also enables restoration of distal blood flow to the limb potentially resulting in higher limb salvage.

Keywords:

PMID: 22707021

DOI: 3ZJN-MK5S

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Salmonella Infections Including Typhoid Disease

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Burnett MW. 14(1). 96 - 98. (Journal Article)

Abstract

It is estimated that more than 20 million cases of Salmonella enterica serotype Typhi and 6 million cases of paratyphoid disease occur worldwide annually, with typhoid disease alone causing more than 200,000 deaths. The clinical manifestations, diagnosis, treatment, and vaccination guidelines are discussed.

Keywords: Salmonella; typhoid disease; vaccination

PMID: 24604446

DOI: OKKN-QBZY

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Sarcoidosis

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Sola CA, Trickett CV, Lehman KA. 13(3). 105 - 108. (Journal Article)

Abstract

An active duty male presents to your clinic with concerns of an increasing number of enlarging papules on his neck. How would you describe the morphology of these lesions? What questions should be included in your history? What would you include in your examination? What would you include in your differential diagnosis? What labs and/or tests would you order? This report discusses cutaneous sarcoidosis and its diagnosis and treatment.

Keywords: cutaneous sarcoidosis; sarcoidosis; papules; pseudofolliculitis barbae; erythema nodosum; lupus pernio

PMID: 24049001

DOI: A4FW-0NOK

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Saving Lives on the Battlefield (Part II) - One Year Later: A Joint Theater Trauma System and Joint Trauma System Review of Prehospital Trauma Care in Combined Joint Operations Area-Afghanistan (CJOA-A)

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Sauer SW, Robinson JB, Smith MP, Gross K, Kotwal RS, Mabry RL, Butler FK, Stockinger Z, Bailey JA, Mavity ME, Gillies DA. 15(2). 25 - 41. (Journal Article)

Abstract

The United States has achieved unprecedented survival rates, as high as 98%, for casualties arriving alive at the combat hospital. Our military medical personnel are rightly proud of this achievement. Commanders and Servicemembers are confident that if wounded and moved to a Role II or III medical facility, their care will be the best in the world. Combat casualty care, however, begins at the point of injury and continues through evacuation to those facilities. With up to 25% of deaths on the battlefield being potentially preventable, the prehospital environment is the next frontier for making significant further improvements in battlefield trauma care. Strict adherence to the evidence-based Tactical Combat Casualty Care (TCCC) Guidelines has been proven to reduce morbidity and mortality on the battlefield. However, full implementation across the entire force and commitment from both line and medical leadership continue to face ongoing challenges. This report on prehospital trauma in the Combined Joint Operations Area - Afghanistan (CJOA-A) is a follow-on to the one previously conducted in November 2012 and published in January 2013. Both assessments were conducted by the US Central Command (USCENTCOM) Joint Theater Trauma System (JTTS). Observations for this report were collected from December 2013 to January 2014 and were obtained directly from deployed prehospital providers, medical leaders, and combatant leaders. Significant progress has been made between these two reports with the establishment of a Prehospital Care Division within the JTTS, development of a prehospital trauma registry and weekly prehospital trauma conferences, and CJOA-A theater guidance and enforcement of prehospital documentation. Specific prehospital trauma-care achievements include expansion of transfusion capabilities forward to the point of injury, junctional tourniquets, and universal approval of tranexamic acid.

Keywords:

PMID: 26125162

DOI: GI15-HVCY

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Scabies

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Crecelius EM, Burnett MW. 19(3). 107 - 108. (Journal Article)

Keywords: infectious diseases; mites; scabies

PMID: 31539443

DOI: U5K0-5N8A

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Scapula Fracture Secondary To Static Line Injury In A 22 Year Old Active Duty Soldier

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Thompson WD. 10(4). 41 - 44. (Journal Article)

Abstract

This radiological case study of scapula fracture is reported in a 22 year-old active duty male Soldier who sustained a static line injury during an airborne operation at Fort Bragg, North Carolina. This is the first reported scapula fracture secondary to this mechanism since a 1973 report by Heckman and Levine. The fracture was neither identified by Emergency Department nor Orthopedic Surgery providers, and was reported in the radiologist's formal read. Ten emergency physicians and emergency medicine physician assistants reviewed the radiographical studies and none successfully identified the injury. Because this injury was uniformly missed by experienced emergency medicine providers it is presented as a radiographic case study in hopes that this injury will not go undiagnosed, potentially causing increased morbidity and mortality in this patient population. The patient was treated with a posterior splint and immobilization and seen by the orthopedic service the next day. Interestingly, the orthopedic surgeon also did not recognize this fracture. This mechanism of injury is rarely seen in clinical practice outside of the airborne community. Scapula fractures can be an indicator of serious thoracic trauma and may prompt the need for further diagnostic studies. The fact that so many providers missed the injury reinforces the need to evaluate the patient as a whole and to be ever suspicious of missing concomitant injuries in the trauma patient.

Keywords: Scapula Fracture; emergency department; Orthopedic; Radiograph; airborne

PMID: 21442591

DOI: 5R60-DGMA

Schistosomiasis: Traverers in Africa

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Strohmayer J, Matthews I, Locke R. 16(3). 47 - 52. (Journal Article)

Abstract

Schistosomiasis is a parasitic infection acquired through freshwater exposure in the tropics. It is an infection that can have devastating implications to military personnel if it is not recognized and treated, especially later in life. While there is an abundance of information available about schistosomiasis in endemic populations, the information on nonendemic populations, such as deployers, is insufficient. Definitive studies for this population are lacking, but there are actions that can and should be taken to prevent infection and to treat patients. This literary review presents a case study, reviews basic science, and explores the information available about schistosomiasis in nonendemic populations. Specifically, the authors provide recommendations for the prevention, diagnosis, and postexposure management in military personnel.

Keywords: Africa; schistosomiasis; disease, tropical; military personnel; DEET; praziquantel; Schistosoma spp.

PMID: 27734442

DOI: KP8A-D310

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Scrub Typhus

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Crecelius EM, Burnett MW. 20(1). 120 - 122. (Journal Article)

Abstract

Scrub typhus, also known as tsutsugamushi disease, is caused by Orientia sp. and approximately 1 million new cases are reported annually. This article discusses the importance of scrub typhus and its clinical presentation, diagnosis, treatment, and prevention.

Keywords: tsutsugamushi disease; scrub typhus; Orientia sp; illness, febrile

PMID: 32203616

DOI: WCLB-0NKA

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Sea State Green

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Banting J, Meriano T. 16(2). 78 - 81. (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 op

Keywords: motion sickness; medication, antimotion sickness

PMID: 27450607

DOI: K8N6-0LND

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Searching for Sustainability: How Niger's CASEVAC Success Is Leading the African Continent and Educating the GHE/IHS Community

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Flatau P. 16(2). 111 - 114. (Journal Article)

Abstract

Against all odds and despite significant challenges and scarce resources, Niger's Armed Forces (FAN) continues to lead a successful casualty evacuation (CASEVAC) program. This program and the Special Operations Command Africa (SOCAFR) model that influenced it has become a template for the Global Health Engagement (GHE)/International Health Specialist (IHS) community. This article provides a summary of the overall CASEVAC mission, outlines the final phase sustainable execution of this program, and provides the reader with critical lessons learned for best practice GHE approaches.

Keywords: Niger; casualty evacuations; Special Operations Command Africa

PMID: 27450614

DOI: RFW4-I3UP

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Secession as an International Phenomenon: From America's Civil War to Contemporary Separatist Movements

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Farr WD. 14(1). 103 - 103. (Book Review)

Abstract

Don H. Doyle, Editor. Athens, GA: University of Georgia Press; 2010. Paperback: 392 pages.
ISBN-13: 978-0820337128

Keywords:

PMID: 24604448

DOI: EMCL-5XRX

Secondary Hypertension, Erythrocytosis, and Unilateral Renal Cystic Disease in a Submariner: A Case Report

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Forbes AS, Yeo FE. 16(4). 1 - 5. (Case Reports)

Abstract

Erythrocytosis, or increased red blood cell mass, may be primary as in the case of polycythemia vera (PV), or secondary due to a variety of causes related to erythropoietin (EPO) secretion and hypoxia. Chronic pulmonary disease and certain EPO-secreting tumors should be addressed and excluded early during the course of evaluation for a patient presenting with increased red blood cell mass. Inclusion of the JAK2 V617F gene mutation in the recent World Health Organization criteria for the diagnosis of PV allows for facilitated diagnosis and guides therapy. EPO levels can be helpful in diagnosis and guiding therapy, but in the case of cystic renal diseases, EPO levels are often not elevated, creating diagnostic uncertainty. This report describes a case of symptoms directly attributable to erythrocytosis in the setting of negative JAK2 mutation and normal EPO levels. The subsequent discovery of a large cystic renal kidney and PV were the leading diagnostic considerations

Keywords: erythocytosis; unilateral renal cystic disease; polycythemia vera

PMID: 28088811

DOI: EYN1-4K34

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Secondary Traumatic Stress in Emergency Services Systems (STRESS) Project: Quantifying Personal Trauma Profiles for Secondary Stress Syndromes in Emergency Medical Services Personnel With Prior Military Service

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Renkiewicz GK, Hubble MW. 21(1). 55 - 64. (Journal Article)

Abstract

Background: EMS personnel are often exposed to traumatic material during their duties. It is unknown how prior military experience affects the presence of stress in EMS personnel. Methods: This was a prospective cross-sectional study. Nine EMS agencies provided data on call mix, while individuals were recruited during training evolutions. The survey evaluated sociodemographic factors and the relationship between childhood trauma and previous military service using the Adverse Childhood Experiences questionnaire, Life Events Checklist DSM-5, and Military History Questionnaire. Descriptive statistics calculated personal trauma profiles, comparing civilian EMS personnel to those with prior service. Hierarchical linear regression assessed the predictive utility of military history to scores on the Impact of Events Scale-Revised. Results: A total of 765 EMS personnel participated in the study; 52.8% were male, 11.4% were minorities, and 11.6% had prior military service. A total of 64.4% of civilian EMS providers had any stress syndrome, while that number was 71.8% in those with prior military service. Hierarchical linear regression identified that years of service and the performance of combat patrols or other dangerous duty accounted for a unique criterion variance in the regression model. Conclusions: Prior military service or combat deployments alone do not contribute to the presence of stress syndromes. However, performance of combat patrols or other dangerous duties while deployed was a contributing factor. These results must be interpreted holistically, as other factors contribute to the presence of vicarious trauma (VT) in EMS personnel who are also veterans.

Keywords: paramedic; EMS; military; compassion fatigue; vicarious trauma; burnout; secondary traumatic stress

PMID: 33721308

DOI: AO3Y-HY3W

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Secret Surgeon

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Farr WD. 20(2). 150 - 150. (Book Review)

Abstract

Sava G. Secret Surgeon. London, UK: William Kimber; 1979. ISBN-10:0718300068; ISBN-13:978-0718300067.

Keywords:

DOI:

Self-Reported Musculoskeletal Injury Healthcare-Seeking Behaviors in US Air Force Special Warfare Personnel

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Hotaling B, Theiss J, Cohen B, Wilburn K, Emberton J, Westrick R. 21(3). 72 - 77. (Journal Article)

Abstract

Purpose: This study evaluated the musculoskeletal injury (MSKI) self-reporting behaviors among active-duty Air Force Special Warfare personnel to explore potential limitations of injury surveillance approaches. Methods: Participants completed a 47-item survey between December 2018 and March 2019 regarding their MSKI history. Participants were asked if they sought medical care for symptoms consistent with MSKIs and reasons they did or did not report their injuries. Injury reporting rates were calculated with descriptive statistics and rank ordering was utilized to determine frequency. Results: A total of 398 airmen reported 1,057 injuries occurring in the previous 12-month period, including 508 (48%) injuries identified as not reported to medical personnel. Approximately 55% (N = 579) of all injuries were described as gradual onset. The most common reason for not reporting injuries (28.8%, N = 62) was "fear of potential impact on future career opportunities." Conclusion: Approximately half of MSKIs in this sample of US Air Force Special Warfare personnel were not reported to medical personnel. The underreporting of injuries may pose unknown levels of risk and negatively impact military readiness levels.

Keywords: underreporting; injury exaggeration; concealment; injury rates; symptoms; self-report MSKI; military

PMID: 34529809

DOI: 96Y6-IKFB

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Sepsis Management in Prolonged Field Care: 28 October 2020

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Rapp J, Keenan S, Taylor D, Rapp A, Turconi M, Maves R, Kavanaugh M, Makati D, Powell D, Loos PE, Sarkisian S, Sakhuja A, Mosely DS, Shackelford SA. 20(4). 27 - 39. (Journal Article)

Abstract

This Role 1 prolonged field care (PFC) guideline is intended for use in the austere environment when evacuation to higher level of care is not immediately possible. A provider must first be an expert in Tactical Combat Casualty Care (TCCC). The intent of this guideline is to provide a functional, evidence-based and experience-based solution to those individuals who must manage patients suspected of having or diagnosed with sepsis in an austere environment. Emphasis is placed on the basics of diagnosis and treatment using the tools most familiar to a Role 1 provider. Ideal hospital techniques are adapted to meet the limitations of austere environments while still maintaining the highest standards of care possible. Sepsis and septic shock are medical emergencies. Patients suspected of having either of these conditions should be immediately evacuated out of the austere environment to higher echelons of care. These patients are often complex, requiring 24-hour monitoring, critical care skills, and a great deal of resources to treat. Obtaining evacuation is the highest treatment priority for these patients. This Clinical Practice Guideline (CPG) uses the minimum, better, best paradigm familiar to PFC and gives medics of varying capabilities and resources options for treatment.

Keywords: prolonged field care; Tactical Combat Casualty Care; sepsis; austere environment

PMID: 33320310

DOI: I18B-1ZQM

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Sepsis-Induced Coagulopathy and Disseminated Intravascular Coagulation: What We Need to Know and How to Manage for Prolonged Casualty Care

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Nam JJ, Wong AI, Cantong D, Cook JA, Andrews Z, Levy JH. 23(2). 118 - 121. (Journal Article)

Abstract

Coagulopathy can occur in trauma, and it can affect septic patients as a host tries to respond to infection. Sometimes, it can lead to disseminated intravascular coagulopathy (DIC) with a high potential for mortality. New research has delineated risk factors that include neutrophil extracellular traps and endothelial glycocalyx shedding. Managing DIC in septic patients focuses on first treating the underlying cause of sepsis. Further, the International Society on Thrombolysis and Haemostasis (ISTH) has DIC diagnostic criteria. "Sepsis-induced coagulopathy" (SIC) is a new category. Therapy of SIC focuses on treating the underlying infection and the ensuing coagulopathy. Most therapeutic approaches to SIC have focused on anticoagulant therapy. This review will discuss SIC and DIC and how they are relevant to prolonged casualty care (PCC).

Keywords: sepsis; disseminated intravascular coagulation; coagulopathy; antithrombin; prolonged casualty care; PCC; austere critical care

PMID: 37302145

DOI: 6OZC-JIOV

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Seroprevalence of Dengue Fever in US Army Special Operations Forces: Initial Results and the Way Ahead

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Caci JB, Blaylock JM, De La Barrera R, Thomas SJ, Lyons AG. 14(3). 111 - 115. (Journal Article)

Abstract

The endemicity of dengue fever (DF) and, consequently, sequelae of DF are increasing worldwide. The increases are largely a result of widespread international travel and the increased range of the mosquito vectors. US Army Special Operations Command (USASOC) personnel are at an increased risk of exposure to dengue based on their frequent deployments to and presence in dengue endemic areas worldwide. Repeated deployments to different endemic areas can increase the risk for developing the more serious sequelae of dengue: dengue hemorrhagic fever (DHF) and dengue shock syndrome (DSS). Information about the seroprevalence rate of dengue in USASOC personnel, in particular, is lacking and is critical to assessing the risk, tailoring preventive medicine countermeasures, leveraging field diagnostics, and maintaining mission capability. In the first part of a two-part project to assess baseline seroprevalence in USASOC units, a random, unit-stratified sample of 500 anonymous serum specimens from personnel assigned to the highest-risk units in USASOC were screened for dengue using a microneutralization assay. Of the 500 specimens screened, 56 (11.2%) of 500 had neutralizing titers (NT) (MN(50) ≥ 10) against at least one DENV serotype. Subsequent sample titration resulted in 48 (85.7%) of 56 of the samples with NT (MN(50) ≥ 10) against at least one dengue serotype for an overall dengue exposure rate of 9.6% (48 of 500). The second part of the ongoing project, started in 2012, was a multicenter, serosurveillance project using predeployment and postdeployment sera collected from USASOC personnel deployed to South and Central America, Africa, and Southeast Asia. Preliminary results show a 13.2% (55 of 414) seropositivity rate. The significance of these findings as they relate to personal risk and operational impact is discussed.

Keywords: dengue fever; USASOC; dengue hemorrhagic fever; dengue shock syndrome

PMID: 25344719

DOI: N7RJ-ZND1

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Serving Those Who Served: The Yellow Ribbon Program and US Medical Education

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Bellaire CP, Shin J, Nietsch KS, Ditzel RM, Appel JM. 21(3). 98 - 99. (Editorial)

Keywords:

PMID: 34529814

DOI: KDV5-J20N

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Severe Lower Body Swelling and Bacteremia Secondary to Shewanella algae Bacteremia During Basic Underwater Demolition SEAL Training

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Bridwell RE, Carius BM, Oliver JJ. 19(4). 19 - 21. (Case Reports)

Abstract

Shewanella algae is a unique bacterium largely documented in skin and soft tissue infections (SSTIs) with a wide range of presentations from gas-producing necrotizing fasciitis to osteomyelitis. Seawater exposure to lower extremity ulcers and wounds is most often correlated with infection, which has been documented in causing complications of bacteremia, sepsis, and infective endocarditis. Further complicating treatment is poor response to most empiric regimens prior to definitive diagnosis and an uneven response to antibiotics, including documented resistance to carbapenem. This case documents the presentation of a Basic Underwater Demolition SEAL (BUD/S) training candidate who presented acutely for complaints of severe lower body swelling and abrasions during "Hell Week" and was found to have polymicrobial bacteremia with Staphylococcus aureus, Enterococcus, and S algae.

Keywords: Shewanella algae; bacteremia; military training; underwater

PMID: 31910468

DOI: TH8K-U7CW

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Shared Blood: Expeditionary Resuscitative Surgical Team (ERST-5) Use of Local Whole Blood to Improve Resuscitation of Host Nation Partner Forces

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Bowman M, Ashbaucher J, Cohee B, Fisher MS, Jennette JB, Huse JD, Copeland C, Muir KB. 19(4). 85 - 87. (Journal Article)

Abstract

US Special Operations Forces work by, with, and through partner forces (PFs) to accomplish mutual objectives. Surgical teams support these forces directly and may assist in treating injuries sustained by PF, based on established medical rules of engagement. These surgical operations are often conducted in austere conditions, with limited access to blood products. Limited blood product availability decreases US medical capacity to resuscitate injured PFs and augment the local trauma system. We present an innovative solution used by an expeditionary resuscitative surgical team (ERST) and Special Operations civil affairs team to partner with host nation (HN) medical personnel to improve PF access to damage control resuscitation and surgery. Whole blood obtained through a local HN hospital was provided to the ERST to allow for increased capacity to resuscitate PF casualties and augment the local trauma system. The ERST subsequently used this blood to resuscitate two PF surgical casualties.

Keywords: walking blood bank; stored whole blood; austere surgical team; US military

PMID: 31910477

DOI: L0IH-CF0A

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Shigellosis

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Burnett MW. 17(4). 102 - 103. (Journal Article)

Keywords: Shigellosis; dysentery; infection

PMID: 29256205

DOI: 2PLM-RQTR

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Shock and Vasopressors

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Lampman P, Kennington K, Assar SM. 22(2). 63 - 68. (Journal Article)

Abstract

Shock is a life-threatening condition carrying a high mortality rate when untreated. The consequences of shock are cellular and metabolic derangements, which are initially reversible. The authors present the case of a Servicemember who sustained mortar shrapnel wounds that resulted in shock.

Keywords: shock; homeostasis; critical care

PMID: 35639896

DOI: 24JR-XNAS

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Shooter-Experienced Blast Overpressure in .50-Caliber Rifles

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Lang M, Kamimori GH, Misistia A, LaValle CR, Ramos AN, Ghebremedhin MY, Egnoto MJ. 18(4). 87 - 91. (Journal Article)

Abstract

Background: Increasingly, military and law enforcement are using .50-caliber rifles for conflict resolution involving barricades, armor, vehicles, and situations that require increased kinetic energy. Consequences to the shooter resulting from the blast produced while firing these rifles remain unknown. We measured blast overpressure (OP) and impulse across various positions, environments, and weapon configurations to evaluate blast exposures to shooters. Methods: Two separate, multiday, .50-caliber rifle training courses were evaluated to understand the blast exposure profile received from various tactical training scenarios, such as different firing positions (e.g., standing, prone, seated, kneeling) and locations (e.g., inside and atop vehicles, inside buildings, on hard/soft surfaces) across a variety of .50-caliber rifles with various barrel lengths, muzzle devices, and ammunition. Blackbox Biometrics, Generation 6, gauges were placed on operators to measure incident blast exposure. A total of 444 rounds fired from various .50-caliber rifles were evaluated to determine what OP was received by 32 different shooters. Results: Our findings indicate OPs >4 psi are common and that muzzle devices are critical to blast exposure. Shooting positions closer to the ground experienced higher OP and impulse than did other positions. Suppressors mitigated blast effects well. Conclusion: When resources and operational parameters allow, suppressors are recommended, as are positions that move the shooter farther from reflective surfaces (standing preferred) to effectively reduce blast exposure. These shooter positions may require the use of supplemental rifle rests/tripods to provide sufficiently stable firing platforms from the standing position.

Keywords: risk evaluation; risk mitigation; work engagement; occupational stress; wearable electronic devices; interdisciplinary research; rifle; overpressure

PMID: 30566729

DOI: 9YOK-PEQH

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Short Report Comparing Generation 6 Versus Prototype Generation 7 Combat Application Tourniquet® in a Manikin Hemorrhage Model

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Kragh JF, Moore VK, Aden JK, Parsons DL, Dubick MA. 16(1). 14 - 17. (Journal Article)

Abstract

Background: The Combat Application Tourniquet® (C-A-T) is the standard-issue military tourniquet used in first aid in 2015, and the current model is called Generation 6. Soldiers in the field, however, have been asking for design changes in a possible Generation 7 to improve ease of use. This study compared the differential performance in use of the C-A-T in two designs: Generation 6 (C-A-T 6) versus a prototype Generation 7 (C-A-T 7). Methods: A laboratory experiment was designed to test the performance of two tourniquet designs in hemorrhage control, ease of use, and user preference. Ten users of the two C-A-T models placed them on a manikin thigh to stop simulated bleeding. Users included trauma researchers and instructors of US Army student medics. Ten users conducted 20 tests (10 each of both designs). Results: Most results were not statistically significant in their difference by C-A-T design. The mean difference in blood loss was statistically significant (ρ = .03) in that the C-A-T 7 performed better than the C-A-T 6, but only in the mixed statistical model analysis of variance, which accounted for user effects. The difference in ease-of-use score was statistically significant (ρ = .002); the C-A-T 7 was easier. All users preferred the C-A-T 7. Conclusion: In each measure, the C-A-T Generation 7 prototype performed similar or better than Generation 6, was easier to use, and was preferred.

Keywords: first aid; damage control; hemorrhage; shock; tourniquet; resuscitation

PMID: 27045489

DOI: RK5J-VMQV

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Short Review of Journal Abstracts for Casualty Care 2020-2022

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Pajuelo Castro JJ. 23(1). 110 - 120. (Journal Article)

Keywords:

PMID: 36800526

DOI: UKYG-LR71

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Should We Teach Every Soldier How To Start An Iv?

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Mabry RL, Cuenca PJ. 09(3). 64 - 66. (Previously Published)

Previously published in Military Medicine,. 2009 Jun;174(6):iii-v. Permission granted to republish in the JSOM.

Keywords:

PMID: 19739478

DOI: 6WJ1-PEUI

Significant Pressure Loss Occurs Under Tourniquets Within Minutes of Application

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Rometti MR, Wall PL, Buising CM, Gildemaster Y, Hopkins JW, Sahr SM. 16(4). 15 - 26. (Journal Article)

Abstract

Background: Pressure decreases occur after tourniquet application, risking arterial occlusion loss. Our hypothesis was that the decreases could be mathematically described, allowing creation of evidence-based, tourniquet-reassessment- time recommendations. Methods: Four tourniquets with width (3.8cm, 3.8cm, 13.7cm, 10.4cm), elasticity (none, none, mixed elastic/nonelastic, elastic), and mechanical advantage differences (windlass, ratchet, inflation, recoil) were applied to 57.5cm-circumference 10% and 20% ballistic gels for 600 seconds and a 57.5cmcircumference thigh and 31.5cm-circumference arm for 300 seconds. Time 0 target completion-pressures were 262mmHg and 362mmHg. Results: Two-phase decay equations fit the pressure-loss curves. Tourniquet type, gel or limb composition, circumference, and completionpressure affected the curves. Curves were clinically significant with the nonelastic Combat Application Tourniquet (C-A-T), nonelastic Ratcheting Medical Tourniquet (RMT), and mixed elastic/nonelastic blood pressure cuff (BPC), and much less with the elastic Stretch Wrap And Tuck-Tourniquet (SWATT). At both completion-pressures, pressure loss was faster on 10% than 20% gel, and even faster and greater on the thigh. The 362mmHg completion-pressure had the most pressure loss. Arm curves were different from thigh but still approached plateau pressure losses (maximal calculated losses at infinity) in similar times. With the 362mmHg completion-pressure, thigh curve plateaus were -68mmHg C-A-T, -62mmHg RMT, -34mmHg BPC, and -13mmHg SWATT. The losses would be within 5mmHg of plateau by 4.67 minutes C-A-T, 6.00 minutes RMT, 4.98 minutes BPC, and 6.40 minutes SWATT and within 1mmHg of plateau by 8.18 minutes C-A-T, 10.52 minutes RMT, 10.07 minutes BPC, and 17.68 minutes SWATT. Timesequenced images did not show visual changes during the completion to 300 or 600 seconds pressure-drop interval. Conclusion: Proper initial tourniquet application does not guarantee maintenance of arterial occlusion. Tourniquet applications should be reassessed for arterial occlusion 5 or 10 minutes after application to be within 5mmHg or 1mmHg of maximal pressure loss. Elastic tourniquets have the least pressure loss.

Keywords: tourniquet; hemorrhage; first aid; emergency treatment

PMID: 28088813

DOI: MA2U-FVOH

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Since When is a Calorie a Calorie?

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Reshel R. 12(1). 71 - 72. (Journal Article)

Keywords:

PMID: 22427052

DOI: KFU0-WJ9O

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Singapore's Perspective, Little India Riot: An Impetus to Develop Tactical Medicine Among Medics in Singapore?

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Chew D, Hammesfahr R. 14(2). 60 - 65. (Journal Article)

Abstract

This is a report of the first riot in Singapore since 1969 and the subsequent emergency response from the police force and emergency medical services. Lessons learned are discussed, and recommendations for future medical response in incidents of civil unrest are made.

Keywords: Tactical Emergency Casualty Care; TECC; Singapore Riots; tactical medicine for law enforcement

PMID: 24952042

DOI: DB9R-1TJM

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Single versus Double Routing of the Band in the Combat Application Tourniquet

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Clumpner BR, Polston RW, Kragh JF, Westmoreland T, Harcke HT, Jones JA, Dubick MA, Billings S, Blackbourne LH. 13(1). 34 - 41. (Journal Article)

Abstract

Background: Common first aid tourniquets, like the Combat Application Tourniquet (CAT) of a windlass and band design, can have the band routed through the buckle in three different ways, and recent evidence indicates users may be confused with complex doctrine. Objective: The purpose of the present study is to measure the differential performance of the three possible routings in order to better understand good tourniquet practice. Methods: A training manikin was used by two investigators to measure tourniquet effectiveness, time to stop bleeding, and blood loss. Results: The effectiveness rate was 99.6% (239/240) overall. Results were similar for both single-slit routings (inside vs. outside, p > 0.05). Effectiveness rates (yes-no results for hemorrhage control expressed as a proportion of iterations) were not statistically different between single and double routing. However, the time to stop bleeding and blood loss were statistically different (ρ < 0.05). Conclusions: CAT band routing, through the buckle either singly or doubly, affects two key performance criteria: time to stop bleeding and volume of blood lost. Single routing proved to be faster, thereby saving more blood. Learning curves required to optimize user performance varied over 30-fold depending on which variable was selected (e.g., effectiveness vs. blood loss).

Keywords: hemorrhage; first aid; trauma; damage control; emergency medical services

PMID: 23526320

DOI: W3VI-REYU

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Sleep and Injuries in Military Personnel With Suggestions for Improving Sleep and Mitigating Effects of Sleep Loss

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Knapik JJ, Caldwell JA, Ritland BM. 22(4). 102 - 110. (Journal Article)

Abstract

Sleep professionals suggest adults should sleep at least seven hours per night and define good sleep quality as 1) sleep onset =15 minutes, 2) one or fewer awakenings per night, 3) awake after sleep onset =20 minutes, and 4) sleep efficiency (ratio of sleep time to time in bed) =85%. This paper focuses on associations between injuries and sleep quality/duration among military personnel and strategies to optimize sleep and mitigate effects of sleep loss. Investigations among military personnel generally used convenience samples who self-reported their injury and sleep quality/quantity. Despite these limitations, data suggest that lower sleep quality or duration is associated with higher risk of musculoskeletal injury (MSI). Possible mechanisms whereby poor sleep quality/duration may influence MSI include hormonal changes increasing muscle catabolism, increases in inflammatory processes affecting post-exercise muscle damage, and effects on new bone formation. Sleep can be optimized by a slightly cool sleeping environment, bedding that maintains a stable thermal microclimate around the body, not using media devices near bedtime or in the sleeping environment, minimizing noise, and having regular bed and awaking times. Sleep loss mitigation strategies include napping (<30 to 90 minutes), sleep banking (extended time in bed), and judicious use of caffeine or modafinil.

Keywords: sleep; sleep banking; musculoskeletal injury; sleep deprivation; sleep loss

PMID: 36525022

DOI: X89P-KV2Q

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Sleep As A Strategy For Optimizing Performance

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Yarnell AM, Deuster PA. 16(1). 81 - 85. (Journal Article)

Abstract

Recovery is an essential component of maintaining, sustaining, and optimizing cognitive and physical performance during and after demanding training and strenuous missions. Getting sufficient amounts of rest and sleep is key to recovery. This article focuses on sleep and discusses (1) why getting sufficient sleep is important, (2) how to optimize sleep, and (3) tools available to help maximize sleep-related performance. Insufficient sleep negatively impacts safety and readiness through reduced cognitive function, more accidents, and increased military friendly-fire incidents. Sufficient sleep is linked to better cognitive performance outcomes, increased vigor, and better physical and athletic performance as well as improved emotional and social functioning. Because Special Operations missions do not always allow for optimal rest or sleep, the impact of reduced rest and sleep on readiness and mission success should be minimized through appropriate preparation and planning. Preparation includes periods of "banking" or extending sleep opportunities before periods of loss, monitoring sleep by using tools like actigraphy to measure sleep and activity, assessing mental effectiveness, exploiting strategic sleep opportunities, and consuming caffeine at recommended doses to reduce fatigue during periods of loss. Together, these efforts may decrease the impact of sleep loss on mission and performance.

Keywords: actigraphy; caffeine; cognitive; napping; readiness; sleep

PMID: 27045502

DOI: DXBC-2L8G

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Slow and Risky to Safe and Briskly: Modern Implementation of Whole Blood

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Fisher AD, Miles EA, Shackelford S. 20(1). 21 - 25. (Case Reports)

Keywords: whole blood; LTOWB; noncompressable torso hemorrhage; damage control resuscitation

PMID: 32203599

DOI: OTXQ-H2DO

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Slow Intravenous Infusion of a Novel Damage Control Cocktail Decreases Blood Loss in a Pig Polytrauma Model

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White N, Asato C, Wenthe A, Wang X, Ringgold K, St. John A, Han CY, Bennett JC, Stern SA. 23(3). 50 - 57. (Journal Article)

Abstract

Background: Our objective was to optimize a novel damage control resuscitation (DCR) cocktail composed of hydroxyethyl starch, vasopressin, and fibrinogen concentrate for the polytraumatized casualty. We hypothesized that slow intravenous infusion of the DCR cocktail in a pig polytrauma model would decrease internal hemorrhage and improve survival compared with bolus administration. Methods: We induced polytrauma, including traumatic brain injury (TBI), femoral fracture, hemorrhagic shock, and free bleeding from aortic tear injury, in 18 farm pigs. The DCR cocktail consisted of 6% hydroxyethyl starch in Ringer's lactate solution (14mL/kg), vasopressin (0.8U/kg), and fibrinogen concentrate (100mg/kg) in a total fluid volume of 20mL/kg that was either divided in half and given as two boluses separated by 30 minutes as control or given as a continuous slow infusion over 60 minutes. Nine animals were studied per group and monitored for up to 3 hours. Outcomes included internal blood loss, survival, hemodynamics, lactate concentration, and organ blood flow obtained by colored microsphere injection. Results: Mean internal blood loss was significantly decreased by 11.1mL/kg with infusion compared with the bolus group (p = .038). Survival to 3 hours was 80% with infusion and 40% with bolus, which was not statistically different (Kaplan Meier log-rank test, p = .17). Overall blood pressure was increased (p < .001), and blood lactate concentration was decreased (p < .001) with infusion compared with bolus. There were no differences in organ blood flow (p > .09). Conclusion: Controlled infusion of a novel DCR cocktail decreased hemorrhage and improved resuscitation in this polytrauma model compared with bolus. The rate of infusion of intravenous fluids should be considered as an important aspect of DCR.

Keywords: hemorrhage; resuscitation; hemorrhagic shock, traumatic brain injury; Fibrinogen; vasopressin; combat casualty care

PMID: 37224392

DOI: MB9O-LXOB

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Smallpox as a Bioagent: A Refresher and Update for the SOF Provider

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Zafar SJ, Shishido AA. 22(3). 124 - 128. (Journal Article)

Abstract

Smallpox plagued humans for millennia until its eradication in 1980 following a successful global campaign led by the World Health Organization (WHO). It is the first known biological weapon to be used in war and has been weaponized in the past by the former Soviet Union. To date, smallpox remains a Category A Bioagent and is assessed to be a relevant threat to US military personnel. Given that the last natural case of smallpox occurred more than 40 years ago, a high level of suspicion along with a substantial understanding of the disease process are required to recognize potential future cases. While available countermeasures are limited, several new agents have recently become available for the prevention and treatment of smallpox and have been added to the strategic national stockpile. This review serves as a refresher and update for the clinical disease, to include its epidemiology and management with updated FDA-approved countermeasures.

Keywords: military medicine; bioterrorism; smallpox; bioagents; bioweapon

PMID: 35862852

DOI: FIIV-8Z9P

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Social Determinant of Unconventional Resilience Tactical Engagement with Bonding Patterns

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Jeschke EA, Wyma-Bradley J, Baker JB, Dorsch J, Huffman SL. Ahead of Print. (Journal Article)

Abstract

Building upon our strategic framework and operational model, we will discuss findings from our ethnographic study, entitled: "The Impact of Catastrophic Injury Exposure on Resilience in Special Operations Surgical Teams (SOSTs)," to explain the tactical nature and importance of social determinants within our new characterization of unconventional resilience. Our fourth paper in this series, will explain how bonding patterns establish the quality of intra- and interpersonal connections that create a tensive conduit for the pressure of performance within our operational model, allowing for dynamic freedom of maneuver to take place in ambiguity. We will use qualita- tive quotes to illustrate various ways SOST medics relate to themselves, other people, and the Special Operations Forces (SOF) culture. To achieve our goals, we will: 1) provide an in- troduction to social determinants as tactical engagement with unconventional resilience; 2) define the social determinant of bonding patterns as extrapolated from qualitative data as well as use qualitative data to thematize various types of bonding patterns; and 3) relate tactical engagement with bonding pat- terns to our metaphor of bag sets. We conclude by gesturing to the importance of bonding patterns in orienting SOF medics' proprioception and kinesthesia in the SOF performance space.

Keywords: unconventional resilience; social determinant; bonding patterns; practical performance; SOF medic

PMID: 38319637

DOI: IFK1-RCU4

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Social Determinant of Unconventional Resilience: Tactical Engagement with Impression Management

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Jeschke EA, Wyma-Bradley J, Baker JB, Dorsch J, Huffman SL. 24(1). 90 - 0. (Journal Article)

Abstract

Building upon our operational model, we will discuss findings from our ethnographic study titled "The Impact of Catastrophic Injury Exposure on Resilience in Special Operations Surgical Teams" to establish that impression management allows Special Operation Forces (SOF) medics to navigate implicit social status symbols to either degrade or optimize performance. We will use qualitative quotes to explore how Special Operations Surgical Team (SOST) medics engage in impression management to establish individual, team, and/or organizational competency to deal with ambiguity. To achieve our goals, we will: 1) provide a background on impression management and perception of competency; 2) define the social determinant of impression management extrapolated from qualitative data as well as use qualitative data to thematize various types of impression management; and 3) relate tactical engagement with impression to our metaphor of bag sets. We conclude by gesturing to the importance of impression management in orienting SOF medics' proprioception and kinesthesia in the SOF performance space.

Keywords: unconventional resilience; social determinant; tactical; impression management; practical performance; SOF medic

PMID: 38109230

DOI: 6DG3-WQW7

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Social Fitness and the Social Domain: A Holistic Approach Based on Total Force Fitness

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McCarthy R, Park GH, Barczak-Scarboro NE, Barrientos S, Chamberlin R, Hansom A, Messina LA. 23(3). 85 - 90. (Journal Article)

Abstract

The Total Force Fitness (TFF) framework was envisioned as a holistic framework of interrelated domains, whereby impact in one domain could have cascading implications for the others. For this reason, definitional clarity surrounding how to achieve fitness in the various domains is crucial. Social fitness definitions tend to focus on individual efforts and overlook the powerful impact of the social group and the social environment on the individual. In this article, various definitions of social fitness are analyzed in an effort to broaden the current understanding of the social domain. Some of the knowledge gaps in understanding social fitness and the resulting challenges are addressed before reviewing a few existing social fitness interventions. Finally, this study offers recommendations for improvement, along with future directions for the increased integration of the social domain into the TFF framework.

Keywords: social environment; social fitness; social domain; total force fitness; performance optimization

PMID: 37699257

DOI: TRM7-423O

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SOF Dentistry

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Harrington RD. 09(4). 3 - 10. (Journal Article)

Abstract

Special Operations Forces (SOF) medics trained to deliver comprehensive dental care (extractions and fillings) to a population in a contested area can be one of the more important elements in a successful UW campaign. This article will highlight and review an inexpensive, lightweight, highly portable dental system that allows the SOF medic to deliver these vital dental services in the field.

Keywords:

PMID: 20112641

DOI: KPY3-4RJY

SOF Leadership in The Face Of Stress

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Bottoms M. 09(4). 107 - 109. (Journal Article)

Keywords:

PMID: 20112655

DOI: YYX4-GY5E

SOFSono Ultrasound

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Poston WH, Hampton K. 16(2). 106 - 106. (Journal Article)

Keywords:

DOI: BGX8-2NFJ

SOLCUS After-Action Report: From Good Idea to the Largest Ultrasound Training Program in the Department of Defense

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Vasios WN. 16(1). 62 - 65. (Editorial)

Keywords:

PMID: 27045496

DOI: TM8J-UFBH

SOLCUS: Update On Point-of-Care Ultrasound In Special Operations Medicine

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Hampton K, Vasios WN, Loos PE. 16(1). 58 - 61. (Journal Article)

Abstract

Point-of-care ultrasonography has been recognized as a relevant and versatile tool in Special Operations Forces (SOF) medicine. The Special Operator Level Clinical Ultrasound (SOLCUS) program has been developed specifically for SOF Medics. A number of challenges, including skill sustainment, high-volume training, and quality assurance, have been identified. Potential solutions, including changes to content delivery methods and application of tele-ultrasound, are described in this article. Given the shift in operational context toward extended care in austere environments, a curriculum adjustment for the SOLCUS program is also proposed.

Keywords: ultrasound, point-of-care; ultrasound, prehospital; tele-ultrasound; ultrasound, clinical, Special Operator level

PMID: 27045495

DOI: 221W-TDOC

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Soldiers Can Take It - A Conceptual Analysis Of Trauma

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Froede K. 11(2). 18 - 22. (Journal Article)

Abstract

Purpose: This article will analyze the concept of trauma, and illustrate distinctions between accepted definitions and actual meaning. For populations at high risk for exposure to traumatic situations, such as Special Operations Forces (SOF) and deployed military personnel, delineating the beliefs and environment-specific comprehension of trauma and its consequences is imperative. Background: Trauma is a common term in health sciences literature and in the social vernacular, but is often misunderstood and lacks specificity. Differences in perception of what trauma is and is not may exist even between civilian and military populations. Therefore, the concept of trauma warrants clarification, to define the terminology and to use it appropriately with full understanding. Data sources: EbscoHost, PubMed, CINAHL, MedLine, and Google Scholar. Only English-language results were accepted, and were limited to publications from the dates of 1975- 2010.

Keywords:

PMID: 21455905

DOI: Z2X8-LCBZ

Sore Throat

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Banting J, Meriano T. 14(4). 124 - 128. (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: sore throat; ENT; procedure

PMID: 25399381

DOI: 7KVU-PP2L

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SORT(ing) Out The Casualties: The Special Operations Resuscitation Team In Afghanistan

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Finlayson K. 09(2). 77 - 86. (Previously Published)

Previously published in Veritas Vol 5 No. 1 2009. Permission granted to republish in JSOM. in the JSOM.

Keywords:

PMID: 19813520

DOI: LUXP-O4BC

Special Forces Medic (18d) And Medical Planning

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Ware OL. 10(2). 26 - 27. (Journal Article)

Keywords:

PMID: 20936601

DOI: QMIP-R0JG

Special Forces Medical Sergeant/Special Operations Independent Duty Corpsman Candidates: Large Animal Module

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Yost JK, Yates J, Smith B, Workman DJ, Matlick D, Wilson ME, Wilson A. 21(2). 115 - 118. (Journal Article)

Abstract

Background: Medical care provided by Special Operations Forces (SOF) combat medics is vital for establishing communication with local populations. In many of these communities, livestock hold a valuable position within the social, political, and cultural structure. The West Virginia University (WVU) Special Forces Medical Sergeant/Special Operations Independent Duty Corpsman (SFMS/SOIDC) Large Animal Module is designed to provide a foundational experience in livestock husbandry and veterinary procedures to SOF combat medic candidates. This study was conducted to determine the participants' base knowledge of food animal production and to evaluate if the program content was sufficient for increasing their knowledge of the subject matter. Methods: A quasi-experimental design utilizing pre-test and post-test instruments was used. The validity of the testing instruments was established by a panel of subject matter experts and the instruments' reliability was determined by a split-half analysis using SPSS® statistical software. The difference between the pre-test and post-test examinations were compared for 66 candidates who were assigned to WVU Health Sciences Center for the applied medical experience program and 46 counterparts assigned to other institutions by a match pair analysis. Results: Seventy-five percent of the subjects had no previous livestock exposure, and only 7% had previously participated in the 4-H program or Future Farmers of America (FFA). The average improvement in scores, pre-test versus post-test, was significantly greater for those that attended the module (18.5 versus 0.9). Conclusion: Few SFMS/SOIDC candidates have prior knowledge of livestock husbandry practices. The large animal module successfully provides education on livestock husbandry practice to participants. Knowledge of livestock production can assist SOF medics in establishing rapport with indigenous populations while on mission.

Keywords: livestock; husbandry; program evaluations; SFMS; SOIDC; Special Operations; animal; veterinary

PMID: 34105135

DOI: ZN29-4AKF

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Special Forces Medical Sergeants' Perceptions and Beliefs Regarding Their Current Medical Sustainment Program: Implications for the Field

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Wilson RL, DeZee KJ. 14(4). 59 - 69. (Journal Article)

Abstract

Background: Special Forces Medical Sergeants (SFMS) are trained to provide trauma and medical care in support of military operations and diplomatic missions throughout the world with indirect physician oversight. This study assessed their perceptions of the current program designed to sustain their medical skills. Methods: An Internet-based survey was developed using the constructs of the Theory of Reasoned Action/Planned Behavior and validated through survey best practices. Results: Of the 334 respondents, 92.8% had deployed at least once as an SFMS. Respondents reported spending 4 hours per week sustaining their medical skills and were highly confident that they could perform their duties on a no-notice deployment. On a 5-point, Likerttype response scale, SFMS felt that only slight change is needed to the Special Operations Medical Skills Sustainment Course (mean: 2.17; standard deviation [SD]: 1.05), while moderate change is needed to the Medical Proficiency Training (mean: 2.82; SD: 1.21) and nontrauma modules (mean: 3.02; SD: 1.22). Respondents desire a medical sustainment program that is provided by subject matter experts, involves actual patient care, incorporates new technology, uses hands-on simulation, and is always available. Conclusions: SFMS are challenged to sustain their medical skills in the current operational environment, and barriers to medical training should be minimized to facilitate sustainment training. Changes to the current medical sustainment program should incorporate operator-level perspectives to ensure acceptability and utility but must be balanced with organizational realities. Improving the medical sustainment program will prepare SFMS for the challenges of future missions.

Keywords: Special Forces Medical Sergeants; medical sustainment program; medical training

PMID: 25399370

DOI: 9WSY-8Y3V

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Special Forces Medicine in Israel

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Ostfeld I, Paran H, Chen J, Barneis Y, Dreyfuss U, Kedem H, Glassberg E. 14(3). 116 - 120. (Journal Article)

Abstract

The Special Forces (SF) of the Israel Defense Force (IDF) have a long and pioneering history in tactical and medical aspects. Moreover, the importance of medical assistance is highly regarded in the Israeli SF community. Consequently, as current military challenges of Israel increase, the need for SF activity and for its medical support increases as well. Therefore, the authors anticipate that further development of SF medicine (SFM), as a specific branch of military medicine in Israel, will continue.

Keywords: Special Forces; Special Forces medicine; military medicine; Israel Defense Force; My Brother's Keeper

PMID: 25344720

DOI: 3UYK-HVN7

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Special Forces: A Unique National Asset Through, With, and By

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Farr WD. 16(3). 97 - 97. (Book Review)

Abstract

Boyatt, Mark D.
Special Forces: A Unique National Asset. Through, With, and By.
Denver, CO: Outskirts Press; 2016. ISBN-10: 1478766395 and ISBN-13: 978-1478766391. 578 pages.

Keywords:

DOI:

Special Operations Alumnus Starts New Challenge

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Green J. 14(1). 111 - 111. (Interview)

Keywords:

PMID: 24604450

DOI: DOPW-L0LE

Special Operations and Space Medicine for a Joint Future

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Hetzler MR, Fogarty JA, Frament C. Ahead of Print. (Journal Article)

Abstract

This paper is designed to introduce, propose, inform, and advocate enhanced relationships between the medical communities of special operations and space. Although each provides service support in different roles and functions, similarities in both the operational context and in medical care are notable. During a recent interaction, significant relationship potential was discovered by both communities, and recommendations for greater engagement are proposed herein. By identifying and appreciating similarities and understanding history, key actors, and authorities to analyze and realize opportunities will enable us to find synergy for the development of like efforts and goals. Collaboration in research on the limits of human performance and medical support to the most austere and challenging operational environments may benefit both communities in different but productive ways. Establishing and increasing cooperation will also meet command strategic intent, explore and advance a policy concept, initiate a relationship between unique medical communities, and provide a tangible success for the advancement of operational support.

Keywords: humans; goals; biomedical research; space flight; resource-limited settings; military science; United States National Aeronautics and Space Administration

PMID: 38488822

DOI: HBHW-O9H2

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Special Operations Force Risk Reduction: Integration of Expeditionary Surgical and Resuscitation Teams

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Satterly S, McGrane OL, Frawley T, Bynum W, Martin J, Clegg C, Pearsall N, Reilly S, Verwiebe E, Eckert M. 18(2). 49 - 52. (Journal Article)

Abstract

Hemorrhage in the presurgical setting has been the most significant cause of death on the battlefield. Damage control surgery (DCS) near the point of injury (POI) is not a new concept, but having conventional medical teams supporting Special Operations Forces (SOF) beyond robust military medical infrastructure is unique for the US military. The Expeditionary Resuscitative Surgical Team (ERST) was formed by the US Army Medical Command as a pilot team to fulfill a request for forces to provide DCS and personnel recovery near POI.

Keywords: Expeditionary Resuscitative Surgical Team; damage control surgery; Golden Hour; presurgical setting

PMID: 29889955

DOI: 5UM7-KBEM

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Special Operations Forces and Incidence of Post-Traumatic Stress Disorder Symptoms

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Hing M, Cabrera J, Barstow C, Forsten RD. 12(3). 23 - 35. (Journal Article)

Abstract

To determine the rates of Post-traumatic Stress Disorder (PTSD) positive symptom scores in Special Operations Forces (SOF) personnel, an anonymous survey of SOF was employed, incorporating the PTSD Checklist (PCLM) with both demographic and deployment data. Results indicate that all SOF units studied scored above the accepted cut-offs for PTSD positive screening.1 When total symptom severity score exceeded established cutoff points and were combined with criteria for Diagnostic and Statistical Manual of Mental Disorders, Edition 4 (DSM-IV) diagnosis of PTSD,2 approximately 16-20% of respondents met scoring threshold for positive screening, almost double those of conventional Army units. Collectively, Special Forces (SF) Soldiers and SOF combat- arms Soldiers had significantly higher PLC-M scores than their non-combat-arms SOF counterparts. SOF Soldiers with three or more deployments to Afghanistan had significantly higher PCL-M scores. Considering the evidence suggesting that SOF Soldiers are hyper-resilient to stress, these results should drive further research schemata and challenge clinical assumptions of PTSD within Special Operations.

Keywords:

PMID: 23032317

DOI: 663M-6L7P

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Special Operations Individual Medical Equipment Part 2 - The In-use And Survival Medical Kits

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Geers D. 10(1). 3 - 15. (Journal Article)

Abstract

Special Operations Forces (SOF) Operators need a variety of individual medical items that can generally be broken down into three types of medical kits: a major trauma kit, to treat major traumatic wounds; an in-use medical kit, to prevent or treat anticipated common medical conditions during operations; and a survival medical kit, to treat minor injuries and ailments when in a survival/evasion situation.

Keywords:

PMID: 20306410

DOI: 7B81-ZW70

Special Operations Individual Medical Equipment Part I - The Major Trauma Kit

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Geers D. 09(4). 43 - 52. (Journal Article)

Abstract

Special Operations Forces (SOF) Operators need a variety of individual medical items that can generally be broken down into three types of medical kits: a major trauma kit, to treat major traumatic wounds; an inuse medical kit, to prevent or treat anticipated common medical conditions during operations; and a survival medical kit, to treat minor injuries and ailments when in a survival/evasion situation.

Keywords:

PMID: 20112648

DOI: 6I5C-DGVI

Special Operations Medicine: A Federal Law Enforcement Perspective

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Schmidt DJ. 07(3). 1 - 2. (Journal Article)

Abstract

This article details the overlapping mission between the Special Operations community and the U.S. Drug Enforcement Administration (DEA) mission. DEA and Special Operations Force (SOF) units operate together all over the world with DEA presence in over 100 foreign countries. The Law Enforcement (LE) mission and the SOF mission have very blurred lines that allow for a very close working relationship and similar counter-drug mission profile. The article specifically details the experiences in tactical medicine and the SOF medic mission overseas relating one specific incident involving Special Forces (SF) and DEA personnel in a third world jungle operation. The article explains the strong bond between DEA and SOF personnel and lessons learned in the field relative to medical issues.

Keywords:

DOI:

Special Operations Soldier With Cardiac Family History: Use of CCTA and Protein Biomarker Testing to Detect Risk of Heart Attack From Noncalcified Plaque

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Singh M, Kroman A, Singh J, Tariq H, Amin S, Morales-Pablon CA, Cahill KV, Harrison EE. 15(1). 7 - 10. (Case Reports)

Abstract

Objective: We sought to characterize the risk of a heart attack in a 48-year-old asymptomatic US Special Operations Command (SOCOM) Soldier without known coronary artery disease (CAD). Background: CAD continues to be a leading cause of morbidity and mortality among most age groups in the United States. Much research is dedicated to establishing new techniques to predict myocardial infarction (MI). Methods: Coronary computed tomography (CT) angiography, also known as CCTA, along with 7-protein serum biomarker risk assessment was performed for risk evaluation. Results: A 48-year-old SOCOM Soldier with a family history of heart disease had skeletal chest pain from war injuries and a 5-fold higher risk of heart attack over the next 5 years on the basis of protein markers. A nonobstructive left anterior descending coronary artery (LAD) plaque with a lipid-rich core and a thin fibrous cap (i.e., vulnerable plaque) was detected by CCTA. The patient was warned about his risk and prescribed four cardiac medications and scheduled for angioplasty even though he fell outside the guidelines by not having a severe obstructive blockage. Four days later, unfortunately, he had a heart attack before starting his medications and before angioplasty. Conclusion: CCTA with biomarker testing may have an important role in predicating acute coronary syndrome (ACS) in Special Operations Forces (SOF) Soldiers with at least one risk factor. Conventional stress testing and nuclear scanning would not detect non-flow-limiting vulnerable plaques in vulnerable patients. In order to collect more data, the PROTECT Registry has been started to evaluate asymptomatic Soldiers with at least one risk factor referred to the clinic by military physicians.

Keywords: cardiac risk; heart attack; CCTA; risk assessment

PMID: 25770793

DOI: KBPQ-18KA

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Special Operator Level Clinical Ultrasound: An Experience In Application And Training

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Morgan AR, Vasios WN, Hubler DA, Benson PJ. 10(2). 16 - 24. (Journal Article)

Abstract

Over the past few decades, ultrasound has evolved from a radiology and subspecialist-centric instrument, to a common tool for bedside testing in a variety of specialties. The SOF community is now recognizing the relevancy of training medics to employ this technology for multiple clinical indications in the austere operating environment. In the Fall 2008 issue of Journal of Special Operations Medicine two of the authors described the concept of training SOF medics to employ portable ultrasound as a diagnostic aid. After over two years of concerted effort, the authors trained 29 out of 40 medics of a Special Forces battalion. Retrospective analysis of the quality assurance data for ultrasound studies conducted placed the 109 studies into six categories, allowing inference of trends in clinical indication for ultrasound exams as determined by the SOF medic-ultrasonographer. The resulting distribution suggests that indications for fractures and superficial applications are as prevalent as those for focused abdominal sonography in trauma (FAST) and pneumothorax exams. This analysis focuses on Special Operator Level Clinical Ultrasound (SOLCUS), an ultrasound training curriculum specifically for SOF medics, and helps appropriately prioritize its objectives. Despite the success of this experience, there are several issues requiring resolution before being able to integrate ultrasound training and fielding into the SOF medical armamentarium.

Keywords:

PMID: 20936599

DOI: BNPY-WWQ8

Spiritual Fitness: An Essential Component of Human Performance Optimization

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Worthington D, Deuster PA. 18(1). 100 - 105. (Journal Article)

Abstract

Spirituality is a key interweaving and interacting domain, and an integral component for maintaining Special Operations Forces readiness; however, it remains an under-researched and likely one of the most poorly understood domains of Preservation of the Force and Family and Total Force Fitness initiatives. Although there are numerous factors that contribute to spiritual performance or spiritual fitness, core values and value-directed living are essential. An initial step toward spiritual performance or fitness is developing core values and identity, followed by a second step toward spiritual performance or fitness, which is developing an increased awareness and deeper understanding of those values. This process of developing core values and identity, and building awareness can be enhanced through cognitive flexibility and agility (psychological performance domain). This article explains the importance of "spirituality" as a component of Special Operations Forces performance and describes approaches to enhancing performance through various spiritual activities, including mindfulness, meditation, and prayer. These three practices can be adapted and modified to be more vertical or more horizontal in their application.

Keywords: spirituality; human performance optimization; Special Operations Forces

PMID: 29533442

DOI: 2R9F-IEFH

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Spontaneous Pneumopericardium, Pneumomediastinum, And Subcutaneous Emphysema In A 22-year Old Active Duty Soldier

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Thompson D. 08(3). 88 - 90. (Journal Article)

Abstract

A radiological case study of spontaneous pneumopericardium, pneumomediastinum, and subcutaneous emphysema is reported in a 22-year old active duty male Soldier undergoing survival, evasion, resistance, and escape (SERE) training and presenting for evaluation of sore throat and retrosternal chest pain. The patient is one of several that presented with similar symptoms in a 24-hour period. After close observation, he was released to his unit and recovered well.

Keywords: pneumopericardium; pneumomediastinum; subcutaneous emphysema; SERE

DOI:

Stability of SARS-CoV-2 on the Army Combat Uniform and Recommendations for Cleaning

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Ibarra C, Bass L, Saler E, Daniels R, Davis N, Washington M. 23(2). 70 - 72. (Journal Article)

Abstract

SARS-CoV-2 is the virus responsible for the disease that is known as COVID-19. While there have been numerous studies detailing the survival rates of SARS-CoV-2 on various materials, there are currently no published data regarding whether this virus is stable on standard military uniforms. Consequently, there are no standard operating procedures for washing uniforms once exposed to the virus. This study aimed to determine whether SARS-CoV-2 could be removed from Army combat uniform material by washing with a commercially available detergent and tap water. Washing the fabric with detergent followed by a rinse step with tap water effectively removes detectable viral particles. Importantly, it was found that washing with hot water alone was not effective. Therefore, it is recommended that military personnel wash their uniforms with detergent and water as soon as possible after exposure to SARS-CoV-2; hot water should not be used as a substitute for detergent.

Keywords: SARS-CoV-2; COVID-19; decontamination; uniform; military; detergent; soap; hot water; wash; exposure

PMID: 37224388

DOI: KR80-X5HF

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Staff Attitudes Regarding the Impact of a Therapy Dog Program on Military Behavioral Health Patients

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Brisson S, Dekker AH. 17(4). 49 - 51. (Journal Article)

Abstract

Background: Human-animal interactions in the form of animal-assisted therapy (AAT) have become common in both civilian and military health care facilities. Evidence supports AAT as a beneficial therapeutic alternative for patients with physical disabilities and psychological disorders. Few studies have been conducted in the civilian health care setting to evaluate staff attitudes regarding the impact of an AAT program on behavioral health (BH) patients. To our knowledge, no research has examined staff attitudes on the impact and effectiveness of AAT on active-duty Servicemembers in a BH program at a military facility. Methods: At the completion of a year-long AAT dog program and after institutional review board exemption, an anonymous, six-question survey was used to examine staff attitudes (n = 29) regarding the impact and continuation of the program with military BH patients. Results: Most staff members (86%) believed the AAT dog program had a positive impact on the BH patients, including improved patient mood, greater patient relaxation, improved patient attitude toward therapy, and increased social interactions among patients. All the staff reported a desire to continue the program at the military facility. Conclusion: Most BH staff thought the year-long AAT dog program had a positive impact on patients. All staff supported continuation of the program.

Keywords: animal-assisted therapy; therapy dog; military; behavioral health; staff attitudes

PMID: 29256194

DOI: VGGG-N5OH

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Standardized Patient Methodology in Tactical Medical Education

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Tang N, Jones KD, Kemp SJ, Knapp JG. 22(1). 130 - 132. (Journal Article)

Keywords: tactical emergency medical support; TEMS; tactical medicine; standardized patient methodology

PMID: 35278329

DOI: WXGA-QYX2

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Staphylococcus sciuri: An Entomological Case Study and a Brief Review of the Literature

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Washington M, Kajiura L, Leong MK, Agee W, Barnhill JC. 15(1). 100 - 104. (Journal Article)

Abstract

Staphylococcus sciuri is an emerging gram-positive bacterial pathogen that is infrequently isolated from cases of human disease. This organism is capable of rapid conversion from a state of methicillin sensitivity to a state of methicillin resistance and has been shown to express a set of highly effective virulence factors. The antibioticresistance breakpoints of S. sciuri differ significantly from the more common Staphylococcus species. Therefore, the rapid identification of S. sciuri in clinical material is a prerequisite for the proper determination of the antibiotic- resistance profile and the rapid initiation of antimicrobial therapy. Here, we present a brief literature review of S. sciuri and an entomological case study in which we describe the colonization of an American cockroach with this agent. In addition, we discuss potential implications for the distribution and evolution of antibiotic- resistant members of the genus Staphylococcus.

Keywords: bacteriology; entomology; operating environment; preventive medicine

PMID: 25770806

DOI: A20X-ENG5

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Step Duration Effects on Blood Loss in Simulated Designs of Tourniquet Use Procedure

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Kragh JF, Aden JK, Dubick MA. 20(2). 76 - 82. (Journal Article)

Abstract

Background: We sought new knowledge by further developing a model of using calculations in the simulation of a first-aid task. The purpose of this study was to develop the model to investigate the performance of tourniquet use in its component steps. Methods: We aimed to design an experiment on a desktop computer by mathematically manipulating simulated data in tourniquet use. A time factor of tourniquet use was ranged widely through time challenges in five degrees from ideal to worst performances. Redesigning the task was assessed by time costs and blood losses. Results: The step of tourniquet application took 17% of the trial time and securing the tourniquet after bleeding control took the longest amount of the trial time, 31%. A minority of the time (48% [17% + 31%] to apply tourniquet plus secure it) was spent after the tourniquet touched the patient, whereas most of the time (52%) was spent before the tourniquet touched the patient. The step of tourniquet application lost 14% of the total blood lost, whereas no blood was lost during securing the tourniquet, because that was the moment of bleeding control despite securing the tourniquet taking much time (31%). Most (86%) of blood lost occurred before the tourniquet touched the patient. But blood losses differed 10-fold, with a maximum of 2,434mL, which, when added to a pretask indication blood loss of 177mL, summed to 2,611mL. Before redesigning the task, costs of donning gloves and calling 9-1-1 included uncontrolled bleeding, but gloving mitigated risk of spreading pathogens among people. By step and person, redesigns of the task altered the risk-benefit profile. Conclusions: The model was useful because it simulated where most of the bleeding occurred before the tourniquet touched the patient. Modeling simulated redesigns of the task, which showed changes in the task's risk-benefit profile by step and among persons. The model generated hypotheses for future research, including the capability to screen candidate ideas among task designs.

Keywords: tourniquet; first aid; bleeding control and prevention; emergency; task deconstruction, simulation, modeling

PMID: 32573742

DOI: QJL0-0KS1

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Sterile Instrument Storage in an Austere Environment: Are Sterile Peel Packaging and Cellulose Wrapping Equivalent?

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Lanham N, Belyea CM, Marcello D, Wataka AB, Musila L. Ahead of Print. (Journal Article)

Abstract

Background: Recommendations for optimal temperature and humidity for sterile instrument storage vary according to different sources. Furthermore, there are limited data comparing methods of packing smaller, lightweight, low-profile instruments. The purpose of this study was to compare sterile peel packaging and sterile cellulose wrapping for sterile instrument storage in an austere environment characterized by elevated temperature and humidity. Methods: Stainless steel screws were sterilized and stored in either sterile peel packaging, sterile cellulose wrapping, or no packaging. Four groups were evaluated. Group 1 consisted of four screws in a sterile peelpack envelope and served as a time-zero control. Group 2 consisted of two groups of five screws, each packaged with blue sterilization cellulose wrap. Group 3 consisted of two groups of five screws, each packaged in sterile peel-pack envelopes. Group 4 consisted of 10 non-sterile unpackaged screws, which served as controls. Screws from groups 2, 3, and 4 were then cultured for 6 and 12 weeks. Temperature and humidity values were recorded in the instrument storage area. Results: Average temperature was 21.3°C (SD 1.2°C; range 18.9°C-27.2°C) and average humidity was 51.7% (SD 3.9%; range 39%- 70%). Groups 1 (time-zero control) and 2 (sterile cellulose wrapping) demonstrated no growth. After 6 and 12 weeks, groups 3 (sterile peel packaging) and 4 (control) demonstrated bacterial growth. Conclusion: The most common culture isolates were gram-positive rods and two common nosocomial Staphylococcius species. Sterile peel packaging was not found to be equivalent to sterile cellulose wrapping in austere environmental conditions.

Keywords: instrument sterility; austere environment; peel packing; cellulose wrapping; sterile instrument storage

PMID: 38423001

DOI: EB2S-XTB5

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Stress Fractures: Etiology, Epidemiology, Diagnosis, Treatment, and Prevention

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Knapik JJ, Reynolds K, Hoedebecke KL. 17(2). 120 - 130. (Journal Article)

Abstract

Stress fractures are part of a continuum of changes in healthy bones in response to repeated mechanical deformation from physical activity. If the activity produces excessive repetitive stress, osteoclastic processes in the bone may proceed at a faster pace than osteoblastic processes, thus weakening the bone and augmenting susceptibility to stress fractures. Overall stress fracture incidence is about three cases per 1,000 in active duty Servicemembers, but it is much higher among Army basic trainees: 19 per 1,000 for men and 80 per 1,000 for women. Well-documented risk factors include female sex, white ethnicity, older age, taller stature, lower aerobic fitness, prior physical inactivity, greater amounts of current physical training, thinner bones, cigarette smoking, and inadequate intake of vitamin D and/or calcium. Individuals with stress fractures present with focal tenderness and local pain that is aggravated by physical activity and reduced by rest. A sudden increase in the volume of physical activity along with other risk factors is often reported. Simple clinical tests can assist in diagnosis, but more definitive imaging tests will eventually need to be conducted if a stress fracture is suspected. Plain radiographs are recommended as the initial imaging test, but magnetic resonance imaging has higher sensitivity and is more likely to detect the injury sooner. Treatment involves first determining if the stress fracture is of higher or lower risk; these are distinguished by anatomical location and whether the bone is loaded in tension (high risk) or compression (lower risk). Lowerrisk stress fractures can be initially treated by reducing loading on the injured bone through a reduction in activity or by substituting other activities. Higher-risk stress fractures should be referred to an orthopedist. Investigated prevention strategies include modifications to physical training programs, use of shock absorbing insoles, vitamin D and calcium supplementation, modifications of military equipment, and leadership education with injury surveillance.

Keywords: stress fracture; risk factors; diagnosis; treatment

PMID: 28599045

DOI: SPMB-1E6L

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Stress Inoculation Training (SIT-NORCAL), Part 1: The Development and Preliminary Evaluation of a Psychological Performance Training Protocol

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Jackson SE, Baity MR, Thomas PR, Barba D, Jacobson D, Goodkind M, Swick D, Ivey AS. 21(4). 37 - 45. (Journal Article)

Abstract

Background: Stress inoculation training (SIT) interventions have demonstrated promise within military contexts for human performance enhancement and psychological health applications. However, lack of manualized guidance on core content selection, delivery, and measurement processes has limited their use. Purpose: The purpose of this study was to develop and evaluate a comprehensive SIT intervention protocol to enhance the performance and health of military personnel engaged in special warfare and first-response activities. Methods: Multidisciplinary teams of subject matter experts (n = 19) were consulted in protocol generation. The performance improvement/human performance technology (HPT) model was used in the selection, refinement, and measurement of core skills. The protocol was trialed and refined (44 cohorts, n = =300; 2013-2020) to generate the results. Results: Four primary aims were achieved: (1) The generation of a flexible, evidence-based/evidence-driven psychological performance and health sustainment hybrid, SIT-NORCAL. (2) Manualized content and process guidance. (3) The creation of multimedia materials using evidence-based methodologies. (4) The design of initial measurement systems. Preliminary quality improvement analysis demonstrated positive results using standard-of-care and performance enhancement assessments. Conclusion: Hybridized human performance and psychological health sustainment protocols represent a paradigm shift in the delivery of psychological performance training with the potential to overcome barriers to success in traditional care. Further study is needed to determine the effectiveness and reach of SIT-NORCAL.

Keywords: stress inoculation; training; performance training

PMID: 34969125

DOI: HCUV-LP37

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Stress Inoculation Training (SIT-NORCAL), Part 2: A Pilot Study Among Explosive Ordnance Disposal Special Warfare Enablers

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Jackson SE, Baity MR, Thomas PR, Walker M, Goodkind M, Swick D, Barba D, Jacobson D, Byrd E, Ivey AS. 21(4). 46 - 53. (Journal Article)

Abstract

Background: Despite being a well-supported strategy, Stress Inoculation Training (SIT) has not been fully incorporated in the advancement of human performance among most military personnel. The RAND Study recommendations for maximizing SIT's potential within high-risk/ high-intensity occupational groups were used in designing the Core Training protocol targeting psychological performance, SIT-NORCAL (Part 1). Purpose: The current project (Part 2) sought to further develop the protocol as a health and human performance hybrid through quality improvement analysis of the content, process, and measurement elements for use in the human performance context. Methods: Evidence-based/evidence-driven methodologies were used in collaborative design tailored to the unique needs of special warfare enablers specializing in Explosive Ordnance Disposal (n = 17). The resultant three-phase training was conducted with a novice group (n = 10) using standardized measurements of collaboration, human performance, and adaptive capabilities on identified training targets. Results: Process elements demonstrated high feasibility, resulting in high collaboration and trainee satisfaction. Significant improvements in psychological performance targets were observed pre- to post-training, and during an Adaptive Environmental Simulation designed by unit members. Two weeks post-training, unit members (n = 5) responded to an actual crash of an F-16 aircraft; measurements indicated maintenance of skill set from training to real-world events. Conclusion: Deployment of the elements in the SIT-NORCAL protocol demonstrated early feasibility and positive training impact on occupationally relevant skills that carried over into real-world events.

Keywords:

PMID: 34969126

DOI: JKSD-4SEW

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Studies on the Correct Length of Nasopharyngeal Airways in Adults: A Literature Review

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Scheuermann-Poley C, Lieber A. 21(3). 45 - 50. (Journal Article)

Abstract

The use of a nasopharyngeal airway (NPA) as an adjunct airway device can be critically important in emergency medicine. When placed correctly, the device can prevent upper airway obstruction. The goal of our review was to learn whether there is scientific evidence about the correct length and the insertion depth, and also possible facial landmarks, that can predict the appropriate length of the NPA. There has been no real consensus on how to measure the appropriate tube length for the NPA. Several studies have been able to demonstrate correlations between facial landmarks and body dimensions; however, we did not find any scientific evidence on this matter. The reviewed studies do not indicate evidence to support current recommended guidelines. This could potentially lead to both military and civilian emergency training programs not having the most accurate scientific information for training on anatomic structures and also not having a better overall understanding of intraoral dimensions. Emergency personnel should be taught validated scientific knowledge of NPAs so as to quickly determine the correct tube length and how to use anatomic correlations. This might require further studies on the correlations and perhaps radiographic measurements. A further approach includes adjusting the tube to its correct length according to the sufficient assessment and management of the airway problem.

Keywords: airway; nasopharyngeal; tubes; emergency; trauma

PMID: 34529804

DOI: GGFN-XJEG

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Study of Tourniquet Use in Simulated First Aid: User Judgment

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Kragh JF, Tan AR, Newton NJ, Aden JK, Dubick MA. 18(3). 15 - 21. (Journal Article)

Abstract

Background: The purpose of this study was to survey the judgments of tourniquet users in simulation to discern opportunities for further study. Methods: The study design constituted two parts: questions posed to four tourniquet users and then their tourniquet use was surveyed in simulated first aid, where the users had to decide how to perform among five different cases. The questions addressed judged confidence, blood volumes, a reason bleeding resumes, regret of preventable death, hemorrhage assessment, need for side-by-side use of tourniquets, shock severity, predicting reliability, and difference in blood losses. The mechanical performance was tested on a manikin. Case 1 had no bleeding. Case 2 had limb-wound bleeding that indicated tourniquet use in first aid. Case 3 was like case 2, except the patient was a child. Case 4 was like case 2, except caregiving was under gunfire. Case 5 was like case 4, but two tourniquets were to be used side by side. Each user made tests of the five cases to constitute a block. Each user had three blocks. Case order was randomized within blocks. The study had 60 tests. Results: In answering questions relevant to first-aid use of limb tourniquets, judgments were in line with previous studies of judgment science, and thus were plausibly applicable. Mechanical performance results on the manikin were as follows: 38 satisfactory, 10 unsatisfactory (a loose tourniquet and nine incorrect tourniquet placements), and 12 not applicable (case 1 needed no mechanical intervention). For cases 1 to 5, satisfactory results were: 100%, 83%, 100%, 75%, and 58%, respectively. For blocks 1 to 3, satisfactory results were 50%, 83%, and 83%, respectively. Conclusion: For tourniquet use in simulated first aid, the results are plausibly applicable because user judgments were coherent with those in previous studies of judgment science. However, the opportunities for further studies were noted.

Keywords: psychomotor performance; practice-based learning; choice behavior; motivation; readiness

PMID: 30222831

DOI: 2ZSJ-J8KX

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Successful Placement of REBOA in a Rotary Wing Platform Within a Combat Theater: Novel Indication for Partial Aortic Occlusion

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Brown SR, Reed DH, Thomas P, Simpson C, Ritchie JD. 20(1). 34 - 36. (Case Reports)

Abstract

Resuscitative endovascular balloon occlusion of the aorta (REBOA) is used to augment resuscitation in patients with noncompressible torso hemorrhage, which is a leading cause of death on the battlefield. However, the implementation of REBOA has resulted in considerable debate within the military medical community. We present a case of the first successful placement of an REBOA by a small surgical team within a mobile rotary wing platform.

Keywords: REBOA; surgery; head injury; trauma; small surgical team; resuscitation

PMID: 32203602

DOI: 787R-5MUN

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Successful Use of Ketamine as a Prehospital Analgesic by Pararescuemen During Operation Enduring Freedom

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Lyon RF, Schwan C, Zeal J, Kharod C, Staak BP, Petersen CD, Rush SC. 18(1). 70 - 73. (Journal Article)

Abstract

Effective analgesia is a crucial part of the care and resuscitation of a traumatically injured patient. These secondary effects of pain may increase morbidity and mortality in the acutely injured patient. When ketamine is administered appropriately in the clinical setting, it can provide analgesia, anxiolysis, and amnesia for patients with less respiratory depression and hypotension than equivalent doses of opioid analgesics.

Keywords: ketamine; analgesia; pain; opioids; prehospital analgesic; Pararescuemen; Operation Enduring Freedom

PMID: 29533436

DOI: SXOO-ORH0

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Sulfur Mustard Exposure: Review of Acute, Subacute, and Long-Term Effects and Their Management

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Wolfe GA, Petteys SM, Phelps JF, Wasmund JB, Plackett TP. 19(2). 81 - 86. (Journal Article)

Abstract

Sulfur mustard has been used in conflicts for more than a century. Despite international recognized bans on the use of chemical weapons, there continue to be reports of their use. The authors provide a contemporary overview of sulfur mustard injury and its management in the acute, subacute, and chronic periods.

Keywords: mustard gas; chemical terrorism; chemical warfare agents; blister/chemically induced; warfare

PMID: 31201756

DOI: DWNJ-ZSVN

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Summary of Recent Changes to the TCCC Guidelines 14 April 2021

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Montgomery HR, Drew B, Butler FK. 21(2). 120 - 121. (Classical Conference)

Keywords:

PMID: 34105137

DOI: NX8I-0AUH

Summary of the CMC Scientific Program 2018

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Luhrs J. 18(4). 113 - 114. (Classical Conference)

Keywords:

PMID: 30566735

DOI: 1G0J-4721

Surgery at Sea: The Effect of Simulated High Sea States on Surgical Performance

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Pierce E, Rapada R, Herder PA, LaPorta AJ, Hoang TN, Pena M, Blankenship J, Kiser J, Catlin SA. 18(2). 64 - 70. (Journal Article)

Abstract

Background: The US Navy initiated design concepts for a Medical Mission Module Support Container (M3SC), a mobile operating room capable of rapid installation aboard maneuverable ships within proximity of active combat units. The M3SC provides an alternative echelon of care in the current trauma system by decreasing the time between point of injury, arrival, and surgical intervention. The mobile ships used as M3SC platforms, however, are more susceptible to oceanic conditions that can induce detrimental physiologic motion sickness in medical personnel and patients aboard the vessels. This study investigated the effects of different sea-state motion conditions on the performance of surgical teams. Methods: Six four-person surgical teams performed 144 procedures in an M3SC aboard a Stewart motion table that simulated motion profiles of sea states 0, 3, and 4. A modified human-worn partial- task surgical simulator was used as a surgical surrogate to simulate the four most common, wartime, improvised explosive device injuries in the past 10 years. Electroencephalographs and heart rate variability (HRV) data were collected from surgeons and surgical technologists during each procedure to assess real-time physiologic responses to motion. Two postprocedure surveys, a Surgical Task Load Index and a Motion Sickness Assessment Questionnaire, were given to assess subjective responses of workload stress and motion-induced kinetosis. Surgical subject matter experts quantified surgical performance after each procedure by measuring blood loss and orthopedic pin placement to evaluate each intervention. Results: Motion did not significantly influence overall performance (ρ = .002). Surgical procedure was the strongest predictor of performance. HRV was used to measure stress and was increased in surgical technologists; however, HRV was decreased for surgeons and technologists in motion. There was a significant interaction between role and motion (ρ = .002): Surgeons had higher workloads than did surgical technologists and neither demonstrated differences between motion and no motion. Surgeons demonstrated significantly decreased workloads under motion conditions (ρ = 0.002); however, surgeons perceived their workload to be higher. We attribute this to their increased critical thinking and physical execution of procedures. Surgeons and surgical technologists showed a trend toward HRV suppression within the motion conditions. This may indicate a coping response to the increased stress of the motion setting. Procedure and team dynamic were the strongest predictors of overall performance, suggesting a learning curve exists and that added focus on training should be enforced. Conclusion: Based on data collected in this study, similar surgical procedures should be implemented aboard these classes of ships. By doing so, injured military personnel would have more timely access to care. Surgical team members were aware of craft motion, used compensatory measures, and exhibited some physiological response.

Keywords: sea medicine; operational medicine; tactical medicine; remote damage control surgery; motion sickness; sea sickness; surgical simulation; trauma; exsanguination

PMID: 29889958

DOI: EMQ7-ROZP

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Surgery In Afghanistan: A Light Model For Field Surgery During War

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Fosse E, Husum H. 08(1). 101 - 105. (Previously Published)

Previously published in Injury (1992) 23, (6), 401-404. Printed in Great Britain. Permission granted to republish in JSOM.

Abstract

Owing to a poor capability for evacuation, mobile medical teams were sent to the area of Gazni in Afghanistan to work with local paramedics as part of a medical programme for the area. The teams were equipped to perform major surgery. During one month a surgical team inside Afghanistan performed 53 operations. The operations were performed in the patients' homes at night. The team had to move frequently so as not to be spotted by the Soviet and government surveillance. Equipment equivalent to a light field hospital was stored in a safe place and the team carried supplies for one or two days on their bicycles. One postoperative death and one wound infection were recorded. It is concluded that adequate surgery can be performed inside territories where enemy forces have air control and under primitive conditions with an acceptable rate of complications. However, due to the nature of the guerrilla warfare with scattered military confrontations over vast areas, the average time between injury and treatment for war casualties was 36 hours.

Keywords:

DOI:

Surgical Airway in a Tactical Environment: A Case Report

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Cowles CE, Santos RE. 20(1). 29 - 30. (Case Reports)

Abstract

Surgical airway management should be regarded as one of many tools available to forward clinical Operators. The need for that intervention should be determined in a quick and decisive manner consistent with accepted protocols for combat care. The case presented discusses immediate surgical access to the airway required after the initial assessment of the patient and illustrates the clinical urgency of patients requiring surgical intervention in the field setting.

Keywords: wounds; gunshot; airway management; airway obstruction; law enforcement

PMID: 32203600

DOI: NQ14-V5MB

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Surgical Instrument Sets for Special Operations Expeditionary Surgical Teams

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Hale DF, Sexton JC, Benavides LC, Benavides JM, Lundy JB. 17(3). 40 - 45. (Journal Article)

Abstract

Background: The deployment of surgical assets has been driven by mission demands throughout years of military operations in Iraq and Afghanistan. The transition to the highly expeditious Golden Hour Offset Surgical Transport Team (GHOST- T) now offers highly mobile surgical assets in nontraditional operating rooms; the content of the surgical instrument sets has also transformed to accommodate this change. Methods: The 102nd Forward Surgical Team (FST) was attached to Special Operations assigned to southern Afghanistan from June 2015 to March 2016. The focus was to decrease overall size and weight of FST instrument sets without decreasing surgical capability of the GHOST-T. Each instrument set was evaluated and modified to include essential instruments to perform damage control surgery. Results: The overall number of main instrument sets was decreased from eight to four; simplified augmentation sets have been added, which expand the capabilities of any main set. The overall size was decreased by 40% and overall weight decreased by 58%. The cardiothoracic, thoracotomy, and emergency thoracotomy trays were condensed to thoracic set. The orthopedic and amputation sets were replaced with an augmentation set of a prepackaged orthopedic external fixator set). An augmentation set to the major or minor basic sets, specifically for vascular injuries, was created. Conclusion: Through the reorganization of conventional FST surgical instrument sets to maintain damage control capabilities and mobility, the 102nd GHOST-T reduced surgical equipment volume and weight, providing a lesson learned for future surgical teams operating in austere environments.

Keywords: austere surgery; forward surgical team; Golden Hour Offset Surgical Treatment Team (GHOST-T)

PMID: 28910466

DOI: Y3K7-7SKP

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Surveillance for Ehrlichia canis, Anaplasma phagocytophilum, Borrelia burgdorferi, and Dirofilaria immitis in Dogs From Three Cities in Colombia

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Mccown M, Monterroso VH, Cardona W. 14(1). 86 - 90. (Journal Article)

Abstract

Objective: Emerging infectious and zoonotic diseases are made up in large proportion by vector-borne diseases (VBD). Dogs are parasitized by disease vectors such as ticks and mosquitoes, making dogs adequate reservoirs for zoonoses. Risk of exposure to VBD exists for the U.S. military personnel and Military Working Dogs (MWD) when deployed globally. The importance of canine VBD surveillance relates to veterinary and public health significance for the host nations as well as for the U.S. troops and MWDs. The objective of this work was to survey dogs from the cities of Medellin, Barranquilla, and Cartagena in Colombia to determine the prevalence of heartworm disease (Dirofilaria immitis), ehrlichiosis (Ehrlichia canis), Lyme disease (Borrelia burgdorferi), and anaplasmosis (Anaplasma phagocytophilum). Methods: Canine (n = 498) blood samples (1-3mL) were collected during July 2011 from Medellin (n = 175), Barranquilla (n = 223), and Cartagena (n = 100) and were tested on-site using IDEXX SNAP® 4Dx® Test Kits. Results: The overall combined sample prevalence of E. canis, A. phagocytophilum, D. immitis, and B. burgdorferi was 62%, 33%, 1.6%, and 0%, respectively. In Medellin, 26% of the samples were positive for E. canis, 12% for A. phagocytophilum, and 0% for D. immitis. In Barranquilla, sample prevalence for E. canis, A. phagocytophilum, and D. immitis was 83%, 40%, and 2%, respectively. In Cartagena, E. canis, A. phagocytophilum, and D. immitis prevalence was 80%, 51%, and 3%, respectively. Conclusion: E. canis and A. phagocytophilum are present in all three surveyed cities. There is a higher sample prevalence for E. canis and A. phagocytophilum than for D. immitis. In addition, the prevalence for these organisms is higher in Barranquilla and Cartagena than in Medellin. Overall, this study emphasizes the value of surveillance for VBDs in order to determine disease prevalence, develop risk assessments, and implement control measures.

Keywords: zoonotic disease; parasites; vector-borne disease; dogs; public health; surveillance; Colombia

PMID: 24604443

DOI: YYT5-90FP

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Survey of Casualty Evacuation Missions Conducted by the 160th Special Operations Aviation Regiment During the Afghanistan Conflict

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Redman TT, Mayberry KE, Mora AG, Benedict BA, Ross EM, Mapp JG, Kotwal RS. 18(2). 79 - 85. (Journal Article)

Abstract

Background: Historically, documentation of prehospital combat casualty care has been relatively nonexistent. Without documentation, performance improvement of prehospital care and evacuation through data collection, consolidation, and scientific analyses cannot be adequately accomplished. During recent conflicts, prehospital documentation has received increased attention for point-of-injury care as well as for care provided en route on medical evacuation platforms. However, documentation on casualty evacuation (CASEVAC) platforms is still lacking. Thus, a CASEVAC dataset was developed and maintained by the 160th Special Operations Aviation Regiment (SOAR), a nonmedical, rotary-wing aviation unit, to evaluate and review CASEVAC missions conducted by their organization. Methods: A retrospective review and descriptive analysis were performed on data from all documented CASEVAC missions conducted in Afghanistan by the 160th SOAR from January 2008 to May 2015. Documentation of care was originally performed in a narrative after-action review (AAR) format. Unclassified, nonpersonally identifiable data were extracted and transferred from these AARs into a database for detailed analysis. Data points included demographics, flight time, provider number and type, injury and outcome details, and medical interventions provided by ground forces and CASEVAC personnel. Results: There were 227 patients transported during 129 CASEVAC missions conducted by the 160th SOAR. Three patients had unavailable data, four had unknown injuries or illnesses, and eight were military working dogs. Remaining were 207 trauma casualties (96%) and five medical patients (2%). The mean and median times of flight from the injury scene to hospital arrival were less than 20 minutes. Of trauma casualties, most were male US and coalition forces (n = 178; 86%). From this population, injuries to the extremities (n = 139; 67%) were seen most commonly. The primary mechanisms of injury were gunshot wound (n = 89; 43%) and blast injury (n = 82; 40%). The survival rate was 85% (n = 176) for those who incurred trauma. Of those who did not survive, most died before reaching surgical care (26 of 31; 84%). Conclusion: Performance improvement efforts directed toward prehospital combat casualty care can ameliorate survival on the battlefield. Because documentation of care is essential for conducting performance improvement, medical and nonmedical units must dedicate time and efforts accordingly. Capturing and analyzing data from combat missions can help refine tactics, techniques, and procedures and more accurately define wartime personnel, training, and equipment requirements. This study is an example of how performance improvement can be initiated by a nonmedical unit conducting CASEVAC missions.

Keywords: casualty evacuations; CASEVAC; en route care; Tactical Combat Casualty Care; TCCC

PMID: 29889961

DOI: RH08-BR6J

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Survey of Military Physician Receptivity to Telemedicine and Perceived Telemedicine-Amenable Conditions in Turkey

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Cetin M, Ylidirim M. 23(3). 13 - 17. (Journal Article)

Abstract

Background: Today, asymmetric conflict and terrorism pose a threat to not only soldiers but also civilians, forcing the North Atlantic Treaty Organization (NATO) to confront new threats and rethink its strategy. Various studies have shown that telemedicine is one of these advancements and that it can eventually bring expert advice to the field. Telemedicine, on the other hand, is new in Turkey and has yet to be implemented in the field. The aim of this study is to evaluate the support of health personnel with telemedicine from the perspective of military physicians. Methods: This study was carried out between 20 August 2021 and 5 October 2021 with the participation of 47 military physicians working as research assistants in a training and research hospital. A questionnaire consisting of 17 questions was used to evaluate military physicians' perspectives on telemedicine and their expectations from it. Results: Forty-six of the participants stated that they wanted a healthcare provider/expert opinion to consult about the patient/injured while they were on field and that telemedicine could be used within the scope of field medicine (4.51 ± 0.62). They also stated that telemedicine centers should employ emergency medicine specialists in particular (n = 40, 85.1%). The participants agreed that these centers would be quite useful, particularly for medical evacuations (n = 42, 89.4%). Conclusion: Telemedicine's long-term viability in our country is thought to be contingent upon it covering medical conditions that are practical, require fewer technical intricacies, and appeal to emergency health services. The openness of the personnel to innovation and change is expected to improve harmony and cooperation.

Keywords: military; telemedicine; emergency; Turkey; armed forces

PMID: 37169529

DOI: TAYD-HUT5

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Survey Of The Indications For Use Of Emergency Tourniquets

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Kragh JF, O'Neill ML, Beebe DF, Fox CJ, Beekley AC, Cain JS, Parsons DL, Mabry RL, Blackbourne LH. 11(2). 30 - 34. (Journal Article)

Abstract

Indications and evidence are limited, multiple and complex for emergency tourniquet use. Good recent outcomes challenge historically poor outcomes. Optimal tourniquet use in trauma care appears to depend on adequate devices, modern doctrine, refined training, speedy evacuation, and performance improvement. Challenges remain in estimation of blood loss volumes, lesion lethality, and casualty propensity to survive hemorrhage. Summary Background Data: Evidence gaps persist regarding emergency tourniquet use indications in prehospital and emergency department settings as indication data are rarely reported. Methods: Data on emergency tourniquet use was analyzed from a large clinical study (NCT00517166 at ClinicalTrials.gov). The study included 728 casualties with 953 limbs with tourniquets. The median casualty age was 26 years (range, 4-70). We compared all other known datasets to this clinical study. Results: Tourniquet use was prehospital in 671 limbs (70%), hospital only in 104 limbs (11%), and both prehospital and hospital in 169 limbs (18%).Major hemorrhage was observed at or before the hospital in 487 (51%) limbs and minor hemorrhage was observed at the hospital in 463 limbs (49%). Anatomic lesions indicating tourniquets included open fractures (27%), amputations (26%), soft tissue wounds (20%), and vascular wounds (17%). Situations, as opposed to anatomic lesions, indicating tourniquets included bleeding from multiple sites other than limbs (24%), hospital mass casualty situations (1%), one multiple injury casualty needed an airway procedure, and one casualty had an impaled object. Conclusions: The current indication for emergency tourniquet use is any compressible limb wound that the applier assesses as having possibly lethal hemorrhage. This indication has demonstrated good outcomes only when devices, training, doctrine, evacuation, and research have been optimal. Analysis of emergency tourniquet indications is complex and inadequately evidenced, and further study is prudent. Prehospital data reporting may fill knowledge gaps. Objective: The purpose of this study is to report and analyze emergency tourniquet use indications to stop limb bleeding.

Keywords:

PMID: 21455908

DOI: 36SQ-1UQU

Survival of Casualties Undergoing Prehospital Supraglottic Airway Placement Versus Cricothyrotomy

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Schauer SG, Naylor JF, Chow AL, Maddry JK, Cunningham CW, Blackburn MB, Nawn CD, April MD. 19(2). 91 - 94. (Journal Article)

Abstract

Background: Airway compromise is the second leading cause of preventable death on the battlefield. Unlike a cricothyrotomy, supraglottic airway (SGA) placement does not require an incision and is less technically challenging. We compare the survival of causalities undergoing cricothyrotomy versus SGA placement. Methods: We used a series of emergency department (ED) procedure codes to search within the Department of Defense Trauma Registry (DODTR) from January 2007 to August 2016. This is a subanalysis of that data set. Results: During the study period, 194 casualties had a documented cricothyrotomy and 22 had a documented SGA as the sole airway intervention. The two groups had similar proportions of explosive injuries (57.7% versus 63.6%, p = .328), similar composite injury severity scores (25 versus 27.5, p = .168), and similar AIS for the head, face, extremities, and external body regions. The cricothyrotomy group had lower AIS for the thorax (0 versus 3, p = .019), a trend toward lower AIS for the abdomen (0 versus 0, p = .077), more serious injuries to the head (67.5% versus 45.5%, p = .039), and similar rates of serious injuries to the face (4.6% versus 4.6%, p = .984). Glasgow Coma Scale (GCS) scores were similar on arrival to the ED (3 versus 3, p = .467) as were the proportion of patients surviving to discharge (45.4% versus 40.9%, p = .691). On repeated multivariable analyses, the odds ratios for survival were not significantly different between the two groups. Conclusions: We found no difference in short-term outcomes between combat casualties who received an SGA vs those who received a cricothyrotomy. Military prehospital personnel rarely used either advanced airway intervention during the recent conflicts in Afghanistan and Iraq.

Keywords: airway; supraglottic; extraglottic; prehospital; cricothyroidotomy

PMID: 31201758

DOI: D4C5-PVHK

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Survival of Casualties Undergoing Prehospital Supraglottic Airway Placement Versus Cricothyrotomy

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Schauer SG, Naylor JF, Chow AL, Maddry JK, Cunningham CW, Blackburn MB, Nawn CD, April MD. 19(3). 86 - 89. (Journal Article)

Abstract

Background: Airway compromise is the second leading cause of preventable death on the battlefield. Unlike a cricothyrotomy, supraglottic airway (SGA) placement does not require an incision and is less technically challenging. We compare survival of causalities undergoing cricothyrotomy versus SGA placement. Methods: We used a series of emergency department (ED) procedure codes to search within the Department of Defense Trauma Registry (DoDTR) from January 2007 to August 2016. This is a subanalysis of that dataset. Results: During the study period, 194 casualties had a documented cricothyrotomy and 22 had a documented SGA as the sole airway intervention. The two groups had similar proportions of explosive injuries (57.7% versus 63.6%, p = .328), similar composite injury severity scores (25 versus 27.5, p = .168), and similar AIS for the head, face, extremities, and external body regions. The cricothyrotomy group had lower AIS for the thorax (0 versus 3, p = .019) a trend toward lower AIS for the abdomen (0 versus 0, p = .077), more serious injuries to the head (67.5% versus 45.5%, p = .039), and similar rates of serious injuries to the face (4.6% versus 4.6%, p = .984). Glasgow Coma Scale (GCS) scores were similar upon arrival to the ED (3 versus 3, p = .467) as were the proportion of patients surviving to discharge (45.4% versus 40.9%, p = .691). On repeated multivariable analyses, the odds ratios (ORs) for survival were not significantly different between the two groups. Conclusion: We found no difference in short-term outcomes between combat casualties who received an SGA vs cricothyrotomy. Military prehospital personnel rarely used either advanced airway intervention during the recent conflicts in Afghanistan and Iraq.

Keywords: airway; supraglottic; extraglottic; prehospital; cricothyroidotomy; injury; explosive

PMID: 31539439

DOI: ZYTI-1RO2

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Suspected Dietary Supplement Injuries In Special Operations Soldiers

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Hughes JR, Shelton B, Hughes T. 10(3). 14 - 24. (Journal Article)

Keywords:

PMID: 21049431

DOI: S1VN-EEQS

Swedish Specialized Boarding Element Members' Experiences of Naval Hostile Duty

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Hindorf M, Lundberg L, Jonsson A. 18(3). 45 - 49. (Journal Article)

Abstract

Background: The Swedish naval specialized boarding element participated in Operation Atalanta in 2013 to mitigate piracy by escorting and protecting ships included in the United Nations World Food Program in the Indian Ocean. We describe the experiences of the Swedish naval specialized boarding-element members during 4 months of international naval hostile duty. Some studies have reported experiences of naval duty for the Coast Guard or the merchant fleet; however, we did not find any studies that identified or described experiences of long-time duty onboard ship for the naval armed forces. Materials and Methods: The respondents wrote individual notes of daily events while onboard. Conventional content analysis was used on the collected data, using an inductive approach. Results: The findings revealed three broad themes: military preparedness, coping with the naval context, and handling physical and mental strain. Different categories emerged indicating that the participants need the ability to adapt to the naval environment and to real situations. Conclusion: The Swedish naval forces should train their specialized element members in coping strategies.

Keywords: Swedish Navy; naval duty; mental strain; coping; qualitative method

PMID: 30222836

DOI: 6XHH-1LG1

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TacMed Updates: Building Community Resilience to Dynamic Mass Casualty Incidents: A Multiagency White Paper in Support of the First Care Provider

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Anonymous A. 15(4). 175 - 177. (Classical Conference)

Keywords:

PMID: 27280224

DOI: G0RQ-S7RN

TacMed Updates: Committee for Tactical Emergency Casualty Care (C-TECC) Update: Summer 2014

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Callaway DW, Smith R, Shapiro G, McKay SD. 14(3). 134 - 134. (Classical Conference)

Keywords:

PMID: 25344722

DOI: 9HER-PN48

TacMed Updates: Committee for Tactical Emergency Casualty Care Spring Update

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Shapiro G, Smith R, Callaway DW. 16(1). 137 - 139. (Classical Conference)

Keywords:

DOI: 1W7E-B7ZU

TacMed Updates: Development of a National Consensus for Tactical Emergency Medical Support (TEMS) Training Programs-Operators and Medical Providers

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Schwartz RB, Lerner B, Llewellyn C, Pennardt A, Wedmore I, Callaway DW, Wightman JM, Casillas R, Eastman AL, Gerold KB, Giebner S, Davidson R, Kamin R, Piazza G, Bollard GA, Carmona PA, Sonstrom B, Seifarth W, Nicely B, Croushorn J, Carmona PA. 14(2). 122 - 138. (Classical Conference)

Keywords:

PMID: 24952052

DOI: 2QZA-HKLC

TacMed Updates: K9 Tactical Emergency Casualty Care Direct Threat Care Guidelines

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Palmer LE, Yee A. 17(2). 174 - 187. (Classical Conference)

Keywords: canines; K9s; Operational K9s; Tactical Emergency Casualty Care

PMID: 28599053

DOI: PXB1-BL4Y

TacMed Updates: Spring Committee for Tactical Emergency Casualty Care (C-TECC) Update

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Smith R, Bobko JP, Shapiro G, Hartford B, Callaway DW. 15(1). 143 - 145. (Classical Conference)

Keywords:

PMID: 27689375

DOI: GDOG-CVDJ

TacMed Updates: Tactical Emergency Casualty Care (TECC) Update: Winter 2014

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Callaway DW, Smith R, Shapiro G. 14(4). 146 - 147. (Classical Conference)

Keywords:

PMID: 27689373

DOI: QMW4-LB02

TacMed Updates: TEMS v. 2014

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Carmona PA. 14(1). 116 - 117. (Classical Conference)

Keywords:

PMID: 27689364

DOI: 0ZTG-GCG6

TacMed Updates: The Committee for Tactical Emergency Casualty Care (C-TECC): Summer Update

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Callaway DW, Smith R, Shapiro G, Hartford B, McKay SD, Kamin R. 15(2). 168 - 170. (Classical Conference)

Keywords:

PMID: 27689377|REJECTED: Cannot Replace Article: ArticleIds do not match, contact LinkOut to change ArticleIds

DOI: 6TKU-98I9

TacMed Updates: The Committee for Tactical Emergency Casualty Care: Fall Update

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Callaway DW, Smith R, Shapiro G, McKay SD, Kamin R. 15(3). 148 - 152. (Classical Conference)

Keywords:

PMID: 27280187

DOI: SMK2-V30V

Tactical Combat Casualty Care (TCCC) Guidelines for Medical Personnel 15 December 2021

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Anonymous A. 22(1). 11 - 17. (Classical Conference)

Keywords:

PMID: 35278312

DOI: ETZI-SI9T

Tactical Combat Casualty Care (TCCC) Guidelines for Medical Personnel: 05 November 2020

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Drew B, Montgomery HR, Butler FK. 20(4). 144 - 151. (Classical Conference)

Keywords:

PMID: 33320328

DOI: RBRA-WMWV

Tactical Combat Casualty Care (TCCC) Guidelines: 25 January 2024

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Deaton TG, Drew B, Montgomery HR, Butler FK. Ahead of Print. (Classical Conference)

Keywords:

PMID: 38364091

DOI: QT3B-XK5B

Tactical Combat Casualty Care (TCCC) Update

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Montgomery HR, Drew B. 20(2). 152 - 153. (Classical Conference)

Keywords:

PMID: 32573756

DOI: 8BYB-KQQG

Tactical Combat Casualty Care for Medical Personnel (TCCC-MP): Recommended Post-Course Metrics (24 July 2018)

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Anonymous A. 18(3). 136 - 146. (Classical Conference)

Keywords:

PMID: 30222852

DOI: PNJD-0BE0

Tactical Combat Casualty Care in Operation Freedom's Sentinel

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Shukla A, Perez C, Hoemann B, Keasal M. 20(3). 67 - 70. (Journal Article)

Abstract

Over the course of nearly 19 years of conflict, Tactical Combat Casualty Care (TCCC) guidelines and their implementation have evolved to incorporate the latest advances in trauma research, casualty care, and transport, playing a large role in generating the lowest incidence of preventable deaths in the history of modern warfare. During the conflicts in Afghanistan and Iraq, the adoption and implementation of TCCC principles by conventional forces have been extrapolated to have been responsible for saving the lives of more than 1,000 US Servicemembers. As the intensity and nature of the military conflicts in Afghanistan and Iraq change, and a growing potential for a near peer conflict rises, it remains important that the lessons of TCCC continue to be instilled in our formations in garrison, before deployment, and while in theater. This article reviews the use of TCCC principles by an assault helicopter battalion, in combination with a variety of other factors, in the successful management of a mass casualty event during Operation Freedom's Sentinel 2019 in Afghanistan.

Keywords: Operation Freedom's Sentinel; TCCC; lessons learned

PMID: 32969006

DOI: SPAS-RZ2W

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Tactical Combat Casualty Care In The Assault On Punta Paitilla Airfield

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Mucciarone JJ, Llewellyn C, Wightman JM. 08(1). 106 - 110. (Previously Published)

Originally published in Military Medicine, 171,8:687,2006. Permission granted to republish in the JSOM.

Abstract

Department of Military and Emergency Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD 20814. The opinions and assertions herein are the private views of the authors and are not to be construed as official or as reflecting the views of the Uniformed Services University, the U.S. Navy or U.S. Air Force, the U.S. Department of Defense, or the U.S. government. This is a U.S. government work. There are no restrictions on its use. This manuscript was received for review in August 2005 and was accepted for publication in November 2005.

Keywords:

DOI:

Tactical Combat Casualty Care Maritime Scenario: Shipboard Missile Strike

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Butler FK, Burkholder T, Chernenko M, Chimiak J, Chung J, Cubano M, Gurney J, Hall AB, Holcomb JB, Kotora J, Lenart M, Long A, Papalski W, Rich TA, Tripp M, Shackelford SA, Tadlock MD, Timby JW, Drew B. 22(2). 9 - 28. (Journal Article)

Abstract

The types of injuries seen in combat action on a naval surface ship may be similar in many respects to the injuries seen in ground combat, and the principles of care for those injuries remain in large part the same. However, some contradistinctions in the care of combat casualties on a ship at sea must be highlighted, since this care may entail a number of unique challenges and different wounding patterns. This paper presents a scenario in which a guided missile destroyer is struck by a missile fired from an unmanned aerial vehicle operated by an undetermined hostile entity. Despite the presence of casualties who require care, the primary focus of a naval vessel that has just been damaged by hostile action is to prevent the ship from sinking and to conserve the fighting force on board the ship to the greatest extent possible. The casualties in this scenario include sailors injured by both blast and burns, as well as a casualty with a non-fatal drowning episode. Several of the casualties have also suffered the effects of a nearby underwater explosion while immersed. Challenges in the care of these casualties include delays in evacuation, the logistics of obtaining whole blood for transfusion while at sea, and transporting the casualties to the next higher level of care aboard a Casualty Receiving and Treatment Ship. As the National Defense Strategy pivots to a focus on the potential for maritime combat, the medical community must continue to maintain readiness by preparing fo

Keywords: underwater blast; TCCC; Tactical Combat Casualty Care; burns; whole blood; hemorrhage control; shipboard; maritime casualties; naval surface warfare

PMID: 35639888

DOI: ZT9J-EI8Z

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Tactical Combat Casualty Care Scenario: Management of a Gunshot Wound to the Chest in a Combat Swimmer

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Butler FK, Littlejohn LF, Byrne T, Martino E, Montgomery HR, Drew B. 21(3). 138 - 142. (Journal Article)

Abstract

Tactical Combat Casualty Care (TCCC) has always emphasized the need to consider the tactical setting in developing a plan to care for wounded unit members while still on the battlefield. The TCCC Guidelines provide an evidence-based trauma care approach to specific injuries that may occur in combat. However, they do not address what modifications might need to be made to the basic TCCC guidelines due to the specific tactical setting in which the scenario occurs. The scenario presented below depicts a combat swimmer operation in which a unit member is shot while in the water. The unit casualty response plan for a combat swimmer who sustains a gunshot wound to the chest while on a mission is complicated by the inability to perform indicated medical interventions for the casualty while he is in the water. It is also complicated by the potential for ballistic damage to his underwater breathing apparatus and the need to remain submerged after wounding for at least for a period of time to avoid further hostile fire. Additionally, there is a potential for a cerebral arterial gas embolism (CAGE) and/or a tension pneumothorax to develop while surfacing because of the decreasing ambient pressure on ascent. The tactical response may be complicated by limited communications between the mission personnel while submerged and by the vulnerability of the mission personnel to antiswimmer measures if their presence is compromised.

Keywords: TCCC; Tactical Combat Casualty Care; gunshot wound; GSW; combat swimmer; cerebral arterial gas embolism; tension pneumothorax

PMID: 34529821

DOI: 5A31-WYTH

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Tactical Combat Casualty Care Skill Sets by Responder Level. 22 April 2019

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Butler FK, Giebner S. 19(2). 143 - 145. (Classical Conference)

Keywords:

PMID: 31201770

DOI: NCG5-VJ4H

Tactical Combat Casualty Care Updates

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Montgomery HR, Butler FK. 17(3). 154 - 154. (Classical Conference)

Keywords:

PMID: 28910488

DOI: LNUM-OWI0

Tactical Combat Casualty Care: Top Lessons for Civilian EMS Systems from 14 Years of War

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Butler FK. 16(2). 120 - 137. (Classical Conference)

Keywords:

PMID: 27689382

DOI: 1I8Z-F6MH

Tactical Emergency Casualty Care (TECC): Guidelines For The Provision Of Prehospital Trauma Care In High Threat Environments

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Callaway DW, Smith ER, Cain JS, Shapiro G, Burnett WT, McKay SD, Mabry RL. 11(4). 104 - 122. (Journal Article)

Keywords:

PMID: 22173602

DOI: 8BUM-KREB

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Tactical Emergency Casualty Care-Pediatric Appendix: Novel Guidelines for the Care of the Pediatric Casualty in the High-Threat, Prehospital Environment

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Bobko JP, Lai TT, Smith R, Shapiro G, Baldridge T, Callaway DW. 13(4). 94 - 107. (Journal Article)

Abstract

Background: Active shooter events and active violent incidents are increasingly targeting civilians, placing children at heightened risk for complex and devastating trauma. The U.S. Department of Homeland Security has identified as a priority preparing domestic first responders to manage complex mass casualty incidents as a primary step in strengthening our medical system. Existing literature suggests that many prehospital providers are uncomfortable treating critically ill or injured pediatric patients and that there is a gap in the consistent provision of high-quality trauma care to these patients. The success of threat-based care developed by the military has led to an exponential rise in the familiarity and utilization of these concepts within certain specialized elements of civilian care. Evolution of these concepts is accelerating to meet the demands of the nonmilitary civilian environment through the formation and subsequent work of the Committee for Tactical Emergency Casualty Care (C-TECC). However, a gap remains in the available literature describing the application of these principles to specialized populations. Methods: In the absence of an evidence-based set of guidelines for prehospital care of the pediatric casualty, the C-TECC sought to establish a set of peer-reviewed guidelines to serve as a foundation describing current best practices. The Pediatric Working Group (PWG) utilized the adult TECC guidelines as a starting point and identified a series of key questions regarding trauma interventions. The PWG conducted a standard PubMed search to identify key relevant or potentially relevant literature. The literature review was presented to the C-TECC Guidelines Committee for review and approval of recommended principles. Recommendations: Given the dearth of supporting literature on the subject, the TECC committee was purposefully conservative in the adaptation of the adult TECC guidelines to a pediatric standard. The guidelines highlight information tailored to the pediatric population and were designed to be a resource for individual agencies seeking guidance for high-threat operations. To our knowledge, the TECC Pediatric Appendix is the first published recommendation for the widespread use of tourniquets in pediatric hemorrhage. In addition, the Guidelines are meant to highlight gaps in trauma literature and stimulate discussion regarding future research in the area of prehospital care of the pediatric casualty.

Keywords: TCCC; pediatric hemorrhage; pediatrics; C-TCCC

PMID: 24227567

DOI: EF77-LDYW

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Tactical Evacuation: Extending Critical Care on Rotary Wing Platforms to Forward Surgical Facilities

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Tobin JM, Via DK, Carter T. 11(1). 43 - 44. (Journal Article)

Keywords:

PMID: 22113726

DOI: S0KX-7GQ3

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Tactical Hemorrhage Control Case Studies Using a Point-of-Care Mechanical Direct Pressure Device

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Kirkpatrick AW, McKee JL. 14(4). 7 - 10. (Journal Article)

Abstract

In 2012, a new hemorrhage control device entered the market, and by May 2013, the iTClamp™ 50 had acquired US Food and Drug Administration approval. The authors describe the use of the iTClamp 50 and present two case studies in which the iTClamp 50 was successfully used in the military environment to control potentially fatal hemorrhage.

Keywords: hemorrhage; prehospital care; iTClamp 50

PMID: 25399362

DOI: ARPB-5IAK

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Tactical Lighting in Special Operations Medicine: Survey of Current Preferences

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Calvano CJ, Enzenauer RW, Eisnor DL, LaPorta AJ. 13(4). 15 - 21. (Journal Article)

Abstract

Success in Special Operations Forces medicine (SOFMED) is dependent on maximizing visual capability without compromising the provider or casualty position when under fire. There is no single ideal light source suitable for varied SOFMED environments. We present the results of an online survey of Special Operations Medical Operators in an attempt to determine strengths and weaknesses of current systems. There was no consensus ideal hue for tactical illumination. Most Operators own three or more lights, and most lights were not night vision compatible. Most importantly, nearly 25% of respondents reported that lighting issues contributed to a poor casualty outcome; conversely, a majority (50 of 74) stated their system helped prevent a poor outcome. Based on the results of this initial survey, we can affirm that the design and choice of lighting is critical to SOFMED success. We are conducting ongoing studies to further define ideal systems for tactical applications including field, aviation, and marine settings.

Keywords: lighting; tactical; dark adaptation; contrast sensitivity; illumination

PMID: 24227557

DOI: 7FAH-U3C2

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Tactical Lighting in Special Operations Medicine: Survey of Current Preferences

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Calvano CJ, Enzenauer RW, Eisnor DL, LaPorta AJ. 13(1). 15 - 21. (Journal Article)

Abstract

Success in Special Operations Forces medicine (SOFMED) is dependent on maximizing visual capability without compromising the provider or casualty position when under fire. There is no single ideal light source suitable for varied SOFMED environments. We present the results of an online survey of Special Operations Medical Operators in an attempt to determine strengths and weaknesses of current systems. There was no consensus ideal hue for tactical illumination. Most Operators own three or more lights, and most lights were not night vision compatible. Most importantly, nearly 25% of respondents reported that lighting issues contributed to a poor casualty outcome; conversely, a majority (50 of 74) stated their system helped prevent a poor outcome. Based on the results of this initial survey, we can affirm that the design and choice of lighting is critical to SOFMED success. We are conducting ongoing studies to further define ideal systems for tactical applications including field, aviation, and marine settings.

Keywords: lighting; tactical; dark adaptation; contrast sensitivity; illumination

PMID: 24227557

DOI: B86I-QRAU

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Tactical Medicine in Response to Acts of Terrorism

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Tang N, Kelen GD. 13(4). 109 - 110. (Journal Article)

Keywords:

PMID: 24227568

DOI: 3YN1-AC72

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Tactical Medicine Training for SEAL Mission Commanders

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Butler FK. 21(1). 127 - 133. (Classical Conference)

Abstract

The Tactical Combat Casualty Care (TCCC) project initiated by Naval Special Warfare and continued by the US Special Operations Command has developed a new set of combat trauma care guidelines that seek to combine good medical care with good small-unit tactics. The principles of care recommended in TCCC have gained increasing acceptance throughout the Department of Defense in the four years since their publication and increasing numbers of combat medical personnel and military physicians have been trained in this concept. Since casualty scenarios in small-unit operations typically present tactical as well as medical problems, however, it has become apparent that a customized version of this course suitable for small-unit mission commanders is a necessary addition to the program. This paper describes the development of a course in Tactical Medicine for SEAL Mission Commanders and its transition into use in the Naval Special Warfare community.

Keywords:

PMID: 33721322

DOI: J774-N297

Tactical Physical Preparation: The Case for a Movement-Based Approach

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Kechijian D, Rush SC. 12(3). 43 - 49. (Journal Article)

Abstract

Progressive injury prevention and physical preparation programs are needed in military special operations to optimize mission success and Operator quality of life and longevity. While physical risk is inherent in Special Operations, non-traumatic injuries resulting from overuse, poor biomechanics, and arbitrary exercise selection can be alleviated with proper medical care and patient education. An integrated approach to physical readiness that recognizes the continuity between rehabilitation and performance training is advocated to ensure that physiological adaptations do not come at the expense of orthopedic health or movement proficiency. Movement quality should be regularly evaluated and enforced throughout the training process to minimize preventable injuries and avoid undermining previous rehabilitative care. While fitness and proper movement are not substitutes for Operator specific tasks, they are foundational to many tactically-relevant skills. In light of how much is at stake, sports medicine care in the military, especially special operations, should parallel that which is practiced in professional and collegiate athletics.

Keywords:

PMID: 23032319

DOI: WT1F-608J

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Targeted Intervention Improves Symptoms and Impairments in Patients With Mild Traumatic Brain Injury With Chronic Symptom: A Prospective, Multiple Interventional Research Trial

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Eagle SR, Kontos AP, Collins MW, Mucha A, Holland CL, Edelman K, Benso S, Schneider W, Soose R, Okonkwo DO. 21(2). 61 - 66. (Journal Article)

Abstract

Background: Mild traumatic brain injury (mTBI) and its potential long-term consequences is a primary concern for the US military. The purpose of the study is to evaluate if participants improved in anxiety/mood symptoms, sleep quality, and vestibular/ocular symptoms following a 6-month active intervention, and to explore the effect of targeted treatment for those with specific symptoms/impairments (e.g., psychological, sleep, ocular, vestibular). Materials and Methods: A multidisciplinary clinical team adjudicated participants (n=72, 35.8±8.6 years old, 19% female) to have one of the following primary clinical trajectories: psychological (PSYCH; n=34), sleep (SLEEP; n=25) and vestibular/ocular (VESTIB/OCULAR; n=18). Participants returned for follow-up assessment 6 months later. Assessments included the Post-Concussion Symptom Scale [PCSS], Generalized Anxiety Disorder-7 [GAD-7], Pittsburgh Sleep Quality Index [PSQI], and Dizziness Handicap Inventory [DHI]. Change in concussion symptoms and primary outcome for the given trajectory (i.e., PSYCH=GAD-7, SLEEP=PSQI, VESTIB/OCULAR=DHI) was assessed. Results: Following the 6-month intervention, participants reduced PCSS Score (-14.5±2.4; p<.001; η2=0.34), GAD-7 (-3.1±0.5; p<.001; η2=0.34), PSQI (-2.7±0.5; p<.001; η2=0.34) and DHI (-9.2±2.0; p<.001; η2=0.23). PSYCH (n=34) reduced PCSS score (-17.9±3.6; p<.001; η2=0.45) and GAD-7 (-3.1±0.7; p<.001; η2=0.38). SLEEP (n=25) reduced PCSS score (-8.8±4.4; p=.06; η2=0.15) and PSQI (-3.6±0.9; p<.001; η2=0.45) scores. VESTIB/OCULAR (n=18) reduced PCSS score (-16.7±4.8; p=.03; η2=0.45), and DHI (-15.7±5.5; p=.012; η2=0.35). Conclusions: Large effects were observed for concussion, anxiety, sleep, and dizziness symptom reduction over 6-month treatment. Each primary outcome demonstrated a larger treatment effect for the given trajectory than the overall sample, indicating that targeted treatment can reduce symptom burden in patients with mTBI with chronic symptoms.

Keywords: concussion; chronic mild traumatic brain injury; targeted intervention

PMID: 34105123

DOI: AEY2-8NRI

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Taser and Conducted Energy Weapons

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LeClair TG, Meriano T. 15(4). 83 - 88. (Journal Article)

Keywords: taser; conducted energy weapons

PMID: 26630100

DOI: 9XC7-PB6V

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TCCC Critical Decision Case Studies

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Anonymous A. 19(3). 18 - 21. (Classical Conference)

Keywords: case reports; airway; TCCC

PMID: 31539428

DOI: WOJU-VFN2

TCCC Critical Decision Case Studies

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Anonymous A. 19(4). 22 - 24. (Classical Conference)

Keywords: case reports; bleeding; TCCC

PMID: 31910469

DOI: 0HZA-852C

TCCC Critical Decision Case Studies

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Anonymous A. 22(4). 132 - 135. (Classical Conference)

Keywords:

PMID: 36525026

DOI: HPHQ-6Y0S

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TCCC Critical Decision Case Studies

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Butler FK. 23(2). 126 - 129. (Case Reports)

Keywords:

PMID: 37169524

DOI: E78X-C6YO

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TCCC Guidelines Comprehensive Review and Edits 2020: TCCC Guidelines Change 20-05 01 November 2020

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Montgomery HR, Drew B, Torrisi J, Adams MG, Remley MA, Rich TA, Greydanus DJ, Shaw TA. 21(2). 122 - 127. (Classical Conference)

Abstract

Based on careful review of the Tactical Combat Casualty Care (TCCC) Guidelines, the authors developed a list of proposed changes and edits for inclusion in a comprehensive change proposal. To be included in the proposal, individual changes had to meet at least one of three criteria: 1. The change was primarily tactical, operational, or educational rather than clinical in nature. 2. The change was a minor modification to the language of an existing TCCC Guideline. 3. The change, though clinical, was straightforward and noncontentious. The authors initially presented their list to the TCCC Collaboration Group for review at the 11 August 2020 online virtual meeting of the Committee on Tactical Combat Casualty Care (CoTCCC). Based on discussions during the virtual meeting and following revisions, a second presentation of guideline modifications was presented during the CoTCCC session of the online virtual Defense Committee on Trauma meeting on 02 September 2020. The CoTCCC conducted voting on the guideline changes in early October 2020 with subsequent inclusion in the updated TCCC Guidelines published on 01 November 2020.1

Keywords: Tactical Combat Casualty Care; TCCC; guidelines; change proposal

PMID: 34105138

DOI: SU0P-ZNLN

TCCC Guidelines Comprehensive Review and Update: TCCC Guidelines Change 16-03

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Montgomery HR, Butler FK, Kerr W, Conklin CC, Morissette DM, Remley MA, Shaw TA, Rich TA. 17(2). 21 - 38. (Classical Conference)

Abstract

Based on careful review of the Tactical Combat Casualty Care (TCCC) Guidelines, the authors developed a list of proposed changes for inclusion in a comprehensive change proposal. To be included in the proposal, individual changes had to meet at least one of three criteria: (1) The change was primarily tactical rather than clinical; (2) the change was a minor modification to the language of an existing TCCC Guideline; and (3) the change, though clinical, was straightforward and noncontentious. The authors presented their list to the TCCC Working Group for review and approval at the 7 September 2016 meeting of the Committee on Tactical Combat Casualty Care (CoTCCC). Twenty-three items met with general agreement and were retained in this change proposal.

Keywords: Tactical Combat Casualty Care; TCCC; T3; Tactical Combat Casualty Care guidelines; TCCC Guidelines Comprehensive Review and Update; battlefield trauma care; Role 1 Care

PMID: 28599032

DOI: ZGAF-INZU

TCCC Standardization: The Time Is Now

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Goforth C, Antico D. 16(3). 53 - 56. (Editorial)

Keywords:

PMID: 27734443

DOI: LQ9Q-2YUF

TCCC Updates

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Anonymous A. 14(3). 124 - 132. (Classical Conference)

Keywords:

PMID: 27689369|REJECTED: Cannot Replace Article: ArticleIds do not match, contact LinkOut to change ArticleIds

DOI: DV8E-2DG2

TCCC Updates

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Butler FK. 16(1). 132 - 135. (Classical Conference)

Keywords:

PMID: 27689381

DOI: 1RST-I42I

TCCC Updates

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Anonymous A. 16(3). 99 - 119. (Classical Conference)

Keywords:

PMID: 27734453

DOI: ICAT-E2RO

TCCC Updates

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Butler FK. 17(4). 142 - 147. (Classical Conference)

Keywords:

PMID: 29256214

DOI: EJ32-XXDX

TCCC Updates: Committee on Tactical Combat Casualty Care Meeting Minutes. Davis Conference Center, MacDill AFB, Fl 4-5 February 2014

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Anonymous A. 14(2). 113 - 120. (Classical Conference)

Keywords:

PMID: 24952051

DOI: DJ05-XF2B

TCCC Updates: Committee on Tactical Combat Casualty Care Meeting: 3-4 February 2014, Atlanta, Georgia. Meeting Minutes: 17 April 2015

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Anonymous A. 15(2). 154 - 167. (Classical Conference)

Keywords:

PMID: 27689376|REJECTED: Cannot Replace Article: ArticleIds do not match, contact LinkOut to change ArticleIds

DOI: PX4B-688T

TCCC Updates: CoTCCC Meeting 3-4 February 2015 Atlanta, Georgia

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Butler FK, Cordoni L. 15(1). 136 - 141. (Classical Conference)

Abstract

Selected Meeting Highlights

Keywords:

PMID: 27689374

DOI: 0715-OB71

TCCC Updates: Tactical Combat Casualty Care Curriculum Annual Update 2014

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Giebner S. 14(4). 144 - 145. (Classical Conference)

Keywords:

PMID: 27689372

DOI: W2P1-7IUE

TCCC Updates: Tactical Combat Casualty Care Guidelines for Medical Personnel: 3 June 2015

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Anonymous A. 15(3). 129 - 147. (Classical Conference)

Keywords:

PMID: 27280186

DOI: QQQM-C7QH

TCCC Updates: TCCC Abstracts

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Anonymous A. 14(1). 113 - 115. (Classical Conference)

Keywords:

PMID: 27689363|REJECTED: Cannot Replace Article: ArticleIds do not match, contact LinkOut to change ArticleIds

DOI: T8XZ-JG88

TCCC Updates: Top Honors Go to . . .

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Anonymous A. 18(4). 159 - 161. (Classical Conference)

Keywords:

PMID: 30566745

DOI: A8Q3-RDHF

TCCC Updates: Translating Military Advances in Exdternal Hemorrhage Control to Law Enforcement

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Butler FK. 15(4). 164 - 174. (Classical Conference)

Keywords:

PMID: 27689379

DOI: ARZP-RFK1

TCCC Updates: Two Decades of Saving Lives on the Battlefield: Tactical Combat Casualty Care Turns 20

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Butler FK. 17(2). 166 - 172. (Classical Conference)

Abstract

Background: Twenty years ago, the original Tactical Combat Casualty Care (TCCC) article was published in this journal. Since TCCC is essentially a set of bestpractice prehospital trauma care guidelines customized for use on the battlefield, the presence of a journal with a specific focus on military medicine was a profound benefit to the initial presentation of TCCC to the US Military. Methods: In the two ensuing decades, which included the longest continuous period of armed conflict in our nation's history, TCCC steadily evolved as the prehospital trauma care evidence base was augmented and as feedback from user medics, corpsmen, and pararescuemen was obtained. Findings: TCCC has taken a leadership role in advocating for battlefield trauma care advances such as the aggressive use of tourniquets and hemostatic dressings to control lifethreatening external hemorrhage; improved fluid resuscitation techniques for casualties in hemorrhagic shock; increased emphasis on airway positioning and surgical airways to manage the traumatized airway; faster, safer, and more effective battlefield analgesia; the increased use of intraosseous vascular access when needed; battlefield antibiotics; and combining good medicine with good small-unit tactics. With the continuing assistance of Military Medicine, these advances and the evidence base that supports them have been presented to TCCC stakeholders. Discussion/Impact: Now-20 years later-TCCC has been documented to produce unprecedented decreases in preventable combat death in military units that have trained all of their members in TCCC. As a result of this proven success, TCCC has become the standard for battlefield trauma care in the US military and for the militaries of many of our allied nations. Committee on TCCC members and the Joint Trauma System also work closely with civilian trauma colleagues through initiatives such as the Hartford Consensus, the White House Stop the Bleed campaign, and the development of National Association of Emergency Medical Technicians TCCC-based courses to ensure that advances in prehospital trauma care pioneered by the military on the battlefield are translated into civilian practice on the streets of America. Active shooter incidents, terrorist bombings, and the day-today trauma that results from motor vehicle accidents and criminal violence create the potential for many additional lives to be saved in the civilian sector. Along with the other components of the Department of Defense's Joint Trauma System, the Committee on TCCC, and the TCCC Working Group have been recognized as a national resource and will continue to advocate for advances in best-practice battlefield trauma care as opportunities to improve are identified.

Keywords:

PMID: 28599052

DOI: PCUC-U3TV

Team of Teams: New Rules of Engagement for a Complex World

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Forsten RD. 16(2). 116 - 116. (Book Review)

Abstract

McChrystal, Stanley; Collins, Tantum; Silverman, David; Fussell, Chris. Team of Teams: New Rules of Engagement for a Complex World. Westminster, London, UK: Portfolio; 2015. 304 pages.
ISBN-10: 1591847486, ISBN-13: 978-1591847489.

Keywords:

DOI:

Teleconsultation in Prolonged Field Care Position Paper

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Vasios WN, Pamplin JC, Powell D, Loos PE, Riesberg JC, Keenan S. 17(3). 141 - 144. (Journal Article)

Keywords:

PMID: 28910484

DOI: MGJ0-L27W

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Telemedicine Supervision of Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) Catheter Placement

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Qasim Z, Graham C. 22(1). 108 - 110. (Case Reports)

Abstract

The rapid control of traumatic or nontraumatic exsanguinating hemorrhage in critically injured patients is key to limiting morbidity and mortality in civilian and military practice. Resuscitative endovascular balloon occlusion of the aorta (REBOA) has been developed to address potentially preventable death from torso or lower extremity junctional hemorrhage. This time-critical, high-acuity, low-occurrence procedure sometimes precludes the appropriate supervision of clinicians familiar with it. We describe the case of a patient who had recently undergone liver transplantation presenting to the intensive care unit (ICU) and found to be in severe nontraumatic hemorrhagic shock, necessitating REBOA placement as part of the resuscitation. The bedside proceduralist was trained but inexperienced in the procedure and was supervised by a telemedicine intensivist, resulting in rapid and safe insertion. We describe what to our knowledge is the first use of telemedicine to supervise the successful placement of a REBOA catheter in a critically ill patient and discuss how this can potentially benefit military clinicians working in low-resource, far-forward environments.

Keywords: case report; resuscitative endovascular balloon occlusion of the aorta; REBOA; hemorrhage

PMID: 35278325

DOI: REX7-41O1

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Telemedicine to Reduce Medical Risk in Austere Medical Environments: The Virtual Critical Care Consultation (VC3) Service

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Powell D, McLeroy RD, Riesberg JC, Vasios WN, Miles EA, Dellavolpe J, Keenan S, Pamplin JC. 16(4). 102 - 109. (Journal Article)

Abstract

One of the core capabilities of prolonged field care is telemedicine. We developed the Virtual Critical Care Consult (VC3) Service to provide Special Operations Forces (SOF) medics with on-demand, virtual consultation with experienced critical care physicians to optimize management and improve outcomes of complicated, critically injured or ill patients. Intensive-care doctors staff VC3 continuously. SOF medics access this service via phone or e-mail. A single phone call reaches an intensivist immediately. An e-mail distribution list is used to share information such as casualty images, vital signs flowsheet data, and short video clips, and helps maintain situational awareness among the VC3 critical care providers and other key SOF medical leaders. This real-time support enables direct communication between the remote provider and the clinical subject matter expert, thus facilitating expert management from near the point of injury until definitive care can be administered. The VC3 pilot program has been extensively tested in field training exercises and validated in several real-world encounters. It is an immediately available capability that can reduce medical risk and is scalable to all Special Operations Command forces.

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

PMID: 28088828

DOI: 6TPC-K6KL

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Telementorship in Underway Naval Operations: Leveraging Operational Virtual Health for Tactical Combat Casualty Care

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Wessels LE, Roper MT, Ignacio RC, Davis KL, Ambrosio AA. 21(3). 93 - 95. (Journal Article)

Abstract

Background: Virtual health (VH) may enhance mentorship to remote first responders. We evaluated the feasibility of synchronous bidirectional VH to mentor life-saving procedures performed by deployed novice providers. Methods: Video teleconferencing (VTC) was established between the USNS Mercy (T-AH 19) underway in the Pacific Ocean to Naval Medical Center San Diego using surgeon teleconsultation. The adult simulated clinical vignette included injuries following a shipboard explosion with subsequent fire. The pediatric simulated vignette included injuries that resulted from an improvised explosive device (IED) blast. Using VTC, augmented reality (AR) goggles, and airway simulation equipment, corpsmen (HMs) received visual cues to perform advanced life-saving procedures. Results: In adult scenarios, 100% of novice hospital HMs performed tasks on first attempt (n = 12). Mean time for tourniquet placement was 46 seconds (standard deviation [SD], 19 seconds); needle thoracostomy, 70 seconds (SD, 67 seconds); tube thoracostomy, 313 seconds (SD, 152 seconds); and cricothyroidotomy, 274 seconds (SD, 82 seconds). In pediatric scenarios, 100% of novice HMs performed tasks on first attempt (n = 5). Mean time for tube thoracostomy completion was 532 seconds (SD, 109 seconds). Conclusion: VH can enhance the training and delivery of trauma care during prolonged field care in resource-limited settings.

Keywords: Tactical Combat Casualty Care; thoracostomy, tube; cricothyroidotomy; augmented reality; tourniquet

PMID: 34529812

DOI: ATK4-KWC0

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Tell Them Yourself: It's Not Your Day to Die

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Graverson SP. Ahead of Print. (Book Review)

Abstract

Frank Butler, Kevin O'Connor, Jeff Butler. Tell Them Yourself: It's Not Your Day to Die. Breakaway Media; May 2024. 304 pages, hardcover. ISBN: 79-8-9902257-0-1.

Keywords:

Temporizing Life-Threatening Abdominal-Pelvic Hemorrhage Using Proprietary Devices, Manual Pressure, or a Single Knee: An Integrative Review of Proximal External Aortic Compression and Even "Knee BOA"

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O'Dochartaigh D, Picard CT, Brindley PG, Douma MJ. 20(2). 110 - 114. (Journal Article)

Abstract

Introduction: Abdominal-pelvic hemorrhage (i.e., originates below the diaphragm and above the inguinal ligaments) is a major cause of death. It has diverse etiology but is typically associated with gunshot or stab wounds, high force or velocity blunt trauma, aortic rupture, and peripartum bleeds. Because there are few immediately deployable, temporizing measures, and the standard approaches such as direct pressure, hemostatics, and tourniquets are less reliable than they are with compressible extremity injuries, risk for death resulting from abdominal-pelvic hemorrhage is high. This review concerns the exciting potential of proximal external aortic compression (PEAC) as a temporizing technique for life-threatening lower abdominal-pelvic hemorrhage. PEAC can be accomplished by means of a device, two locked arms (manual), or a single knee (genicular) to press over the midline supra-umbilical abdomen. The goal is to compress the descending aorta and slow or halt downstream hemorrhage while not delaying more definitive measures such as hemostatic packing, tourniquets, endovascular balloons, and ultimately operative repair. Methods: Clinical review of the Ovid MEDLINE, In-Process, & Other Non-Indexed, and Google Scholar databases was performed for the period ranging from 1946 to 3 May 2019 for studies that included the following search terms: [proximal] external aortic compression OR vena cava compression AND (abdomen or pelvis) OR (hemorrhage) OR (emergency or trauma). In addition, references from included studies were assessed. Conclusion: Sixteen studies met the inclusion criteria. Evidence was grouped and summarized from the specialties of trauma, aortic surgery, and obstetrics to help prehospital responders and guide much-needed additional research, with the goal of decreasing the high risk for death after life-threatening abdominal-pelvic hemorrhage.

Keywords: hemorrhage; trauma; shock; junctional trauma; noncompressible hemorrhage; prehospital care; austere environment; proximal external aortic compression; PEAC

PMID: 32573746

DOI: 7HOX-2JW6

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Testicular Cancer in an American Special Forces Soldier: A Case Report

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Ho TT, Rocklein Kemplin K, Brandon JW. 19(1). 23 - 26. (Case Reports)

Abstract

Testicular cancer is the most common solid tumor and the most common cause of cancer mortality in men between 25 and 34 years of age. Limited data exist comparing testicular cancer in military Servicemembers and the general population. Research indicates that Navy, Air Force, and Coast Guard Servicemembers have a higher risk of testicular cancer than do members of the Army or Marines. A military lifestyle including operational tempo and long deployments may contribute to delayed diagnosis and subsequent treatment planning, potentially increasing morbidity and mortality. We used the National Institutes of Health case-study format recommendations as a framework for this presentation of the case of a 36-year-old US Special Forces Soldier who noticed new testicular masses while deployed in Iraq but did not seek help until 5 months later, upon redeployment home.

Keywords: testicular cancer; military medicine; Special Forces; occupational health; deployment

PMID: 30859521

DOI: XQO0-ACRL

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Testing of Junctional Tourniquets by Medics of the Israeli Defense Force in Control of Simulated Groin Hemorrhage

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Chen J, Benov A, Nadler R, Landau G, Sorkin A, Aden JK, Kragh JF, Glassberg E. 16(1). 36 - 42. (Journal Article)

Abstract

Background: Junctional hemorrhage is a common cause of battlefield death but little is known about testing of junctional tourniquet models by medics. The purpose of the testing described herein is to assess military experience in junctional tourniquet use in simulated prehospital care. Methods: Fourteen medics were to use the following four junctional tourniquets: Combat Ready Clamp (CRoC), Abdominal Aortic Junctional Tourniquet (AAJT), Junctional Emergency Treatment Tool (JETT), and SAM Junctional Tourniquet (SJT). The five assessment categories were safety, effectiveness, time to effectiveness, and two categories of user preference: (1) by all models assessed, and (2) by only the model most preferred. Users ranked preference by answering, "If you had to go to war today and you could only choose one, which tourniquet would you choose to bring?" Results: All tourniquet uses were safe. By the time the first five testers were done, all three AAJT models had been broken. CRoC and AAJT had the highest percentage effectiveness as their difference was not statistically significant. SJT and JETT had fastest mean times to effectiveness as their difference was not significant. For preference, using each user's ranking of all models assessed, SJT and AAJT were most preferred as their difference was not significant. For each user's most preferred model, SJT, AAJT, and JETT were most preferred as their difference was not significant. Conclusion: In the five assessment categories, multiple tourniquet models performed similarly well; SJT and AAJT performed best in four categories, JETT was best in three, and CRoC was best in two. Differences between the top-ranked models in each category were not statistically significant.

Keywords: tourniquets; hemorrhage; resuscitation; groin; inguinal; medical device; injuries; wounds

PMID: 27045492

DOI: L6YP-2WM8

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

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Kragh JF, Parsons DL, Kotwal RS, Kheirabadi BS, Aden JK, Gerhardt RT, Billings S, Dubick MA. 14(3). 58 - 63. (Journal Article)

Abstract

Background: Junctional hemorrhage is a common cause of death on the battlefield, but there is no documented direct comparison for the use of junctional tourniquet models by US medics. The purpose of this testing is to assess military medic experience with the use of junctional tourniquets in simulated out-of-hospital trauma care. Methods: Nine medics (seven men and two women) used four different junctional tourniquets: Combat Ready Clamp™ (CRoC™; http://www.combatmedicalsystems .com), Abdominal Aortic and Junctional Tourniquet™ (AAJT™; http://www.compressionworks.net), Junctional Emergency Treatment Tool (JETT™; http://www.narescue .com), and SAM Junctional Tourniquet® (SJT®; http:// www.sammedical.com/products). These medics also acted as simulated casualties. Effectiveness percentages, as measured by stopped distal pulse by Doppler auscultation, and time to effectiveness were recorded in two tests per tourniquet (72 total tests). Tourniquet users ranked their preference of model by answering the question: "If you had to go to war today and you could only choose one, which tourniquet would you choose to bring?" Results: All tourniquets used were safe under the conditions of this study. Both the SJT and the CRoC had high effectiveness percentages; their rate difference was not statistically significant. The SJT and the CRoC had fast times to effectiveness; their time difference was not statistically significant. Users preferred the SJT and the CRoC; their ranked difference was not statistically significant. Conclusion: The SJT and the CRoC were equally effective and fast and were preferred by the participants.

Keywords: tourniquet; hemorrhage; resuscitation; groin; inguinal; medical device; injuries; wounds

PMID: 25344708

DOI: JAD6-PS0C

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Testing Tourniquet Use in a Manikin Model: Two Improvised Techniques

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Lyles WE, Kragh JF, Aden JK, Dubick MA. 15(4). 21 - 26. (Journal Article)

Abstract

Background: Improvised tourniquets may be used to treat limb wound hemorrhage, but there is little evidence for best techniques of use. The purpose of the present study is to compare use of two techniques of improvised tourniquet application and use of a common commercial tourniquet that is nonimprovised. Methods: A laboratory experiment was conducted to assess three groups of strap-and-windlass tourniquet designs on a manikin to test for differences in performance. Groups included two types of improvised tourniquets (bandage and bandana) and a third group that served as a control, the commercial Combat Application Tourniquet. Two users performed 10 tests of each group. Results: The commercial CAT had 100% effectiveness, but both improvised tourniquets had poor effectiveness (40% and 10% for the bandage and bandana groups, respectively). The commercial CAT performed fastest; the two improvised tourniquet groups were slower than the commercial group (p < .0001, both) but were not statistically different from each other. All time-of-application results in the commercial group were less than the minimums of either improvised group. The commercial CAT had the highest mean pressures, and all such pressures were within safe and effective ranges. Low pressures generated by both improvised tourniquet groups were ineffective. All results of simulated blood loss with the commercial CAT group were less than the minimums of either improvised tourniquet group. Conclusion: In the present experiment, the commercial CAT performed better than either improvised tourniquet.

Keywords: first aid; hemorrhage; resuscitation; groin; inguinal; medical device; injuries; wounds; tourniquet

PMID: 26630092

DOI: EJ4J-SS7L

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Tetanus

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Burnett MW. 18(4). 137 - 138. (Journal Article)

Keywords: prophylaxis; tetanus; vaccines

PMID: 30566739

DOI: WKAR-G1P0

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The 10 Commandments of Nutrition: 2014

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Deuster PA, Lindsey AT, Butler FK. 14(3). 80 - 89. (Journal Article)

Abstract

The US Special Operations Command requires sound recommendations on nutrition to ensure optimal performance of Special Operations personnel. New information continues to emerge, and previous recommendations need to be modified as the evidence base continues to grow. The first 10 Commandments of Nutrition were published in the SEAL professional journal Full Mission Profile in 1992, published for the second time in this journal in 2005, and now revised a second time to reflect the newest science. Whether you are part of the Special Operations Forces (SOF) community or an athlete seeking to improve your performance, these are simple and helpful nutrition guidelines to follow.

Keywords: dietary supplements; omega-3 fatty acids; protein; carbohydrate; grains; fresh fruits and vegetables

PMID: 25344712

DOI: 0G11-VMKF

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The 15:17 to Paris: The True Story of a Terrorist, a Train, and Three American Heroes

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Graverson SP. 23(1). 127 - 127. (Book Review)

Abstract

Anthony Sadler; Alek Skarlatos; Spencer Stone; Jeffrey E. Stern. The 15:17 to Paris: The True Story of a Terrorist, a Train, and Three American Heroes. 2018. 256 pp. ISBN: 978-1-61039-734-6 (EB)

Keywords:

The Agitated Patient

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Goldstein S. 13(3). 87 - 91. (Journal Article)

Abstract

Caring for an agitated patient can be a daunting task for the tactical emergency medical support (TEMS) or Special Operations Forces (SOF) medic. The cause, degree, and duration of agitation can vary among such individuals. These patients create a high-stress and disruptive environment, needing numerous people involved to control. One agitated patient can disrupt an entire tactical team or casualty evacuation. The patient's history and physical examination can give important clues to the cause, thereby directing treatment and leading to a quick and safe resolution. The variety of treatments for the agitated patient are just as numerous as the causes and range from verbal deescalation to medications and physical restraint, all of which have a risk-benefit profile to consider.

Keywords: agitated patients; brain; TBI; hypoxia; hypoglycemia; hypothermia; delirium; ketamine; dissociative; combative; sedation

PMID: 24048996

DOI: 68SR-SHRZ

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The Application of Regional Anesthesia by the Special Forces Medical Sergeant

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Ho TT, Hall C. 13(4). 111 - 111. (Letter)

Keywords:

PMID: 24227569

DOI: K4QE-S1TG

The Benefits of Reflexology for the Chronic Pain Patient in a Military Pain Clinic

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Kern C, McCoart A, Beltran T, Martoszek M. 18(4). 103 - 105. (Journal Article)

Abstract

Background: Chronic pain is a major cause of disability across the military, especially for the combat Soldier. More than twothirds of Americans with chronic pain are now using complementary medicine. Methods: Patients with chronic pain opting for reflexology as part of their treatment plan received bilateral therapy. Alternating pressure was applied to the individual patient's reflex points corresponding to their pain sites. Following a single treatment session, patients were asked to complete a short survey. Discussion: There is evidence that reflexology is therapeutic for many conditions, to include sleep and anxiety, both of which can be comorbidity in the patient with chronic pain. There is a lack of evidence on the use of reflexology with chronic pain patients receiving multidisciplinary pain care. Results: A total of 311 participants completed the survey. Posttreatment pain scored decreased by a median of 2 points (interquartile range [IQR] 1-3) on a 10-point pain scale. This represents a median 43% (IQR 25%-60%) reduction in pain for males and a 41% (IQR 30%-60%) reduction in pain for females. Conclusion: Currently research is limited on effects of reflexology in treating chronic pain, yet, like acupuncture, this is an inexpensive, reliable, teachable, and simple noninvasive treatment. Further studies are warranted.

Keywords: reflexology; pain; chronic pain; complementary treatments; alternative treatments

PMID: 30566732

DOI: HE83-7LY7

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The Challenges of Treating Complex Medical Patients in the Role 2 Environment: A Case Series

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Ward H, Downing N, Goller S, Stremick J. 22(4). 93 - 96. (Case Reports)

Abstract

The Role 2 environment presents several challenges in diagnosing and treating complex medical and life-threatening conditions. They are primarily designed to perform damage control resuscitation and surgery in the setting of trauma with less emphasis on complex medical care and limited ability to hold patients for more than 72 hours. Providing care to Soldiers and civilians in the deployed setting is made more difficult by the limited number of personnel, lack of advanced diagnostic equipment such as CT scanners, harsh working conditions, and austere resources. Despite these challenges, deployed physicians have continued to provide high levels of care to injured Soldiers and civilians by using clinical judgment, validated clinical decision-making tools, and adjunct diagnostic tools, such as ultrasound. In this case series we will present three complex medical cases involving pulmonary embolism (PE), ventricular tachycardia (VT), and aortic dissection that were seen in a deployed Role 2 setting. This article will highlight and discuss the challenges faced by deployed providers and ways to mitigate these challenges.

Keywords: Role 2; damage control resuscitation; surgery; pulmonary embolism; ventricular tachycardia; aortic dissection

PMID: 36525020

DOI: 8MRX-GXR1

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The Combat Application Tourniquet Versus the Tactical Mechanical Tourniquet

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Beaven A, Ballard M, Sellon E, Briard R, Parker PJ. 18(3). 75 - 78. (Journal Article)

Abstract

Background: Exsanguination from limb injury is an important battlefield consideration that is mitigated with the use of emergency tourniquets. The Combat Application Tourniquet (C-A-T®) is the current British military standard tourniquet. Methods: We tested the self-application of a newer tourniquet system, the Tactical Mechanical Tourniquet (TMT), against self-application of the C-A-T. A total of 24 healthy British military volunteers self-applied the C-A-T and the TMT to their mid thigh in a randomized, sequential manner. Popliteal artery flow was monitored with a portable ultrasound machine, and time until arterial occlusion was measured. Pain scores were also recorded. Results The volunteers allowed testing on their lower limbs (n = 48 legs). The C-A-T was applied successfully to 22 volunteers (92%), and the TMT was successfully applied to 17 (71%). Median time to reach complete arterial occlusion was 37.5 (interquartile range [IQR], 27-52) seconds with the C-A-T, and 35 (IQR, 29-42) seconds with the TMT. The 2.5-second difference in median times was not significant (ρ = .589). The 1-in-10 difference in median pain score was also not significant (ρ = .656). The success or failure of self-application between the two tourniquet models as assessed by contingency table was not significant (p= .137). Conclusion: The TMT is effective when self-applied at the mid thigh. It does not offer an efficacy advantage over the C-A-T.

Keywords:

PMID: 30222842

DOI: P6Z3-VN4B

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The Combat Medic Aid Bag: 2025 CoTCCC Top 10 Recommended Battlefield Trauma Care Research, Development, and Evaluation Priorities for 2015

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Butler FK, Blackbourne LH, Gross K. 15(4). 7 - 19. (Journal Article)

Keywords:

PMID: 26630091

DOI: 5G8Q-R379

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The Command Of Biotechnology And Merciful Conquest In Military Oppositions

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Guo J. 09(1). 69 - 73. (Previously Published)

Previously published in Military Medicine, 171, 11:1150, 2006. Permission was granted to republish in JSOM by AMSUS.

Abstract

Biotechnology has an increasingly extensive use for military purposes. With the upcoming age of biotechnology, military operations are depending more on biotechnical methods. Judging from the evolving law of the theory of command, the command of biotechnology is feasible and inevitable. The report discusses some basic characteristics of modern theories of command, as well as the mature possibility of the command theory of military biotechnology. The evolution of the command theory is closely associated with the development of military medicine. This theory is expected to achieve successes in wars in an ultramicro, nonlethal, reversible, and merciful way and will play an important role in biotechnological identification and orientation, defense and attack, and the maintenance of fighting powers and biological monitoring. The command of military biotechnology has not become a part of the virtual military power yet, but it is an exigent strategic task to construct and perfect this theory.

Keywords:

PMID: 19813351

DOI: PWZR-55N0

The Continuing Threat of Intentional Mass Casualty Events in the U.S.

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Fabbri WP. 15(4). 142 - 145. (Journal Article)

Keywords:

PMID: 26630108

DOI: AWCR-B62L

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The Correlation of Early Hyperglycemia With Outcomes in Adult Trauma Patients: A Systematic Review

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Peffer J, McLaughlin C. 13(4). 34 - 39. (Journal Article)

Abstract

Background: Hyperglycemia is often treated in both acute and long-term settings and has recently garnered attention for its utility as a prognostic marker in traumatic injury. This could be of vital importance in Special Operations, as triage and disposition of trauma patients are often accomplished under less-than-ideal conditions. Blood glucose levels are easily obtained, require inexpensive instruments, but are likely not routinely taken in the field for trauma patients. Objective: The objective of this review was to systematically search available medical literature for early (within 48 hours of presentation) hyperglycemia in trauma patients and present the relevant data regarding prognosis in a qualitative fashion. Sources: A systematic review was conducted of published Englishlanguage articles using PubMed/MEDLINE in addition to searching bibliographies. Search terms included hyperglycemia, trauma, and prognosis. Study Eligibility Criteria: Eligible analytical studies had an adult population, who had experienced a traumatic injury, with blood glucose measurements within the first 48 hours of care, and had prognostic end points such as morbidity measures (intensive care unit time, infection, length of stay, etc.) and/or mortality. Study Appraisal and Synthesis Methods: Studies were appraised according to their design, size, population characteristics, definition of "hyperglycemic" and "normoglycemic," and morbidity and mortality outcomes. Results: We reviewed 104 studies. Ninety-five were identified from a PubMed/MEDLINE search, and an additional nine were from relevant citations and bibliographies. Eighty-seven studies were excluded; 17 articles met inclusion criteria and were analyzed for the review. Five were prospective in nature and 12 were retrospective reviews. Five studies analyzed patients with traumatic brain injury, and one study exclusively concerned burn patients. Sixteen of the studies found negative outcomes with early hyperglycemia. One study found no significant relationship between serum glucose measurements and mortality. Limitations: Limitations of this review included the use of one database and articles available online and in English. Conclusions and Implications of Key Findings: There is strong evidence that early hyperglycemia is correlated with a worse prognosis in trauma patients. Providers at all levels could potentially use this information to aid in the triage and disposition of traumatic injury victims.

Keywords: trauma; hyperglycemia; prognosis; mortality

PMID: 24227559

DOI: LDC8-73C0

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The Cric-Key™ and Cric-Knife™: A Combined Tube-Introducer and Scalpel-Hook Open Cricothyrotomy System

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Levitan RM. 14(1). 45 - 49. (Journal Article)

Abstract

The author describes a cricothyrotomy system that consists of two devices that, packaged together, are labeled the Control-Cric™ system. The Cric-Key™ was invented to verify tracheal location during surgical airway procedures- without the need for visualization, aspiration of air, or reliance on clinicians' fine motor skills. The Cric-Knife™ combines a scalpel with an overlying sliding hook to facilitate a smooth transition from membrane incision to hook insertion and tracheal control. In a recent test versus a traditional open technique, this system had a higher success rate and was faster to implement.

Keywords: cricothyrotomy; airway device; Cric-Key™; Cric-Knife™

PMID: 24604438

DOI: 9PRT-KJ05

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The Daring Dozen: Special Forces Legends of World War II

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Farr WD. 14(3). 121 - 121. (Book Review)

Abstract

Mortimer, Gavin. The Daring Dozen: Special Forces Legends of World War II.
Oxford, United Kingdom: Osprey Publishing; 2012. Hardcover, 304 pages.
ISBN-10: 184908842X/ISBN-13: 978-1849088428.

Keywords:

PMID: 25344721

DOI: WDLP-GX2S

The Death of The Golden Hour and the Return of the Future Guerrilla Hospital

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Neal CA. 18(1). 155 - 156. (Book Review)

Abstract

Farr, Warner D. "Rocky." The Death of The Golden Hour and the Return of the Future Guerrilla Hospital. MacDill Air Force Base, FL: Joint Special Operation University (JSOU) Press; 2017. 72 pp. Dr Farr's monograph is available from JSOU Press Publications: http://jsou.libguides.com/ld.php?content_id=37706446

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The Downrange Acoustic Toolbox: An Active Solution for Combat-Related Acute Acoustic Trauma

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Lee JD, Bowley DM, Miles JA, Muzaffar J, Poole R, Orr LE. 20(4). 104 - 111. (Journal Article)

Abstract

Frontline military personnel are at high risk of acute acoustic trauma (AAT) caused by impulse noise, such as weapon firing or blast. This can result in anatomic disruption of the tympanic membrane and damage to the middle and inner ear, leading to conductive, sensorineural, or mixed hearing loss that may be temporary or permanent. AAT reduces warfighters' operational effectiveness and has implications for future quality of life. Hearing protection devices can mitigate AAT but are not completely protective. Novel therapeutic options now exist; therefore, identification of AAT as soon as possible from point of injury is vital to ensure optimal treatment and fulfillment of the duty of care. Early recognition and treatment of frontline AAT can maintain the deployed team's capabilities, avoid unnecessary case evacuation (CASEVAC), and raise awareness of military occupational AAT. This will help prioritize hearing preservation, maintain the fighting force, and ultimately retain personnel in service. The UK Defence hearWELL research collaboration has developed a frontline protocol for the assessment of AAT utilizing future-facing technology developed by the US Department of Defense: the Downrange Acoustic Toolbox (DAT). The DAT has been operationally deployed since 2019 and has successfully identified AAT requiring treatment, thereby improving casualties' hearing and reducing unnecessary repatriation.

Keywords: hearing loss, noise-induced; acute acoustic trauma; noise, occupational; military personnel; hearing protective devices; telemedicine; steroid

PMID: 33320322

DOI: R1KY-M91Z

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The Dust of Empire: The Race for Mastery in the Asian Heartland

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Farr WD. 12(1). 77 - 77. (Book Review)

Abstract

Karl E. Meyer
Public Affairs Press: New York, NY. 2003. ISBN-13: 978-0756791940, Hardback. 252 pages.

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The Effect of Prehospital Blood Transfusion on Patient Body Temperature from the Time of Emergency Medical Services Transfusion to Arrival at the Emergency Department

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Mannion E, Pirrallo RG, Dix A, Estes L. 23(1). 46 - 53. (Journal Article)

Abstract

Background: Transfusion of blood products is life-saving and time-sensitive in the setting of acute blood-loss anemia, and is increasingly common in the emergency medical services (EMS) setting. Prehospital blood products are generally "cold-stored" at 4°C, then warmed with a portable fluid-warming system for the purpose of preventing the "lethal triad" of hypothermia, acidosis, and coagulopathy. This study aims to evaluate body temperature changes of EMS patients receiving packed red blood cells (PRBC) and/or fresh frozen plasma (FFP) when using the LifeWarmer Quantum Blood & Fluid Warming System (LifeWarmer, https://www.lifewarmer.com/). Methods: From 1 January 2020 to 31 August 2021, patients who qualified for and received PRBC and/or FFP were retrospectively reviewed. Body-temperature homeostasis pre- and post-transfusion were evaluated with attention given to those who arrived to the emergency department (ED) hypothermic (<36°C). Results: For all 69 patients analyzed, the mean initial prehospital temperature (°C) was 36.5 ± 1.0, and the mean initial ED temperature was 36.7 ± 0.6, demonstrating no statically significant change in value pre- or post-transfusion (0.2 ± 0.8, p = .09). Shock index showed a statistically significant decrease following transfusion: 1.5 ± 0.5 to 0.9 ± 0.4 (p < .001). Conclusion: Use of the Quantum prevents the previously identified risk of hypothermia with respect to unwarmed prehospital transfusions. The data is favorable in that body temperature did not decrease in critically ill patients receiving cold-stored blood warmed during administration with the Quantum.

Keywords: prehospital blood transfusion; lethal triad; damage-control resuscitation; Tactical Combat Casualty Care

PMID: 36753715

DOI: KCZS-41KZ

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The Effects of Movement on Hemorrhage When QuikClot® Combat Gauze™ Is Used in a Hypothermic Hemodiluted Porcine Model

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Garcia-Blanco J, Gegel B, Burgert J, Johnson S, Johnson D. 15(1). 57 - 60. (Journal Article)

Abstract

Background: The purpose of this study was to compare the effectiveness of QuikClot® Combat Gauze™ (QCG) to a control wound dressing to withstand movement in a porcine model with hemodilution and hypothermia. Design: This was a prospective study with a between-subjects experimental design. Twenty-six Yorkshire swine were randomly assigned to two groups: QCG (n = 13) or a control dressing (n = 13). Methods: The subjects were exsanguinated to 30% of the blood volume; hypothermia was induced for 10 minutes. The hemostatic agent, QCG, was placed into the wound, followed by standard wound packing. If hemostasis was achieved, 5L of crystalloid solution were rapidly administered intravenously, and the wound was again observed for rebleeding. If no bleeding occurred, the extremity on the side of the injury was systematically moved through flexion, extension, abduction, and adduction sequentially 10 times or until rebleeding occurred. Results: An independent t test indicated there were significant differences in the number of movements before rebleeding between the QCG group (mean ± standard deviation [SD], 32.92 ± 14.062) and the control group (mean ± SD, 6.15 ± 15.021) (ρ < .0001). Conclusion: QCG produces a robust clot that can withstand more movement than a control dressing.

Keywords: movement; hemorrhage; QuikClot®; Combat Gauze™; hypothermic hemodiluted porcine model

PMID: 25770799

DOI: J6YJ-1GY1

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The Emergence and Evolution of the Journal of Special Operations Medicine: An Interview With Publisher Michelle Landers

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Pennardt A. 18(4). 149 - 150. (Interview)

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PMID: 30566742

DOI: PVTM-YUTA

The Expanded Scope of Emergency Medical Practice Necessary for Initial Disaster Response: Lessons from Haiti

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Menon AS, Norris RL, Racciopi J, Tilson H, Gardner J, Mcadoo G, Brown IP, Auerbach PS. 12(1). 31 - 36. (Journal Article)

Abstract

A team of emergency physicians and nurses from Stanford University responded to the devastating January 2010 earthquake in Haiti. Because of the extreme nature of the situation, combined with limited resources, the team provided not only acute medical and surgical care to critically injured and ill victims, but was required to uniquely expand its scope of practice. Using a narrative format and discussion, it is the purpose of this paper to highlight our experience in Haiti and use these to estimate some of the skills and capabilities that will be useful for physicians who respond to similar future disasters.

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PMID: 22427047

DOI: 5S5P-7AOD

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The Future of Prehospital Critical Care

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Johnson A, Dodge M, Fisher AD. 22(2). 116 - 118. (Journal Article)

Abstract

As technology improves, the capabilities of prehospital providers increase. Innovations and realizations from military counterparts are being transitioned to civilian emergency care with the same hopes of increasing survivability of patients. Looking to the future, the incorporation of drone aircraft in the critical care field will likely impact the way medicine is practiced. Education is the key to improving outcomes in the prehospital setting.

Keywords: innovations; prehospital; EMS; emergency medical services; drone; transportation; military; future; technology

PMID: 35639904

DOI: UFYI-VDI1

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The Golden Hour Offset Surgical Treatment Team Operational Concept: Experience of the 102nd Forward Surgical Team in Operation Freedom's Sentinel 2015-2016

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Benavides JM, Benavides LC, Hale DF, Lundy JB. 17(3). 46 - 50. (Journal Article)

Abstract

Theater Special Operations Force (SOF) medical planners have begun using Army Forward Surgical Teams (FSTs) to maintain a golden hour for U.S. SOF during Operation Freedom's Sentinel required adaptation in FST training, configuration, personnel, equipment, and employment to form Golden Hour Offset Surgical Treatment Teams (GHOST-Ts). This article describes one such FST's experience in Operation Freedom's Sentinel while deployed for 9 months in support of SOF in southern Afghanistan.

Keywords: Golden Hour Offset Surgical Treatment Team (GHOST-T); austere surgery

PMID: 28910467

DOI: 6EZN-5KGE

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The Good, the Bad, and the Future of Drones in Tactical/Operational Medicine

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Bradley KD. 19(4). 91 - 93. (Journal Article)

Abstract

Unmanned aerial vehicles (UAVs) have seen expansion with their applications in many fields, including the opportunity these tools offer to improve medical care. Drones have significant potential for use in the tactical setting. New, unique possibilities for these drones are emerging constantly, but there is no standardized inclusion specifically with tactical medicine operations. This article is a review of the future possibilities of drones, the associated risks that drones present, and the current application of drone technology in the field of civilian operational/tactical medicine.

Keywords: drone(s); medical; medicine; tactical; operational; UAV; unmanned aerial vehicle

PMID: 31910479

DOI: 0U9U-GD66

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The Hidden Complexity of Biological "Dirty Bombs": Implications for Special Operations Medical Personnel

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Washington MA, Blythe J. 16(4). 82 - 84. (Journal Article)

Abstract

The recent capture of a terrorist in Belgium carrying explosives, fecal matter, and animal tissue may indicate a shift from conventional weapons to crude bacteriological preparations as instruments of terror. It is important to note that although such weapons lack technological sophistication, bacteria are inherently complex, unpredictable, and undetectable in the field. Therefore, it is important that Special Operations medical personnel understand the complications that such seemingly simple devices can add to the treatment of casualties in the field and subsequent evaluation in the clinic.

Keywords: dirty bombs; terrorists; warfare, biological

PMID: 28088824

DOI: ZBFP-Q8MZ

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The Highest-Impact Combat Orthopedic and Extremity Injury Articles in the Past 70 Years: A Citation Analysis

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Nam JJ, Do WS, Stinner DJ, Wenke JC, Orman JA, Kragh JF. 17(1). 55 - 66. (Journal Article)

Abstract

The objective of this study was to identify the most-cited peer-reviewed combat orthopedic and extremity injury articles published during the past 70 years. Orthopedic trauma presents ongoing challenges to both US civilian and military healthcare personnel. Improvements in combat trauma and extremity injury survival and quality of life are the result of advances in orthopedic trauma research. The Web of Science (including Science Citation Index) was searched for the most cited articles related to combat orthopedic trauma, published from 1940 to 2013. The most-cited article was by Owens et al. (Journal of Orthopaedic Trauma, 2007; 137 citations). Between the 1990s and 2000s, there was a 256% increase in the number of highly cited publications. A total of 69% of the articles were on the topics of comorbid vascular trauma (25%), epidemiology (23%), or orthopedic trauma (21%). This study identifies some of the most important contributions to combat orthopedic trauma and research and the areas of greatest scientific interest to the specialty during the past seven decades and highlights key research that has contributed to the evolution of modern combat orthopedic traumatology.

Keywords: combat; orthopaedics; trauma; extremity injury

PMID: 28285481

DOI: 5U6I-I4OA

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The Impact of Progressive Simulation-Based Training on Tourniquet Application

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Cole R, Steffens K, Flash Z, Conley S, Givens ML. 23(4). 43 - 46. (Journal Article)

Abstract

The Advanced Combat Medical Experience (ACME) is a progressive simulation-based training held for second-year medical students at the Uniformed Services University (USU). This study explored the impact of participating in ACME on students' tourniquet application skills. A panel of emergency medicine physician experts developed an assessment to evaluate the participants' performance. Trained raters then scored students' tourniquet application performance before and after participating in ACME. We conducted a Wilcoxon signed-rank test to detect any significant difference in the participants' pretest and posttest ratings as well as time it took them to apply the tourniquet. Our results indicated a significant difference in the pre- and posttest ratings of students as well as the time it took them to apply the tourniquet. This study confirms the effectiveness of progressive simulation-based education for teaching TCCC skills to military medical trainees.

Keywords: simulation; education; medical student; medical education; tourniquet; combat; ACME; Advanced Combat Medical Experience

PMID: 37851858

DOI: X6XO-RVXC

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The Impact of Special Operations Medics and Corpsmen on Military Medical Student Training: A Qualitative Study

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Wagner R, Cole R, Thompson J, Egan SJ, VanShufflin MW, Tilley L. 23(2). 78 - 81. (Journal Article)

Abstract

Operation Gunpowder is a high-fidelity military medical field practicum conducted by the Uniformed Services University of Health Sciences, Bethesda, MD. During this multi-day combat simulation, Special Operations Medics and Corpsmen teach military medical students how to treat patients in an austere, resource-limited environment. To investigate the effectiveness of this teaching model, our research team used a qualitative phenomenological design to explore medical students' experiences being taught by Special Operations Medics and Corpsmen during Operation Gunpowder. We found two themes regarding the medical students' personal and professional development: an increased understanding of medics' skills and capabilities and the realization of their future roles as educators and leaders. Our study suggests that the use of Special Operations Corpsmen and Medics in medical student training is a valuable model for both military and civilian medical education and training

Keywords: medical student; educators; professional development; training; simulation; qualitative study; military medical officer; teaching model; medical student experiences; medic capabilities; corpsman capabilities

PMID: 36951634

DOI: RSA6-6FA7

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The Impedance Threshold Device (ITD-7) A New Device For Combat Casualty Care To Augment Circulation And Blood Pressure In Hypotensive Spontaneously Breathing Warfighters

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Parsons DL, Convertino VA, Idris A, Smith S, Lindstrom D, Parquette B, Aufderheide T. 09(2). 49 - 53. (Journal Article)

Abstract

Inspiration through -7cm H2O resistance results in an increase in venous blood flow back to the heart and a subsequent increase in cardiac output and blood pressure in hypotensive animals and patients. Breathing through the impedance threshold device with 7cm H2O resistance (ITD-7) also reduces intracranial pressure with each inspiration, thereby providing greater blood flow to the brain. A new device called an ITD-7 was developed to exploit these physiological mechanisms to buy time in hypotensive War Fighters when other therapies are not readily available. Animal and clinical data with the ITD-7 demonstrate the potential value and limitations of this new non-invasive approach to enhancing circulation

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PMID: 19813518

DOI: 3F1L-5UQF

The Importance of Physical Fitness for Injury Prevention: Part 1

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Knapik JJ. 15(1). 123 - 127. (Journal Article)

Abstract

Physical fitness can be defined as a set of attributes that allows the ability to perform physical activity. The attributes or components of fitness were identified by testing large numbers of individuals on physical performance tests (e.g., sit-ups, push-ups, runs, pull-ups, rope climbs, vertical jump, long jumps), and using statistical techniques to find tests that seem to share common performance requirements. These studies identified strength, muscular endurance, cardiorespiratory endurance, coordination, balance, flexibility, and body composition as important fitness components. Military studies have clearly shown that individuals with lower levels of cardiorespiratory endurance or muscular endurance are more likely to be injured and that improving fitness lowers injury risk. Those who are more fit perform activity at a lower percentage of their maximal capability and so can perform the task for a longer period of time, fatigue less rapidly, recover faster, and have greater reserve capacity for subsequent tasks. Fatigue alters movement patterns, putting stress on parts of the body unaccustomed to it, possibly increasing the likelihood of injury. Soldiers should develop and maintain high levels of physical fitness, not only for optimal performance of occupational tasks but also to reduce injury risk.

Keywords: physical fitness; injury prevention; activity; stress; cardiorespiratory endurance; injuries; muscular endurance

PMID: 25770810

DOI: AS9H-FO5O

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The Importance of Physical Fitness for Injury Prevention: Part 2

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Knapik JJ. 15(2). 112 - 115. (Journal Article)

Abstract

This report examines associations between injuries and flexibility, stretching, warm-up, and body composition. Military studies show that either too much or too little flexibility increases injury risk. Static stretching prior to exercise does not appear to reduce the overall injury incidence, although further research is needed on some types of injuries. Static stretching also appears to reduce strength and power (explosive strength). Warm-up (low intensity activity prior to exercise or sports) appears to reduce injury risk. Body mass index (BMI; weight in kg/ height in m²) is a surrogate measure of body fat because it is highly related to laboratory measures of body fat. However, Soldiers can also have a high BMI because of higher muscle mass. If high BMI reflects a larger percentage of body fat relative to height, injury risk might be increased because the additional fat would increase the intensity of physical activity, leading to more rapid fatigue and repetitive stress on the musculoskeletal system. Low BMI could reflect a paucity of fat or muscle/ bone, or both. Low BMI may make Soldiers more susceptible to injury if they lack the muscle mass or strength in the supportive structures (ligaments, bones) required to perform certain physical tasks, and if they overexert or overuse the available muscle mass or supportive structures. Studies in basic combat training show that both high and low BMI increases injury risk. However, studies among active duty Soldiers only show that injury risk increases as BMI increases, possibly because very few active duty Soldiers have very low BMI (i.e., less than 18 kg/m²).

Keywords: body mass index; physical fitness; injury prevention

PMID: 26125174

DOI: 1IEC-921I

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The Invention of Ecocide: Agent Orange, Vietnam, and the Scientists Who Changed the Way We Think About the Environment

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Hester RA. 12(1). 76 - 77. (Book Review)

Abstract

Zierler, David
University of Georgia Press, 2011. ISBN-0820338265, 9780820338262. 252 pages.

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The JSOM Critical Care Supplement

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Fisher AD, Carius BM. 22(2). 42 - 42. (Letter)

Keywords: critical care; prehospital; combat; emergency medical services; medical evacuation

PMID: 35639892

DOI: HR9Z-AQZW

The Management of Abdominal Evisceration in Tactical Combat Casualty Care: TCCC Guideline Change 20-02

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Riesberg JC, Gurney JM, Morgan M, Northern DM, Onifer DJ, Gephart WJ, Remley MA, Eickhoff E, Miller C, Eastridge BJ, Montgomery HR, Butler FK, Drew B. 21(4). 138 - 142. (Classical Conference)

Abstract

Historically, about 20% of hospitalized combat injured patients have an abdominal injury. Abdominal evisceration may be expected to complicate as many as one-third of battle-related abdominal wounds. The outcomes for casualties with eviscerating injuries may be significantly improved with appropriate prehospital management. While not as extensively studied as other forms of combat injury, abdominal evisceration management recommendations extend back to at least World War I, when it was recognized as a significant cause of morbidity and was especially associated with bayonet injury. More recently, abdominal evisceration has been noted as a frequent result of penetrating, ballistic trauma. Initial management of abdominal evisceration for prehospital providers consists of assessing for and controlling associated hemorrhage, assessing for bowel content leakage, covering the eviscerated abdominal contents with a moist, sterile barrier, and carefully reassessing the patient. Mortality in abdominal evisceration is more likely to be secondary to associated injuries than to the evisceration itself. Attempting to establish education, training, and a standard of care for nonmedical and medical first responders and to leverage current wound management technologies, the Committee on Tactical Combat Casualty Care (CoTCCC) conducted a systematic review of historical Service guidelines and recent medical studies that include abdominal evisceration. For abdominal evisceration injuries, the following principles of management apply: (1) Control any associated bleeding visible in the wound. (2) If there is no evidence of spinal cord injury, allow the patient to take the position of most comfort. (3) Rinse the eviscerated bowel with clean fluid to reduce gross contamination. (4) Cover exposed bowel with a moist, sterile dressing or a sterile water-impermeable covering. It is important to keep the wound moist; irrigate the dressing with warm water if available. (4) For reduction in wounds that do not have a substantial loss of abdominal wall, a brief attempt may be made to replace/reduce the eviscerated abdominal contents. If the external contents do not easily go back into the abdominal cavity, do not force or spend more than 60 seconds attempting to reduce contents. If reduction of eviscerated contents is successful, reapproximate the skin using available material, preferably an adhesive dressing like a chest seal (other examples include safety pins, suture, staples, wound closure devices, etc.). Do not attempt to reduce bowel that is actively bleeding or leaking enteric contents. (6) If unable to reduce, cover the eviscerated organs with water-impermeable, nonadhesive material (transparent preferred to allow ability to reassess for ongoing bleeding; examples include a bowel bag, IV bag, clear food wrap, etc.), and then secure the impermeable dressing to the patient using an adhesive dressing (e.g., Ioban, chest seal). (7) Do NOT FORCE contents back into abdomen or actively bleeding viscera. (8) Death in the abdominally eviscerated patient is typically from associated injuries, such as concomitant solid organ or vascular injury, rather than from the evisceration itself. (9) Antibiotics should be administered for any open wounds, including abdominal eviscerating injuries. Parenteral ertapenem is the preferred antibiotic for these injuries.

Keywords: abdominal injury; abdominal evisceration; battle-related abdominal wounds; prehospital management

PMID: 34969144

DOI: 9U6S-1K7M

The Military Acute Concussion Evaluation (MACE)

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French L, McCrea M, Baggett MR. 08(1). 68 - 77. (Journal Article)

Abstract

Traumatic brain injury (TBI), in both times of peace and times of war is a significant public health issue for the military. Even at its most mild, TBI (concussion) can degrade fighting effectiveness, put individuals at increased risk for another injury, and in some cases cause persistent difficulties in cognition, and aspects of physical and emotional functioning. Key to the appropriate treatment of those with TBI is the identification of those that have suffered TBI. This article describes one such tool for the identification of TBI in a military setting, the Military Acute Concussion Evaluation (MACE) including its history, administration, and interpretation.

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The Mosul Trauma Response: A Case Study

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Farr WD. 18(3). 134 - 135. (Book Review)

Abstract

Spiegel PB, Garber K, Kushner A, Wise P. The Mosul Trauma Response. A Case Study. The Johns Hopkins Center for Humanitarian Research; February 2018; 140 pages.

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The Myth of Hyperresilience Evolutionary Concept Analysis of Resilience in Special Operations Forces

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Rocklein Kemplin K, Paun O, Sons N, Brandon JW. 18(1). 54 - 60. (Journal Article)

Abstract

Despite many resilience studies and resilience-building initiatives in the military, resilience as a concept remains granularly unexamined, vague, and inconsistently interpreted throughout military-specific research literature. Specifically, studies of military suicide and related mental health constructs assert that Servicemembers in Special Operations Forces (SOF) possess higher levels of resilience without providing an empirical basis for these statements. To provide rigorous evidence for future studies of resilience in SOF, a concept analysis was performed via Rodgers' evolutionary method to contextualize resilience in the SOF community and provide accurate redefinitions on which theoretical and methodological frameworks can be constructed reliably.

Keywords: resilience; military; concept analysis; Special Operations Forces; suicide

PMID: 29533434

DOI: 1VKO-UVDZ

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The Myths of Uncontrolled Emergence Reactions and Consideration to Stop Mandatory, Protocolled Midazolam Coadministration With Ketamine

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Hiller HM, Drew B, Fisher AD, Cuthrell M, Spradling JC. 22(1). 49 - 54. (Journal Article)

Abstract

Ketamine continues to demonstrate its utility and safety in the austere and prehospital environment, but myths persist regarding the frequency of behavioral disturbances and unpleasant reactions. These myths have led to protocolled midazolam co-administration. Properties of midazolam and other benzodiazepines have the potential to cause significant morbidity and potential mortality. Because of this risk, benzodiazepines should only be administered when the treating provider determines that the patient's symptoms warrant it. We also present evidence that agitation and altered mental status (AMS) encountered with ketamine occurs during titration of lower pain control regimens and is much less likely to occur with higher doses. As such, in most prehospital situations, the treatment for this "incomplete dissociation" is more ketamine, not the addition of a potentially dangerous benzodiazepine.

Keywords: ketamine; emergence; midazolam; Versed; dissociation

PMID: 35278314

DOI: PNGH-P2CK

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The NATO Special Operations Surgical Team Development Course A Program Overview

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Parker PJ. 19(3). 26 - 29. (Journal Article)

Abstract

The Special Operations Surgical Team Development Course (SOSTDC) is a 5-day course held two or three times a year at the North Atlantic Treaty Organization (NATO) training facility within the Special Operations Medical Branch (SOMB) of the Allied Centre for Medical Education (ACME). Its aim is to teach, train, develop, and encourage NATO partner nations to provide robust, hardened, and clinically able surgical resuscitation teams that are capable of providing close support to Special Operations Forces (SOF).

Keywords: Special Operations Surgical Team; resuscitation; in-flight surgery; blood

PMID: 31539431

DOI: TYQ6-1Y9E

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The Neurometabolic Cascade And Implications Of mTBI: Mitigating Risk To The SOF Community

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DeLellis SM, Kane S, Katz K. 09(4). 36 - 42. (Journal Article)

Abstract

Over the last decade, our understanding of biochemical changes that occur in the brain following an injury has increased dramatically. Although we have been able to discern and image severe injury and traumatic changes using techniques like computed tomography (CT) and magnetic resonance imaging (MRI) for decades, we have only recently begun to understand the physiologic changes that occur following a mild traumatic brain injury. Understanding the pathophysiology of a disease process enables healthcare providers to treat their patients better, but military healthcare providers shoulder the additional burden of conserving the fighting force. Neurocognitive testing in concert with clinical acumen and conservative profiling enables providers to protect their patients from further injury; while educating the patient and the chain of command will prevent additional injury and long-term cognitive sequelae, ultimately preserving the fighting force.

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PMID: 20112647

DOI: 0OI6-W6Z7

The Ongoing Evolution (Revolution) of TEMS

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Carmona PA. 14(3). 139 - 141. (Journal Article)

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PMID: 25344726|REJECTED: Bibliographic data does not match

DOI: KA8C-VDEV

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The Operational Canine and K9 Tactical Emergency Casualty Care Initiative

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Palmer LE, Maricle R, Brenner J. 15(3). 32 - 38. (Journal Article)

Abstract

Background: Approximately 20% to 25% of traumarelated, prehospital fatalities in humans are due to preventable deaths. Data are lacking, however, on the nature and the prevalence of operational canine (OC) prehospital deaths. It is plausible that OCs engaged in high-threat operations are also at risk for suffering some type of preventable death. Tactical Combat Casualty Care has significantly reduced human fatality rates on the battlefield. Standardized guidelines specifically for prehospital trauma care have not been developed for the OC caregiver. An initiation has been approved by the Committee for Tactical Emergency Casualty Care to form a K9-Tactical Emergency Casualty Care (TECC) working group to develop such guidelines. Significance: The intent of the K9-TECC initiative is to form best practice recommendations for the civilian high-risk OC caregiver. These recommendations are to focus on interventions that (1) eliminate the major causes of canine out-of-hospital preventable deaths, (2) are easily learned and applied by any civilian first responder, and (2) minimize resource consumption.

Keywords: canine; trauma; preventable death; Tactical Emergency Casualty Care; K9-TECC; guidelines

PMID: 26360351

DOI: RMVA-7381

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The Operator: Firing the Shots That Killed Osama bin Laden and My Years as a SEAL Team Warrior

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Graverson SP. 23(2). 122 - 122. (Book Review)

Abstract

O'Neill, Robert. The Operator: Firing the Shots That Killed Osama bin Laden and My Years as a SEAL Team Warrior. New York, NY: Scribner, Publisher: 2018. 368 pages. ISBN-10: 1501145037/ISBN-13: 977-1-5011-4503-2

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The Potential Use of the Abdominal Aortic Junctional Tourniquet® in a Military Population: A Review of Requirement, Effectiveness, and Usability

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Handford C, Parker PJ. 19(4). 74 - 79. (Journal Article)

Abstract

Uncontrolled hemorrhage is the leading cause of preventable prehospital death on the battlefield; 20% is junctional. This is a challenge to manage in the forward and prehospital military environment. With the widespread use of body armor, peripheral tourniquets and continued asymmetric warfare this consistent figure is unlikely to reduce. Resuscitative endovascular balloon occlusion of the aorta (REBOA) is an often-quoted potential solution; however, this invasive strategy requires a high skill level alongside a significant failure and complication rate. The Abdominal Aortic Junctional Tourniquet® (AAJT) is a noninvasive potential adjunct for the management of hemorrhage below the level of the aortic bifurcation with published case reports of successful use in prehospital blast and gunshot wounds. When placed at the level of the aortic bifurcation, alongside a pelvic binder, it can be used to control pelvic hemorrhage, buying time until definitive management. Importantly it has a low training burden and is easy to use. The AAJT has potential use as a prehospital device in the exsanguinating patient, those in traumatic cardiac arrest, as a bridging device, and as fluid conserving device in resource-limited environments. The evidence surrounding the AAJT is reviewed, and potential uses in the military setting are suggested.

Keywords: tourniquet; trauma; military; junctional; hemorrhage; combat; mortality; pelvic injury; prehospital

PMID: 31910475

DOI: 39ZK-FAZZ

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The Prehospital Trauma Registry Experience With Intraosseous Access

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Schauer SG, Naylor JF, April MD, Fisher AD, Cunningham CW, Fernandez JD, Shreve BP, Bebarta VS. 19(1). 52 - 55. (Journal Article)

Abstract

Background: Peripheral intravenous (IV) cannulation is often difficult to obtain in a patient with hemorrhagic shock, delaying the appropriate resuscitation of critically ill patients. Intraosseous (IO) access is an alternative method. To date, few data exist on use of this procedure by ground forces in Afghanistan. Here, we compare patient characteristics and concomitant interventions among patients undergoing IO access versus those undergoing IV access only. Methods: We obtained data from the Prehospital Trauma Registry (PHTR). When possible, patients were linked to the Department of Defense Trauma Registry for outcome data. To develop the cohorts, we searched for all patients with documented IO or IV access placement. Those with both IO and IV access documented were placed in the IO group. Results: Of the 705 available patients in the PHTR, we identified 55 patients (7.8% of the population) in the IO group and 432 (61.3%) in the IV group. Among patients with documentation of access location, the most common location was the tibia (64.3%; n = 18). Compared with patients with IV access, those who underwent IO access had higher urgent evacuation rates (90.9% versus 72.4%; p = .01) and air evacuation rates (58.2% versus 14.8%; p < .01). The IO cohort had significantly higher rates of interventions for hypothermia, chest seals, chest tubes, needle decompressions, and tourniquets, but a significantly lower rate of analgesic administration (ρ ≤ .05). Conclusion: Within the registry, IO placement was relatively low (<10%) and used in casualties who received several other life-saving interventions at a higher rate than casualties who had IV access. Incidentally, lower proportions of analgesia administration were detected in the IO group compared with the IV group, despite higher intervention rates.

Keywords: hemorrhagic shock; intraosseous access; intravenous access; prehospital; combat; hypotension; resuscitation; military

PMID: 30859527

DOI: PT72-OX2K

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The Present State of Military Physician Leadership: A Lacking Paradigm?

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Pfaff J. 22(3). 101 - 103. (Editorial)

Keywords: military health system; health care; preventive measures

PMID: 36651928

DOI: 2J8E-MSXS

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The Prevalence And Impact Of Musculoskeletal Injuries During A Pre-deployment Workup Cycle: Survey Of A Marine Corps Special Operations Company

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Hollingsworth DJ. 09(4). 11 - 15. (Journal Article)

Abstract

Musculoskeletal injuries are a primary cause of morbidity and missed training throughout the military. Only a handful of studies have been performed which focus on the Special Operations community. This study was performed to determine a baseline understanding of the prevalence of musculoskeletal injuries within an operational element of the newly formed Marine Corps Special Operations Command. The results of this survey reveal that nearly one-third of all members of 1st Marine Special Operations Battalion, Delta Company, experienced pain or physical limitation due to a musculoskeletal injury. Of those who were injured, nearly 30% reported that their injury impacted their ability to train during their pre-deployment training cycle. These results confirm that musculoskeletal injuries are a significant problem within the Marine Corps Special Operations Command. Further investigation is warranted to examine etiological factors resulting in these injuries and changes to training regimens that may result in decreased injuries.

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PMID: 20112642

DOI: 7AEL-6RHG

The Quiet Soldier: On Selection With 21 SAS

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Farr WD. 18(1). 157 - 157. (Book Review)

Abstract

Ballinger, Adam. The Quiet Soldier: On Selection With 21 SAS. Orion Books, Ltd.: London, United Kingdom, 1992. Paperback, 240 pages. ISBN 1-85797-158-2.

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DOI:

The Ranger First Responder Program and Tactical Emergency Casualty Care Implementation: A Whole-Community Approach to Reducing Mortality From Active Violent Incidents

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Fisher AD, Callaway DW, Robertson JN, Hardwick SA, Bobko JP, Kotwal RS. 15(3). 46 - 53. (Journal Article)

Abstract

Active violent incidents are dynamic and challenging situations that can produce a significant amount of preventable deaths. Lessons learned from the military's experience in Afghanistan and Iraq through the Committee on Tactical Combat Casualty Care and the 75th Ranger Regiment's Ranger First Responder Program have helped create the Committee for Tactical Emergency Casualty Care (C-TECC) to address the uniqueness of similar wounding patterns and to end preventable deaths. We propose a whole-community approach to active violent incidents, using the C-TECC Trauma Chain of Survival and a tiered approach for training and responsibilities: the first care provider, nonmedical professional first responders, medical first responders, and physicians and trauma surgeons. The different tiers are critical early links in the Chain of Survival and this approach will have a significant impact on active violent incidents.

Keywords: Committee on Tactical Combat Casualty Care; Ranger First Responder Program; Committee on Emergency Casualty Care; wounding patterns; Chain of Survival; preventable death

PMID: 26360353

DOI: J3TF-9EKV

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The Rise of the Stop the Bleed Campaign in Italy

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Valsecchi D, Sassi G, Tiraboschi L, Bonetti M, Lagazzi E, Michelon AM, Nicolussi T, Stevan A, Bonasera-Vincenti NM, Guelfi-Pulvano R, Tripodi R. 19(4). 95 - 99. (Journal Article)

Abstract

Background: The B-Con Basic 1.0 protocol is a medical training designed to teach how to control massive external haemorrhages in emergency conditions. Spread throughout the United States since 2013, thanks to the Stop the Bleed campaign, it has seen a progressive international spread during 2016-2018. We report here data from the first 18 months of our training in Italy. Methods: Since January 2017, military Operators enlisted to the Volunteer Military Corps of the Italian Red Cross and registered to the ACS B-Con instructor database have provided B-Con courses. These instructors have provided extensive training, involving learners among military and civilian populations, especially health professionals and students. Further, they have obtained a formal adhesion to the National Stop the Bleed Day 2018. Results: Through August 2018, we trained 1186 learners in Italy on the B-Con protocol. The learners were mainly military personnel and law enforcement agents (620 [52%]) but also students and civilian health personnel (566 [48%]). Conclusion: The B-Con protocol has been very well received in Italy by military and police personnel. Good results have been assessed among civilian health professionals and medical students, especially by those operators involved in the field of emergency medicine.

Keywords:

PMID: 31910480

DOI: RXGJ-K1S5

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The Role I Resuscitation Team and Resuscitative Endovascular Balloon Occlusion of the Aorta

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Fisher AD, Teeter WA, Cordova CB, Brenner ML, Szczepanski MP, Miles EA, Galante JM, DuBose JJ, Rasmussen TE. 17(2). 65 - 73. (Journal Article)

Abstract

The medical advancements made during the wars in Iraq and Afghanistan have resulted in an unprecedented survival rate, yet there is still a significant number of deaths that were potentially survivable. Additionally, the ability to deliver casualties to definitive surgical care within the "golden hour" is diminishing in many areas of conflict. Resuscitative endovascular balloon occlusion of the aorta (REBOA) has been implemented successfully in the hospital setting. REBOA may be a possible adjunct for the Role I and point-of-injury (POI) care to provide temporary control of noncompressible torso hemorrhage (NCTH) and junctional hemorrhage. Here the authors advocate for the development of the Role I Resuscitation Team (RT) and a training pathway to meet the challenge of the changing battlefield

Keywords: Tactical Combat Casualty Care; TCCC; resuscitation; resuscitative endovascular balloon occlusion of the aorta; REBOA; hemorrhage; shock

PMID: 28599036

DOI: ME32-0LIR

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The Role of Magnetic Resonance Imaging in Optimizing Injury Management in Air Force Pararescuemen, Combat Rescue Officers, and Survival Specialists

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Rush SC, Foresto C, Hewitt CW, Grossman MG, Petersen CD, Gallo I, Staak BP, Rush JT. 18(2). 86 - 89. (Journal Article)

Abstract

Operators perform physically demanding jobs associated with a variety of overuse and acute musculoskeletal injuries. The current management of musculoskeletal complaints in the Air Force includes plane radiographs and 6 weeks of physical therapy (PT) before consideration of orthopedic consultation and magnetic resonance imaging (MRI); however, MRI shows a clear advantage compared with plane radiographs. We conducted a performance improvement project and conclude that (1) MRI allowed for definitive diagnosis as well as definitive triage for care in a timely manner, (2) guidelines for ordering lumbosacral MRIs should be followed and not ordered for pain that is not progressive and severe or not associated with a neurological finding, and (3) because of the risk of X-ray exposure in patients in their 20 and 30s, X-rays should be avoided in this setting unless definitely indicated.

Keywords: radiography; X-rays; magnetic resonance imaging; injuries, musculoskeletal; imaging

PMID: 29889962

DOI: 3Y2T-OU5E

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The Shrail: A Comparison of a Novel Attachable Rail System With the Current Deployment Operating Table

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Dilday J, Sirkin MR, Wertin T, Bradley F, Hiles J. 18(1). 29 - 31. (Case Reports)

Abstract

The current forward surgical team (FST) operating table is heavy and burdensome and hinders essential movement flexibility. A novel attachable rail system, the Shrail, has been developed to overcome these obstacles. The Shrail turns a North Atlantic Treaty Organization litter into a functional operating table. A local FST compared the assembly of the FST operating table with assembling the Shrail. Device weight, storage space, and assembly space were directly measured and compared. The mean assembly time required for the Shrail was significantly less compared with the operating table (23.36 versus 151.6 seconds; p ≤ .01). The Shrail weighs less (6.80kg versus 73.03kg) and requires less storage space (0.019m3 versus 0.323m3) compared with the current FST operating table. The Shrail provides an FST with a faster, lighter surgical table assembly. For these reasons, it is better suited for the demands of an FST and the implementation of prolonged field care.

Keywords: Shrail; litter; operating table; prolonged field care; austere, military

PMID: 29533429

DOI: AQ93-4OE7

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The SOF Truths for Army Special Operations Forces Surgical Teams

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Baker JB, Modlin RE, Ong RC, Remick KN. 17(4). 52 - 55. (Journal Article)

Abstract

The US Army Special Operations Command and Army Medical Command are at a critical junction in Army medical training. Army Special Operations Forces (ARSOF) will receive Forward Resuscitative Surgical Teams (FRSTs) in the near future and must establish a training model to enable successful support for ARSOF operations. The military has been directed by Congress through the 2017 National Defense Authorization Act to embed trauma combat casualty care teams in civilian trauma centers. ARSOF FRSTs should be embedded in the nation's leading civilian trauma centers to build and sustain true expertise in delivering trauma care on the battlefield. The SOF Truths provide valuable insights into the required conditions for success of this new training paradigm.

Keywords: forward resuscitative surgical team; trauma

PMID: 29256195

DOI: 2WCU-5TZB

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The Sole Provider: Preparation for Deployment to a Medically Austere Theater

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Corso P, Mandry C, Reynolds S. 17(2). 74 - 81. (Journal Article)

Abstract

The combat focus of the US Military over the past 15 years has primarily centered on the Iraq and Afghanistan areas of operation (AOs). Thus, much human and financial capital has been dedicated to the creation of a robust medical infrastructure to support those operations. However, Special Operation Forces (SOF) are often called upon to deploy in much more medically austere AOs. SOF medical providers operating in such environments face significant challenges due to the diversity of medical threats, extremely limited access to medical resupply, a material shortage of casualty evacuation platforms, lack of medical facilities, and limited access to higher-level care providers. This article highlights the challenges faced during a recent Special Forces deployment to such an austere environment. Many of these challenges can be mitigated with a specific approach to premission training and preparation.

Keywords: prolonged field care; austere environments; deployed preparation

PMID: 28599037

DOI: DFVE-PNUN

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The Soviet Counterinsurgency in the Western Borderlands

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Farr WD. 18(2). 147 - 147. (Book Review)

Abstract

Statiev, Alexander. The Soviet Counterinsurgency in the Western Borderlands. New York, NY: Cambridge University Press; 2013. Paperback: 386 pages. ISBN-10: 1107616476; ISBN-13: 978-1107616479.

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The Special Operations Rescuscitation Team: Robust Role Ii Medical Support For Today's SOF Envrionment

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Riesberg JC. 09(1). 27 - 32. (Journal Article)

Abstract

Special Operation Forces (SOF) have historically relied upon conventional medical assets for Role II and higher medical support. Over the last five years, the need for SOF-specific medical teams and surgical support was identified and addressed. Several Special Operations based Role II assets are now available to support operations, each with unique personnel and capabilities. The Special Operations Resuscitation Teams (SORT) have been engaged in several joint deployments in the last year, demonstrating the mission readiness and lifesaving trauma support for which the teams were designed. The future of SOF Role II has many unique challenges, including personnel resourcing, training, and joint operational planning. OBJECTIVES Provide a historical perspective on the evolution of SOF-specific Role II medical support. Review current SOF-specific Role II capabilities and employment. Discuss unresolved issues related to SOF-specific Role II capabilities and employment.

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PMID: 19813346

DOI: 666C-ZNI0

The Supply of Pharmaceuticals in Humanitarian Assistance Missions: Implications for Military Operations

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Mahmood M, Riley K, Bennett D, Anderson W. 11(1). 37 - 42. (Previously Published)

Previously published in Military Medicine, 176, 8:852, 2011

Abstract

In this article, we provide an overview of key international guidelines governing the supply of pharmaceuticals during disasters and complex emergencies. We review the World Health Organization's guidelines on pharmaceutical supply chain management and highlight their relevance for military humanitarian assistance missions. Given the important role of pharmaceuticals in addressing population health needs during humanitarian emergencies, a good understanding of how pharmaceuticals are supplied at the local level in different countries can help military health personnel identify the most appropriate supply options. Familiarity with international guidelines involved in cross-border movement of pharmaceuticals can improve the ability of military personnel to communicate more effectively with other actors involved in humanitarian and development spheres. Enhancing the knowledge base available to military personnel in terms of existing supply models and funding procedures can improve the effectiveness of humanitarian military operations and invite policy changes necessary to establish more flexible acquisition and funding regulations.

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PMID: 22113725

DOI: C6W1-M3H2

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The Surgical Resuscitation Team: Surgical Trauma Support For U.s. Army Special Operations Forces

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Remick KN. 09(4). 20 - 25. (Journal Article)

Abstract

Special Operations Forces need trauma surgical support that is flexible and rapidly mobile. Current operations in the Afghanistan Theater of Operations required the U.S. Army 772nd Forward Surgical Team (FST) to provide support for Special Operations missions and conventional missions on short-notice using its mobile Surgical Resuscitation Team (SRT). The 772nd FST's experience over a 15-month deployment validates the concept of and the requirement for the SRT. This paper provides a framework for planners to design and implement this capability for support of U.S. Army Special Operations Forces (ARSOF).

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PMID: 20112644

DOI: N0TY-O6ZK

The Tactical Combat Casualty Care Casualty CardTCCC Guidelines - Proposed Change 1301

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Kotwal RS, Butler FK, Montgomery HR, Brunstetter T, Diaz GY, Kirkpatrick JW, Summers NL, Shackelford SA, Holcomb JB, Bailey JA. 13(2). 82 - 87. (Journal Article)

Abstract

Optimizing trauma care delivery is paramount to saving lives on the battlefield. During the past decade of conflict, trauma care performance improvement at combat support hospitals and forward surgical teams in Afghanistan and Iraq has increased through Joint Trauma System and DoD Trauma Registry data collection, analysis, and rapid evidence-based adjustments to clinical practice guidelines. Although casualties have benefitted greatly from a trauma system and registry that improves hospital care, still lacking is a comprehensive and integrated system for data collection and analysis to improve performance at the prehospital level of care. Tactical Combat Casualty Care (TCCC) based casualty cards, TCCC after action reports, and unit-based prehospital trauma registries need to be implemented globally and linked to the DoD Trauma Registry in a seamless manner that will optimize prehospital trauma care delivery.

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PMID: 23877773

DOI: 7DN3-A0JX

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The Time To Field Freeze Dried Plasma Is Now

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Pennardt A. 10(3). 49 - 49. (Editorial)

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PMID: 21140981

DOI: ELVE-D21S

The Twilight War: The Secret History of America's Thirty-Year Conflict With Iran

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Farr WD. 13(4). 121 - 122. (Book Review)

Abstract

David Crist. New York, NY: The Penguin Press; 2012. 638 pages. ISBN: 1-59420-341-1. $36.00.

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The Two Jobs I Love The Most Are the Two That Pay Me the Least: An Interview With Dan Godbee

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Pennardt A. 19(1). 131 - 132. (Interview)

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PMID: 30859542

DOI: EG20-C61Y

The Ultrasound Detection Of Simulated Long Bone Fractures By U. S. Army Special Forces Medics

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Heiner JD, Baker BL, McArthur TJ. 10(2). 7 - 10. (Journal Article)

Abstract

Introduction: U.S. Army Special Forces Medics (18Ds) operate in austere environments where decisions regarding patient management may be limited by available resources. Portable ultrasound may allow for the detection of fractures in environments where other imaging modalities such as radiography are not readily available or practical. Objective: We used a simulation training model for the ultrasound diagnosis of long bone fractures to study the ability of 18Ds to detect the presence or absence of a fracture using a portable ultrasound. Methods: The fracture simulation model is composed of a bare turkey leg bone that is mechanically fractured and housed in a shallow plastic container within an opaque gelatin base solution. Five fracture patterns were created: transverse, segmental, oblique, comminuted, and no fracture. After a brief orientation session, twenty 18Ds evaluated the models in a blinded fashion with a SonoSite M-Turbo portable ultrasound device for the presence or absence of a fracture. Results: 18Ds demonstrated 100% sensitivity (95% CI: 94.2% to 100%) in fracture detection and an overall specificity of 90% (95% CI: 66.8-98.2%) due to two false positive assessments of the no fracture model. Conclusions: Using a portable ultrasound device, 18Ds were able to correctly detect the presence or absence of a simulated long bone fracture with a high degree of sensitivity and specificity. Future studies are needed to investigate the clinical impact of this diagnostic ability.

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PMID: 20936597

DOI: K7EU-35TF

The United States Army Special Forces - Walter Reed Army Institute Of Research Field Epidemiologic Survey Team (Airborne)

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Dorogi LT. 09(2). 54 - 71. (Journal Article)

Abstract

The U.S. Army Special Forces - Walter Reed Army Institute of Research Field Epidemiological Survey Team (Airborne) was formed in late 1965 and later deployed to Vietnam in 1966. Funded by Walter Reed Army Institute of Research and staffed by highly trained Special Forces qualified medical personnel from Fort Bragg, North Carolina, the team was attached to the 5thSpecial Forces Group (Airborne) while in Vietnam. During its short existence, the team conducted extensive and important field studies on diseases of military medical importance, often under combat conditions.

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PMID: 19813519

DOI: LUYA-QQU0

The Use of Chest Seals in Treating Sucking Chest Wounds: A Comparison of Existing Evidence and Guideline Recommendations

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Kuhlwilm V. 21(1). 94 - 101. (Journal Article)

Abstract

Introduction: Sucking chest wounds occur when injuries penetrate the thorax and inhalation results in air entering the pleural cavity. Well documented in the prehospital environment, treatment should be chest seal application to attempt prevention of an expanding pneumothorax. However, a seal might occlude the pathway for the escape of air and lead to a worsening tension pneumothorax. Methods: The author conducted a literature search of studies reporting the efficacy of various chest seals for treating sucking chest wounds and the prevention of a tension pneumothorax. Study results were compared to current international guidelines. Results/Discussion: Included were four studies testing chest seals in a swine model of hemopneumothorax. Vented and unvented chest seals stabilized cardiorespiratory parameters after an open pneumothorax, but only vented chest seals showed more success at preventing a tension pneumothorax. Chest seals with flutter valves seemed to be inferior. An additional study showed that vertical movements and soiled skin were more stressful on the applied chest seals. Eight international guidelines were identified: four focused on the tactical environment, and four appeared to be more civilian-oriented. Only two of the civilian-oriented guidelines did not prefer vented chest seals. Conclusion: Vented chest seals seem to be superior to unvented chest seals, and most international guidelines have updated their recommendations for the use of vented chest seals. However, frequent physical examinations for early signs of a developing or worsening tension pneumothorax are the best medical care.

Keywords: open pneumothorax; sucking chest wound; thoracic trauma; chest seal; vented chest seal; unvented chest seal; combat medical care; tactical medicine

PMID: 33721314

DOI: 3G6H-14FD

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The Use of Dexamethasone in Support of High-Altitude Ground Operations and Physical Performance: Review of the Literature

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O'Hara R, Serres J, Dodson W, Bruce W, Ordway J, Powell E, Wade M. 14(4). 53 - 58. (Journal Article)

Abstract

Objective: Military Special Operators (SOs) are exposed environmental conditions that can alter judgment and physical performance: uneven terrain, dryness of ambient air, reduction of air density, and a diminished partial pressure of oxygen. The primary purpose of this review was to determine the medical efficacy of dexamethasone as an intervention for the prevention and treatment of high-altitude illness. The secondary purpose was to determine its ability to maintain physical performance of SOs at high altitudes. Methods: A search of the literature from 1970 to 2014 was performed, locating 61 relevant articles, with 43 addressing the primary and secondary purposes of this literature review. Conclusions: The review indicates that dexamethasone is an effective prevention and treatment intervention for high-altitude illness. Commonly used dosages of either 2mg every 6 hours or 4mg every 12 hours can prevent high-altitude illnesses in adults. Currently in USSOCOM operations, there is an option to use 4mg every 6 hours (concurrently with acetazolamide 125mg bid) if ascending rapidly to or above 11,500 ft without time for acclimatization. Researchers also determined that acute exposure to high altitude, even in asymptomatic subjects, resulted in small cognitive deficits that could be reversed with dexamethasone. Dexamethasone may also help improve cognition and maximal aerobic capacity in SOs who are susceptible to high-altitude pulmonary edema.

Keywords: high altitude; mountain; performance; strength; endurance; physical; military; Special Operations

PMID: 25399369

DOI: 5JV1-0FIP

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The use of Dietary Supplement Among Soldiers From the Macedonian Special Operations Regiment

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Kjertakov M, Hristovski R, Racaj M. 13(1). 19 - 24. (Journal Article)

Abstract

Objectives: To determine the prevalence and type of dietary supplement used, reasons for use, and sources of supplement information among Macedonian elite Soldiers. Methods: Anonymous self-reported questionnaires containing questions about demographic characteristics and dietary supplementation practices were distributed to 134 Soldiers, of whom 80 were recruited from the Ranger Battalion (R) and 54 from the Special Force Battalion (SF). Results: The Soldiers completed and returned 132 questionnaires. Overall, 66.6% of the Soldiers, including 70.3% of SF and 64.1% of R, reported using supplements within the 3 months before the survey. On average, each of these Soldiers used 3.7 ± 2.9 supplements. The most commonly used supplements were multivitamins (50.0%) and vitamin C (47.7%). The most frequently cited reason for using supplements was to improve general health (51.6%). Primary sources of supplement information were friends (42.0%) and books/magazines (40.9%). Conclusions: Dietary supplement use was found to be common and widespread among this military subpopulation. Given this, and the fact that the majority of the Soldiers do not receive accurate information about supplements, educational intervention regarding the safety and efficacy of these products is needed if unnecessary or harmful supplementation practices are to be prevented.

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PMID: 23526317

DOI: EWOV-G9RZ

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The Use Of Fresh Whole Blood Transfusions By The Sof Medic For Hemostatic Resuscitation In The Austere Environment

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Bowling F, Pennardt A. 10(3). 25 - 35. (Journal Article)

Keywords:

PMID: 21049432

DOI: 0370-FW6J

The Use of Pelvic Binders in Tactical Combat Casualty Care: TCCC Guidelines Change 1602 7 November 2016

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Shackelford S, Hammesfahr R, Morissette DM, Montgomery HR, Kerr W, Broussard M, Bennett BL, Dorlac WC, Bree S, Butler FK. 17(1). 135 - 147. (Classical Conference)

Keywords: pelvic binder; prehospital guidelines; TCCC Guideline

PMID: 28285493

DOI: 1WLZ-MKW4

The Use of the Abdominal Aortic and Junctional Tourniquet Versus Combat Gauze in a Porcine Hemicorporectomy Model

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Schwartz RB, Shiver SA, Reynolds BZ, Lowry J, Holsten SB, Akers TW, Lyon M. 19(2). 69 - 72. (Journal Article)

Abstract

Background: Junctional hemorrhage is a potentially preventable cause of death. The Abdominal Aortic and Junctional Tourniquet (AAJT) compresses major vascular structures and arrests blood flow in exsanguinating hemorrhage. In a human model, the AAJT was effective in stopping blood flow in the femoral arteries via compression of the distal aorta. This study compares the ability of AAJT and Combat Gauze (CG) to stop hemorrhagic bleeding from a hemicorporectomy in a swine model. Method: Six anesthetized swine were used. Carotid arterial catheters were placed for continuous mean arterial pressure (MAP) readings. A hemicorporectomy was accomplished with a blade lever device by cutting the animal through both femoral heads transecting the proximal iliac arteries and veins. Hemorrhage control was attempted with the AAJT and regular Kerlix gauze or CG packing and direct pressure followed by Kerlix gauze placed over the CG. The primary outcome measure was survival at 60 minutes. Results: The 60-minute survival was 100% for the AAJT and 0% for the CG group. During the 60-minute monitoring period, only one CG animal achieved hemostasis. For the AAJT group, the mean time to hemostasis was 30 seconds. Initial MAP was higher in the AAJT group (mean, 87mmHg) than the CG group (mean, 70mmHg). The mean 60-minute MAP was 73mmHg for the AAJT group. Mean blood loss at 5 minutes and mean total blood loss were greater in the CG group than in the AAJT group. Conclusion: AAJT is superior to CG in controlling hemorrhage in a junctional wound in a swine model.

Keywords: junctional hemorrhage; gauze; tourniquet

PMID: 31201753

DOI: DIA2-IDCY

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The Use of Tourniquets in the Russo-Ukrainian War

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Samarskiy IM, Khoroshun EM, Vorokhta Y. Ahead of Print. (Journal Article)

Abstract

Aim: The objective of the study was to evaluate the use of tourniquets in the Russo-Ukrainian war. Methods: The type, number, and duration of tourniquets per limb, the clinical course of limb injuries, and the functional status of the injured limbs during the 24 hours post-injury were evaluated in military hospital facilities for the period of 2014-2022. Statistical frequencies and variances were analyzed. Results: During active hostilities, the medical units of the Southern Operational Command received 2,496 patients with limb injuries that required the application of tourniquets. Lower extremity injuries were predominantly observed (84.4%). A single tourniquet was used in 1,538 cases (61.6%), whereas two tourniquets were used in 533 (21.4%), and three tourniquets in 425 cases (17.0%). During the 2014- 2021 period, Esmarch's tourniquet was most commonly used. However, in 2022, it was mostly replaced by the Combat Application Tourniquet and similar systems (e.g., Sich, Dnipro). The duration of the tourniquet use ranged from 50 to 380 minutes (mean 205.9 [standard error 8.1] min), which prolonged ischemia in a significant number of cases. Limb amputations, mainly due to extensive necrosis, were performed in 92 cases (3.7%). In addition to 101 deaths (4.0% of patients), 11 cases of severe tourniquet syndrome were encountered. The limb was salvaged in 9 cases (81.8%). Conclusion: Prompt triage and evacuation of injured combatants can save affected limbs, even when the duration of tourniquet use exceeds 2 hours. Tourniquet syndrome can be prevented using a hemostatic tourniquet.

Keywords: tactical medicine; limb injury; tourniquets; vascular surgery; Russo-Ukrainian war

PMID: 38408044

DOI: CB0O-GYYX

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The Use of Tranexamic Acid in Tactical Combat Casualty Care: TCCC Proposed Change 20-02

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Drew B, Auten JD, Cap AP, Deaton TG, Donham B, Dorlac WC, DuBose JJ, Fisher AD, Ginn AJ, Hancock J, Holcomb JB, Knight J, Koerner AK, Littlejohn LF, Martin MJ, Morey JK, Morrison J, Schreiber MA, Spinella PC, Walrath B, Butler FK. 20(3). 36 - 43. (Journal Article)

Abstract

The literature continues to provide strong support for the early use of tranexamic acid (TXA) in severely injured trauma patients. Questions persist, however, regarding the optimal medical and tactical/logistical use, timing, and dose of this medication, both from the published TXA literature and from the TCCC user community. The use of TXA has been explored outside of trauma, new dosing strategies have been pursued, and expansion of retrospective use data has grown as well. These questions emphasize the need for a reexamination of TXA by the CoTCCC. The most significant updates to the TCCC Guidelines are (i) including significant traumatic brain injury (TBI) as an indication for TXA, (ii) changing the dosing protocol to a single 2g IV/IO administration, and (iii) recommending TXA administration via slow IV/IO push.

Keywords: TXA; tranexamic acid; hemorrhage; hemostatics; antifibrinolytics; hemorrhagic shock; traumatic brain injury; traumatic injuries

PMID: 32969002

DOI: ZWV3-5CBW

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The Use of Tranexamic Acid in the Prehospital Setting: A Retrospective Study

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Boever J, Krasowski MS, Brandt M, Woods T. 19(3). 82 - 85. (Journal Article)

Keywords:

PMID: 31539438

DOI: L8D5-KYSC

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This Is Africa

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Verlo AR, Bailey HH, Cook MR. 15(3). 114 - 119. (Journal Article)

Abstract

Military deployments will always result in exposure to health hazards other than those from combat operations. The occupational and environmental health and endemic disease health risks are greater to the Special Operations Forces (SOF) deployed to the challenging conditions in Africa than elsewhere in the world. SOF are deployed to locations that lack life support infrastructures that have become standard for most military deployments; instead, they rely on local resources to sustain operations. Particularly, SOF in Africa do not generally have access to advanced diagnostic or monitoring capabilities or to medical treatment in austere locations that lack environmental or public health regulation. The keys to managing potential adverse health effects lie in identifying and documenting the health hazards and exposures, characterizing the associated risks, and communicating the risks to commanders, deployed personnel, and operational planners.

Keywords: Africa; health risk assessment; food and water ; occupational and environmental health; site survey

PMID: 26360366

DOI: BQAS-1D1O

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This Is Africa. Bites, Stings, and Rigors: Clinical Considerations in African Operations

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Lynch JH, Verlo AR, Givens ML, Munoz CE. 14(4). 113 - 121. (Journal Article)

Abstract

The natural health threats in Africa pose daunting clinical challenges for any provider, as evidenced by the current Ebola epidemic in West Africa, but the threat is multiplied for the Special Operations provider on the continent who faces these challenges with limited resources and the tyranny of distance. The majority of operationally significant health risks can be mitigated by strict adherence to a comprehensive force health protection plan. The simplest, yet most effective, technique for preventing mosquito-borne diseases is the prevention of mosquito bites with repellent, bed nets, and appropriate clothing in addition to chemoprophylaxis. Some of the more likely or lethal infectious diseases encountered on the continent include malaria, Chikungunya, dengue, human immunodeficiency virus, and Ebola. Venomous snakes pose a particular challenge since the treatment can be as deadly as the injury. Providers supporting African operations should educate themselves on the clinical characteristics of possible envenomations in their area while promoting snake avoidance as the primary mitigation measure. To succeed in Africa, the Special Operations provider must consider how to meet these challenges in an environment where there may not be reliable evacuation, hospitalization, or logistics channels.

Keywords: Africa; tactical medicine; tropical infectious disease; chemoprophylaxis; malaria; dengue; Chikungunya; HIV; Ebola; snake evenomation; antivenin; wilderness medicine

PMID: 25399379

DOI: 0TOR-N6ZS

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This Is Africa: An Introduction to Medical Operations on the African Continent

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Givens ML, Lynch JH. 14(3). 107 - 110. (Journal Article)

Abstract

This article regarding Special Operations Forces (SOF) medical operations in Africa is an introduction to a follow- on series of articles that will address in more detail pertinent medical topics which pertain to operations on the African continent. Medical operations in Africa require dynamic and systematic approaches that consider the myriad challenges, yet offer flexible solutions applied as situations and environments dictate. We believe this series of articles will be of high interest to readers and provide key information that will be germane to future SOF operations.

Keywords: medical operations; evacuation; tropical infectious disease; tactical medicine; Africa; wilderness medicine

PMID: 25344718

DOI: HKX2-FT8U

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Thoughts on Aid Bags Part One

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Hetzler MR, Ball JA. 08(3). 47 - 53. (Journal Article)

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Thoughts On Aid Bags Part Two

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Ball JA, Hetzler MR. 08(4). 30 - 35. (Journal Article)

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Threat Appraisal, Recovery Operations, and PTSD Symptoms Among US Air Force Rescue Personnel

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Bryan CJ, Rush SC, Fuessel-Herrmann D, Bryan AO, Morrow CE, Haskell J, Jones MJ, Bowerfind C, Stephenson JA. 23(1). 18 - 22. (Journal Article)

Abstract

Background: Research among military personnel and veterans indicates that subjective appraisal of warzone stressors explains the relation of combat exposure to posttraumatic stress disorder (PTSD), but not the relation of exposure to injury and death to PTSD. Studies have primarily been limited to conventional forces using aggregate measures of warzone stressor exposure. Threat appraisal may play a different role in the emergence of PTSD among military personnel for whom dangerous deployment experiences are more closely associated with exposure to injury and death, such as US Air Force Pararescuemen and Combat Rescue officers. Materials and Methods: In a sample of 207 rescue personnel, correlations among various types of warzone stressor exposure, threat appraisal, and postdeployment PTSD symptoms were examined. Results: The relative strongest correlates of threat appraisal were stressors related to injury, death, and human remains. Although exposure to these stressors was also correlated with PTSD symptom severity, partial correlations of stressor exposure and PTSD symptoms were no longer significant when adjusting for threat appraisal. Conclusion: Results support the contributing role of threat appraisal to PTSD among military personnel whose primary duties entail exposure to injury and death under hostile and dangerous conditions.

Keywords: PTSD; combat; pararescue; threat appraisal

PMID: 36764287

DOI: P58K-BDYT

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Thrombotic Microangiopathy Syndrome in a Basic Underwater Demolition/SEAL Student

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Croom D, Tracy H. 16(3). 16 - 19. (Journal Article)

Abstract

Thrombotic microangiopathy (TMA) syndromes represent a spectrum of illnesses that share common clinical and pathologic features of microangiopathic hemolytic anemia, thrombocytopenia, and organ injury from pathologic small-vessel thrombosis. At least nine primary TMA syndromes have been described and classified based on common probable etiologies, diagnostic criteria, and treatments. The most recognized of the TMA syndromes include thrombotic thrombocytopenic purpura (TTP) and hemolytic-uremic syndrome (HUS). Advanced laboratory techniques are required to distinguish between these syndromes; however, all patients should initially be treated with plasma exchange for presumed ADAMTS13 deficiency-mediated TMA. The authors present a case of a TMA syndrome in a Navy SEAL (Sea, Air, Land) candidate.

Keywords: syndrome, hemolytic-uremic; thrombotic thrombocytopenic purpura; microangiopathies, thrombotic; disseminated intravascular coagulation

PMID: 27734437

DOI: GUJX-4F6D

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Thrown for a Loop

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Urbaniak MK, Hampton K. 18(4). 148 - 148. (Journal Article)

Keywords:

PMID: 30566741

DOI: 4QW3-HS14

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Tick-Borne Encephalitis: An Update for the Special Operations Forces Provider

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Kaur H, Shishido AA. 23(2). 110 - 113. (Journal Article)

Abstract

Tick-borne encephalitis (TBE) is a severe disease caused by the tick-borne encephalitis virus (TBEV). TBEV is endemic throughout Eurasia and can cause persistent neurologic deficits and death. Special Operations Forces (SOF) participating in field exercises or operations in TBE-endemic countries are at significantly increased risk of infection. Unlike Lyme disease and other tick-borne illnesses, transmission of TBEV can be immediate, and early tick removal does not reduce the risk of infection. While there are no virus-specific treatments available, the US Food and Drug Administration (FDA) recently approved a TBE vaccine that has yet to be incorporated into formal Department of Defense (DoD) recommendations. SOF medical providers should be aware of this disease entity and consider the TBE vaccine when planning exercises and operations in areas of responsibility (AORs) with TBE-endemic countries. This review serves as a refresher and update on the epidemiology, transmission, and management of TBE for the SOF provider.

Keywords: Tick-borne encephalitis; tick-borne disease; vector; biphasic; vaccines; biodefense

PMID: 37126779

DOI: KAY2-1QTV

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Time For A Change: Recommended Mtoe Rank Adjustment For Army Special Operations Physician Assistants

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Detro JF. 10(3). 10 - 13. (Journal Article)

Keywords:

PMID: 21049430

DOI: BPXW-KWIW

Time for the Department of Defense to Field Video Laryngoscopy Across the Battlespace

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Schauer S, Long B, Fisher AD, Stednick PJ, Bebarta VS, Ginde AA, April MD. 23(4). 110 - 111. (Editorial)

Keywords: airway; military; video; laryngoscopy; trauma

PMID: 38029417

DOI: LZ5V-QDH4

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Timeline of Psychological and Physiological Effects Occurring During Military Deployment on a Medical Team

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Hall AB, Qureshi I, Wilson RL, Glasser JJ. 21(3). 118 - 122. (Journal Article)

Abstract

Background: The negative effects of deployment on military mental health is a topic of major interest. Predeployment and postdeployment assessments are common, but to date there has been little to no intradeployment assessment of military members. This study attempts to determine the physiological and psychiatric effects on Servicemembers over the course of deployment, to provide a baseline data set and to allow for better prediction, prevention, and intervention on these negative effects. Methods: A retrospective analysis was performed on physiological and psychiatric data collected on a single deployed medical team between 16 January 2020 and 12 July 2020. Patient health screening questionnaires (PHQ-9) and physiological measurements were completed serially twice weekly on five active-duty military volunteers for the entirety of a scheduled 6-month deployment. Results: Depression symptom development followed a linear trend (p = .0149) and severity followed a quadratic trend (p < .001) over a length of a deployment. Weight (p = .435) and pulse (p = .416) were not statistically altered. Mean arterial pressure (MAP) had a statistically significant reduction (p < .001). Conclusion: In this specific population, there was a linear relationship between time deployed and depression symptoms and severity. Depression symptom severity decreases toward the end of deployment but does not return to baseline before deployment's end.

Keywords: mental health; deployment; depression; military; physiology; blood pressure; weight; pulse

PMID: 34529818

DOI: P0Q2-0FO1

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Tinnitus, A Military Epidemic: Is Hyperbaric Oxygen Therapy The Answer?

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Baldwin TM. 09(3). 33 - 43. (Journal Article)

Abstract

Tinnitus is the phantom perception of sound in the absence of overt acoustic stimulation. Its impact on the military population is alarming. Annually, tinnitus is the most prevalent disability among new cases added to the Veterans Affairs numbers. Also, it is currently the most common disability from the War on Terror. Conventional medical treatments for tinnitus are well documented, but prove to be unsatisfying. Hyperbaric oxygen (HBO2) therapy may improve tinnitus, but the significance of the level of improvement is not clear. There is a case for large randomized trials of high methodological rigor in order to define the true extent of the benefit with the administration of HBO2 therapy for tinnitus.

Keywords:

PMID: 19739475

DOI: DKV9-ZBC0

To Cut or Not to Cut: That Is an Ultrasound Question!

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Poston WH, Hampton K. 17(3). 145 - 145. (Journal Article)

Keywords:

PMID: 28910485

DOI: RHA6-0CFR

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Tools to Assess and Reduce Injury Risk (Part 1)

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Knapik JJ. 17(3). 116 - 119. (Journal Article)

Abstract

Many injuries are preventable. Useful tools are available that can aid in assessing injury risks and developing methods to reduce these risks. This is part 1 of a two-part article that will discuss these tools, which include the Haddon Matrix, the 10 Countermeasure Strategies, the Injury Control Process, and the Army Risk-Management Process. The Haddon Matrix is 3 ® 3 table that, across the top (columns), provides an approach to conceptualizing injury prevention and control through modifications of the human, equipment, and environment; and, across rows, thinking about injury prevention and control before, during, and after the injury-producing event. The basic premise of the 10 Countermeasure Strategies is that injuries are largely due to energy exchanges between a person and the external environment in such a way that body cannot properly avoid or absorb the energy and anatomic structures are damaged. The Countermeasure Strategies are (1) eliminating the hazard altogether, (2) reducing the amount of the hazard, (3) preventing release of the hazard, (4) modifying the rate or spatial distribution of the hazard, (5) separating in space or time the hazard and the individual, (6) separating the individual from the hazard using a barrier, (7) modifying the basic qualities of the hazard, (8) strengthening the individual to make them more resistant to damage, (9) countering the damage done, and (10) stabilizing, healing, and rehabilitating the individual. Part 2 of this series will discuss the injury control process and the Army risk management process.

Keywords: injuries; injury prevention; Haddon Matrix; Counter-measure Strategies

PMID: 28910480

DOI: ZIEY-PPRS

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Tools to Assess and Reduce Injury Risk (Part 2)

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Knapik JJ. 17(4). 104 - 108. (Journal Article)

Abstract

Research has shown that many injuries are preventable if the operational environment is understood. Useful tools are available to assist in assessing injury risks and in developing methods to reduce risks. This is part 2 of a two-part article that discusses these tools, which include the Haddon Matrix, the 10 Countermeasure Strategies, the Injury Prevention Process, and the US Army Risk Management Process. Part 1 covered the Haddon Matrix and the 10 Countermeasure Strategies; part 2 outlines and provides examples of the Injury Prevention Process and the US Army Risk Management Process. The Injury Prevention Process is largely oriented to systematic research and involves (1) surveillance and survey to document the size of the injury problem, (2) identification of the causes of and risk factors for injuries, (3) intervention to identify what works to prevent injuries, (4) program implementation based on documented research, and (5) program evaluation to see how well the program works in the operational environment. The US Army Risk Management Process involves (1) identifying hazards, (2) assessing hazards, (3) developing controls for reducing hazards, (4) implementing controls, and (5) supervising and evaluating controls. There is overlap among the four approaches, but each has unique aspects that can be useful for thinking about and implementing injury prevention and control measures.

Keywords: US Injury Control Process; US Army Risk Management Process; injury prevention

PMID: 29256206

DOI: FK4G-VR9O

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Tourniquest

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Wall PL, Buising CM. 20(2). 22 - 23. (Journal Article)

Keywords:

PMID: 32573739

DOI: O997-KLTT

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Tourniquet Application by Urban Police Officers: The Aurora, Colorado Experience

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Jerome JE, Pons PT, Haukoos JS, Manson J, Gravitz S. 21(1). 71 - 76. (Journal Article)

Abstract

Background: Uncontrolled external hemorrhage is a common cause of preventable death. The Hartford Consensus recommendations presented the concept of a continuum of care, in which police officers should be considered an integral component of the emergency medical response to active shooter incidents. Recent publications have reported individual cases of tourniquet application by police officers. This report analyzed all documented cases of hemorrhage control using tourniquets applied by police officers in a single large metropolitan police department. Methods: A retrospective computerized search of all public safety communications center reports and police officer documentation for cases of tourniquet application was conducted by searching for the word "tourniquet." Each case was evaluated for indication and appropriateness using Stop The Bleed criteria for tourniquet placement. In addition, police response time was compared to emergency medical services (EMS) response time in an effort to determine if there was a time difference in response to the bleeding patient that could potentially impact patient outcomes. Results: Forty- three cases were identified over the 6-year period ending in December 2019. The majority of cases involved gunshot wounds and most were civilian victims. Injured police officers accounted for two cases (gunshot wound and dog bite). Review of the officers' narratives indicated that most applications appeared justified using the Stop The Bleed criteria (two cases were questionable if a tourniquet was necessary and one may have been placed in an incorrect location). On average, police arrived 4 minutes sooner than EMS did. Conclusion: Several reports in the literature document the success of police officer application of tourniquets to control limb hemorrhage. Most of the reports involved a small number of case reports. This is the largest case series to date from a single urban police department.

Keywords: tourniquet; hemorrhage control; police; emergency medical services

PMID: 33721310

DOI: 9YEC-A5CE

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Tourniquet Conversion: A Recommended Approach in the Prolonged Field Care Setting

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Drew B, Bird D, Matteucci M, Keenan S. 15(3). 81 - 85. (Journal Article)

Abstract

Life-saving interventions take precedence over diagnostic maneuvers in the Care Under Fire stage of Tactical Combat Casualty Care. The immediate threat to life with an actively hemorrhaging extremity injury is addressed with the liberal and proper use of tourniquets. The emphasis on hemorrhage control has and will continue to result in the application of tourniquets that may not be needed past the Care Under Fire stage. As soon as tactically allowable, all tourniquets must be reassessed for conversion. Reassessment of all tourniquets should occur as soon as the tactical situation permits, but no more than 2 hours after initial placement. This article describes a procedure for qualified and trained medical personnel to safely convert extremity tourniquets to local wound dressings, using a systematic process in the field setting.

Keywords: prolonged field care; tourniquets; tourniquet conversion; Tactical Combat Casualty Care

PMID: 26360360

DOI: IJ9C-6AIF

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Tourniquet Effectiveness When Placed Over the Joint Service Lightweight Integrated Suit Technology

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Peponis T, Ramly E, Roth KA, King DR. 16(2). 17 - 19. (Journal Article)

Abstract

Background: Chemical, biological, radiological, and nuclear threats (CBRNs) are uncommon; however, Special Operations Forces (SOF) are likely at the highest risk for tactical exposure. In the event of exposure, SOF will rely on the Joint Service Lightweight Integrated Suit Technology (JSLIST) for survival. Doctrine dictates that a tourniquet should be applied over the JSLIST after a severe limb injury with hemorrhage. There is no evidence in the literature that the Combat Application Tourniquet (C-A-T), which is currently the most widely available tourniquet on the battlefield, can effectively occlude arterial blood flow when applied over the JSLIST. We hypothesized that C-A-T application over the JSLIST would be ineffective at occluding arterial blood flow in the lower extremity. Materials and Methods: Following institutional review board approval, 20 healthy volunteers were recruited to participate. All volunteers wore the G3 Combat Pant and they donned the JSLIST. First, an operating room pneumatic tourniquet (gold standard) was applied in the proximal thigh and inflated to 300mmHg. Distal arterial interrogation was performed by examination of distal pulses and noninvasive arterial plethysmography wave-form analysis. After a 1-hour recovery period, the C-A-T was applied and tightened. A double routing technique was used, with three 180° turns of the windlass. The same distal interrogation followed. Half of the volunteers had the pneumatic tourniquet applied first, and the other half had the C-A-T applied first. Results: All volunteers had palpable pulses at baseline despite a wide range in volunteer body mass index. Distal pulses were absent in all volunteers following inflation of the pneumatic tourniquet as well as tightening of the C-A-T. The observed difference between the mean amplitude of plethysmographic waveforms was not different. Conclusion: The C-A-T effectively occludes arterial flow in the lower extremity, even when applied over the JSLIST. This finding supports existing military doctrine for tourniquet application over the JSLIST in the nonpermissive CBRN environment to control extremity exsanguination.

Keywords: tourniquet; hemorrhage; Combat Application Tourniquet; Joint Service Lightweight Integrated Suit Technology

PMID: 27450598

DOI: E9CM-EGUR

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Tourniquet Pressures: Strap Width and Tensioning System Widths

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Wall PL, Coughlin O, Rometti MR, Birkholz S, Gildemaster Y, Grulke L, Sahr SM, Buising CM. 14(4). 19 - 29. (Journal Article)

Abstract

Background: Pressure distribution over tourniquet width is a determinant of pressure needed for arterial occlusion. Different width tensioning systems could result in arterial occlusion pressure differences among nonelastic strap designs of equal width. Methods: Ratcheting Medical Tourniquets™ (RMTs; m2® inc., http://www.ratcheting buckles.com) with a 1.9cm-wide (Tactical RMT) or 2.3cmwide (Mass Casualty RMT) ladder were directly compared (16 recipients, 16 thighs and 16 upper arms for each tourniquet ® 2). Then, RMTs were retrospectively compared with the windlass Combat Application Tourniquet (C-A-T ["CAT"], http://combattourniquet.com) with a 2.5cm-wide internal tensioning strap. Pressure was measured with an air-filled No. 1 neonatal blood pressure cuff under each 3.8cm-wide tourniquet. Results: RMT circumferential pressure distribution was not uniform. Tactical RMT pressures were not higher, and there were no differences between the RMTs in the effectiveness, ease of use ("97% easy"), or discomfort. However, a difference did occur regarding tooth skipping of the pawl during ratchet advancement: it occurred in 1 of 64 Tactical RMT applications versus 27 of 64 Mass Casualty RMT applications. CAT and RMT occlusion pressures were frequently over 300mmHg. RMT arm occlusion pressures (175-397mmHg), however, were lower than RMT thigh occlusion pressures (197-562mmHg). RMT effectiveness was better with 99% reached occlusion and 1% lost occlusion over 1 minute versus the CAT with 95% reached occlusion and 28% lost occlusion over 1 minute. RMT muscle tension changes (up to 232mmHg) and pressure losses over 1 minute (24 ± 11mmHg arm under strap to 40 ± 12mmHg thigh under ladder) suggest more occlusion losses may have occurred if tourniquet duration was extended. Conclusions: The narrower tensioning system Tactical RMT has better performance characteristics than the Mass Casualty RMT. The 3.8cmwide RMTs have some pressure and effectiveness similarities and differences compared with the CAT. Clinically significant pressure changes occur under nonelastic strap tourniquets with muscle tension changes and over time periods as short as 1 minute. An examination of pressure and occlusion changes beyond 1 minute would be of interest.

Keywords: tourniquet; hemorrhage control; first aid; emergency treatment

PMID: 25399364

DOI: IT3C-9I89

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Tourniquet Use In Combat Trauma: Uk Military Experience

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Brodie S, Hodgetts TJ, Ollerton J, McLeod J, Lambert P, Mahoney P. 09(1). 74 - 77. (Previously Published)

Previously published in J R Army Med Corps 2007; 153(4): 310-313. Reprinted in the JSOM with kind permission of the editor of the Journal of the Royal Army Medical Corps’.

Abstract

Aim: To determine the prevalence of tourniquet use in combat trauma, the contribution to lives saved and the complications of their use in this environment. Population: All casualties treated at UK field hospital facilities in Iraq and Afghanistan and meeting criteria for entry into UK Joint Theatre Trauma Registry (JTTR) from 04 Feb 03 to 30 Sep 07. Methods: Cases were identified from UK JTTR. Casualties from Permanent Joint Overseas Bases (PJOBs) were excluded. ISS, NISS, TRISS and ASCOT were calculated automatically within JTTR from AIS 2005 (Military) codes. Results: 1375 patients met UK JTTR entry criteria for the period specified (excluding PJOBs). 70/1375 patients (5.1%) were treated with one or more tourniquets (total 107 tourniquet applications). 61/70 (87%) survived their injuries. 17/70 (24%) patients had 2 or more tourniquets applied. 64/70 patients received a tourniquet after April 2006, when tourniquets were introduced as an individual first aid item. 43/70 (61%) patients were UK military. Conclusions: ISS and TRISS are poorly representative of injury severity and outcome for combat trauma involving isolated multiple limb injuries and cannot be used to discriminate whether a tourniquet is life-saving. The presence of severe isolated limb injuries, profound hypovolaemic shock and the requirement for massive transfusion reasonably identifies a cohort where the use of one or more tourniquets pre-hospital to control external bleeding can be said to be life-saving.

Keywords:

PMID: 19813352

DOI: 6S1B-8KAG

Tourniquet Use on a Pediatric Patient

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Gattere M, Scaffei N, Gozzetti L, Alessandrini M. 21(1). 120 - 123. (Journal Article)

Abstract

As a result of the increasing use and application of military tourniquets in civilian settings, it is necessary to evaluate the size and effectiveness of the equipment on patients that differ from the military-aged population for whom the devices have been primarily created. This case report describes the application of a tourniquet on a pediatric patient while also profiling a common situation in which the Combat Application Tourniquet GEN 7 (C-A-T Resources) might be used in civilian care systems. The case is that of a 14-month-old child who suffered a limb amputation secondary to a road accident in Italy and the ensuing life-saving treatment. The intervening nurse at the scene had been trained on the use of hemorrhage-control devices through the American College of Surgeons "Stop the Bleed" campaign.

Keywords: tourniquet; hemorrhage; child; pediatric; military personnel; accidents; amputation; Stop the Bleed; NATO Special Operations Combat Medic; NSCOM

PMID: 33721320

DOI: T8HM-PJV5

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Tourniquets For The Control Of Traumatic Hemorrhage: A Review Of The Literature

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Richey SL. 09(1). 56 - 64. (Previously Published)

Previously published in the 24 October 2007 World Journal of Emergency Surgery 2007, 2:28. This article is available from: http://www.wjes.org/content/2/1/28. Republished in JSOM with permission.

Keywords:

PMID: 19813349

DOI: YIEG-FXLT

Tourniquets Last to Tourniquets First

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Kragh JF, Aden JK, Dubick MA. 20(2). 20 - 21. (Journal Article)

Keywords:

PMID: 32573738

DOI: FEEA-WXO7

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Tourniquets USA: A Review of the Current Literature for Commercially Available Alternative Tourniquets for Use in the Prehospital Civilian Environment

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Martinson J, Park H, Butler FK, Hammesfahr R, DuBose JJ, Scalea TM. 20(2). 116 - 122. (Journal Article)

Abstract

The American College of Surgeons' "Stop the Bleed" (STB) campaign emphasizes how to apply the Combat Application Tourniquet (CAT), a device adopted by the military to control extremity hemorrhage. However, multiple commercially available alternatives to the CAT exist, and it would be helpful for instructors to be knowledgeable about how these other models compare. A PubMed search from January 2012 to January 2020 cross-referenced with a Google search for "tourniquet" was performed for commercially available tourniquets that had been trialed against the CAT. Windlass-type models included the Special Operations Forces Tactical Tourniquet (SOFT-T), the SOFT-T Wide (SOFFT-W), the SAM-XT tourniquet, the Military Emergency Tourniquet (MET), and the Tactical Medical Tourniquet (TMT). Elastic-type tourniquets included were the Stretch, Wrap, And Tuck Tourniquet (SWAT-T), the Israeli Silicone Tourniquet (IST), and the Rapid Activation Tourniquet System (RATS). Ratchet-type tourniquets included were the Ratcheting Medical Tourniquet (RMT) and TX2/TX3 tourniquets, and pneumatic-type tourniquets were the Emergency and Military Tourniquet (EMT) and Tactical Pneumatic Tourniquet (TPT). This review aims to describe the literature surrounding these models so that instructors can help laypeople make more informed purchases, stop the bleed, and save a life.

Keywords: tourniquets; alternate; Stop the Bleed; review

PMID: 32573747

DOI: CT9D-TMZE

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Toward A Serious Game to Help Future Military Doctors Face Mass Casualty Incidents

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de Lesquen H, Paris R, Fournier M, Cotte J, Vacher A, Schlienger D, Avaro JP, de La Villeon B. 23(2). 88 - 93. (Journal Article)

Abstract

Introduction: To prepare military doctors to face mass casualty incidents (MCIs), the French Army Health Service contributed to the development of TRAUMASIMS, a serious game (SG) for training medical responders to MCIs. Methods: French military doctors participated in a three-phase training study. The initial war trauma training was a combination of didactic lectures (Phase 1), laboratory exercises (Phase 2), and situational training exercises (STX) (Phase 3). Phase 1 lectures reviewed French Forward Combat Casualty Care (FFCCC) practices based on the acronym MARCHE (Massive bleeding, Airway, Respiration, Circulation, Head, hypothermia, Evacuation) for the detection of care priorities and implementation of life-saving interventions, triage, and medical evacuation (MEDEVAC) requests. Phase 2 was a case-control study that consisted of a traditional text-based simulation of MCIs (control group) or SG training (study group). Phase 3 was clinical: military students had to simultaneously manage five combat casualties in a prehospital setting. MCI management was evaluated using a standard 20-item scale of FFCCC benchmarks, 9-line MEDEVAC request, and time to evacuate the casualty collection point (CCP). Emotional responses of study participants were secondarily analyzed. Results: Among the 81 postgraduate military students included, 38 took SG training, and 35 trained with a text-based simulation in Phase 2. Regarding the error rates made during STX (Phase 3), SG improved FFCCC compliance (11.9% vs. 23.4%; p < .001). Additionally, triage was more accurate in the SG group (93.4% vs. 88.0%; p = .09). SG training mainly benefited priority and routine casualties, allowing faster clearance of the CCP (p = .001). Stress evaluations did not demonstrate any effect of immersive simulation. Conclusion: A brief SG-based curriculum (2 hours) improved FFCCC performance and categorization of casualties in MCI STX.

Keywords: traumatology; damage control; triage; mass casualty; simulation; medical education

PMID: 37126778

DOI: IJCP-BLY6

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Tragedy Into Drama: An American History of Tourniquet Use in the Current War

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Kragh JF, Walters TJ, Westmoreland T, Miller RM, Mabry RL, Kotwal RS, Ritter BA, Hodge DC, Greydanus DJ, Cain JS, Parsons DL, Edgar EP, Harcke HT, Billings S, Dubick MA, Blackbourne LH, Montgomery HR, Holcomb JB, Butler FK. 13(3). 5 - 25. (Journal Article)

Abstract

Background: Although the scientific results of recent tourniquet advances in first aid are well recorded, the process by which tourniquet use advances were made is not. The purpose of the present report is to distill historical aspects of this tourniquet story during the current wars in Afghanistan and Iraq to aid scientists, leaders, and clinicians in the process of development of future improvements in first aid. Methods: The process of how developments of this tourniquet story happened recently is detailed chronologically and thematically in a "who did what, when, where, why, and how" way. Results: Initially in these wars, tourniquets were used rarely or were used as a means of last resort. Such delay in tourniquet use was often lethal; subsequently, use was improved incrementally over time by many people at several organizations. Three sequential keys to success were (1) unlocking the impasse of enacting doctrinal ideas already approved, (2) reaching a critical density of both tourniquets and trained users on the battlefield, and (3) capturing their experience with tourniquets. Other keys included translating needs among stakeholders (such as casualties, combat medics, providers, trainers, and decision-makers) and problem-solving logistic snags and other issues. Eventually, refined care was shown to improve survival rates. From all medical interventions evidenced in the current wars, the tourniquet broke rank and moved to the forefront as the prehospital medical breakthrough of the war. Conclusion: The recorded process of how tourniquet developments in prehospital care occurred may be used as a reference for parallel efforts in first aid such as attempts to improve care for airway and breathing problems.

Keywords: hemorrhage; first aid; damage control; resuscitation; tourniquet

PMID: 24048983

DOI: QN66-A9MG

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Train to Failure

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Kragh JF. 14(2). 111 - 111. (Interview)

Abstract

MSG Dennis Lyons of USASOC on Medical Training and Learning

Keywords:

DOI:

Transfusion Medicine

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Johnson TR, Kacprowicz RF, Mosely DS. 07(3). 22 - 30. (Journal Article)

Abstract

Far-forward blood transfusion is a controversial topic. Transfusion of stored packed red blood cells (pRBCs) has come under increasing scrutiny in civilian trauma centers and may have fewer benefits than previously believed. The unnecessary transfusion of stored blood products has the potential to do significant harm, particularly when the blood has been stored for the long periods typically seen in the combat theater. Therefore, when transfusion is considered for an acutely injured patient, careful attention must be paid to the risks, benefits, and indications for transfusion. Once transfusion therapy is chosen, the provider must carefully adhere to established guidelines and procedures to minimize potential harm to the patient.

Keywords:

DOI:

Trauma Anesthesia Plan For Non-permissive Environments

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Tobin JM. 09(4). 32 - 35. (Journal Article)

Abstract

The current war has, like past conflicts, presented the medical community with opportunities to innovate novel approaches to old problems. Although trauma anesthesia is provided adequately in the majority of cases, a standardized approach for treating these complex and critically ill patients is lacking. While this technique was developed for anesthesia in non-permissive environments, the principles suggested here could serve as a template for trauma anesthesia in other environments as well. The algorithm is designed as a standardized protocol in an effort to simplify the approach to these complex patients who often present in a dynamic environment. A list of required equipment is included to serve as a guide for preparation prior to employment of the algorithm.

Keywords:

PMID: 20112646

DOI: U9KB-M0ZE

Traumatic Amputation Of A Finger- A Stark Reminder

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Calvillo A, Spivey JL. 07(3). 1 - 4. (Journal Article)

Abstract

Because service members wear rings while on military duty, the potential for undue injury to the hands and fingers of service members is increased. Therefore, it is important to be informed about how and when they occur. Soldiers wear rings while on duty because they forget to take them off, don't want to lose them, or, for marital and other varying reasons. This article will show the consequences of ring related injuries.

Keywords:

DOI:

Traumatic Brain Injury Management in Prolonged Field Care

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van Wyck D, Loos PE, Friedline N, Stephens D, Smedick BC, McCafferty R, Rush SC, Keenan S, Powell D, Shackelford S. 17(3). 130 - 140. (Journal Article)

Keywords:

PMID: 28910483

DOI: 7R6W-1M9U

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Traumatic Brain Injury: Analysis of Functional Deficits and Posthospital Rehabilitation Outcomes

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Lewis FD, Horn GJ. 13(3). 56 - 61. (Journal Article)

Abstract

Background: Advances in emergency medicine, both in the field and in trauma centers, have dramatically increased survival rates of persons sustaining traumatic brain injury (TBI). However, these advances have come with the realization that many survivors are living with significant residual deficits in multiple areas of functioning, which make the resumption of a quality lifestyle extremely difficult. To this point, TBI has recently been characterized as a chronic disease. As with other chronic diseases, TBI is often causative of persistent disabling symptoms in multiple organ systems. Therefore, posthospital residential rehabilitation programs have emerged to treat these symptoms with the goal of helping these individuals regain function and live more productive and independent lives. Purpose: This study examined the nature and severity of residual deficits experienced by a group of 285 brain-injured individuals and evaluate the efficacy of posthospital residential rehabilitation programs in treating those deficits. Method: Participants consisted of 285 individuals who had sustained a TBI and, due to multiple residual deficits, were unable to care for themselves, necessitating admission to residential posthospital rehabilitation programs. All participants were evaluated at admission and discharge on the Mayo-Portland Adaptability Inventory-Version 4 (MPAI-4). The MPAI-4, developed specifically for persons with acquired brain injury, measures 29 areas of function often affected by TBI. Results: From the 29 skills evaluated, the 12 most often rated as causing the greatest interference with function were identified. Of these skills, the cognitive deficits including memory, attention/concentration, novel problem solving, and awareness of deficits were highly correlated with disruption in performing everyday societal roles. The impact of treatment for reducing the level of disability in these areas was statistically significant, t(284) = 17.43, p < .0001. Improvement was significant even for participants admitted more than 1 year postinjury, t(78) = 8.05, p < .0001. Conclusions: Skill deficits interfering with reintegration into home and community are highly interrelated and should be treated with the understanding that progress in one area may be dependent on change in another area. Cognitive skills including memory, attention/ concentration, novel problem solving, and awareness of deficits were highly correlated with measures of overall functional outcome. Posthospital programs using a multidisciplinary treatment approach achieved significant reduction in disability from program admission to discharge. The benefits of these programs were realized even for the most chronically-impaired participants.

Keywords: traumatic brain injury; Mayo-Portland Adaptability Inventory - Version 4; prehospital residential rehabilitation programs; acquired brain injury

PMID: 24048991

DOI: ATYP-5WSB

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Traumatic Brain Injury: Its Outcomes On High Altitude

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Ismailov RM, Lytle JM. 16(1). 67 - 69. (Editorial)

Keywords:

PMID: 27045498

DOI: XB41-XWP1

Traumatic Pelvic Hematoma After a Military Static-Line Parachute Jump: A Case Series

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Barbee GA, Booms Z. 14(3). 1 - 6. (Journal Article)

Abstract

The authors report five cases of pelvic hematoma without associated pelvic fracture after military static-line parachute operations, a significantly underreported injury. The case reports and discussion include initial emergency department presentation, stabilization requirements, and imaging, disposition, and management recommendations. Data were collected retrospectively through review of medical records from a single institution over the course of a single calendar year, 2012-2013. Pelvic hematoma should be strongly considered in the patient with lower abdominal, hip, or pelvic pain after blunt injury from parachute landing fall even in the absence of associated fracture. The cases discussed display this underreported injury and highlight the frequent necessity for admission to a high-acuity care center for close monitoring.

Keywords: hematoma; retroperitoneal hemorrhage; trauma; vertical shear injury; military static-line parachute jump

PMID: 25344704

DOI: Q5J1-T59F

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Traumatic Visual Loss and a Limitation of Point-of-Care Ocular ultrasound: A Case Report

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Nydam T, Tanksley S. 13(1). 55 - 57. (Journal Article)

Abstract

Incorporation of point-of-care ultrasound into the skill set of Special Operations medical providers should come with an appreciation of the potential limitations of the technology. We present a case of a U.S. Army Special Forces Soldier who suffered traumatic monocular vision loss after being struck in the eye during a combatives tournament. Evaluation in the emergency department (ED) included an unremarkable ocular ultrasound, despite a high clinical suspicion of intraocular pathology. Ophthalmologic consultation was obtained emergently. Optical coherence topography and a dilated fundoscopic examination were performed, which revealed a small subretinal hemorrhage. We will review the history of ocular ultrasound and its sensitivity to detect intraocular pathology. We will also emphasize the need to obtain specialty consultation when the clinical suspicion for intraocular pathology is high despite a negative ocular ultrasound.

Keywords:

PMID: 23526323

DOI: H01L-L6O7

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Treatment of Psoriasis in the Deployed Setting

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Bongiorno MA, Rivard SS, Meyerle JH. 15(2). 12 - 15. (Journal Article)

Abstract

Psoriasis is a chronic immune-mediated disorder that can be triggered by environmental changes, illness, smoking, or medications. This case describes a 25-year-old, activeduty Marine Corps Sergeant with a severe perideployment psoriatic flare, and illustrates treatment limitations, restricted access to specialized care, and the importance of mitigating triggers in the deployed setting.

Keywords: psoriasis; psoriasis, plaque; psoriasis, guttate; arthritis, psoriatic; smoking, cessation; ultraviolet light, exposure; deployment; military provider

PMID: 26125160

DOI: 4DC6-K44Y

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Treatment of Sea Urchin Injuries

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King DR, Larentzakis A. 14(2). 56 - 59. (Journal Article)

Abstract

Sea urchin injuries can be sustained in a variety of environments in which U.S. Forces are operating, and familiarity with this uncommon injury can be useful. Injuries by sea urchin spines can occur during military activities close to rocky salt aquatic ecosystems via three mechanisms. The author describes these mechanisms and discusses the diagnosis, management, and treatment of sea urchin injuries.

Keywords: sea urchin; spines; laser; ablation

PMID: 24952041

DOI: M5U1-2Y40

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Trigger-Point Dry Needling for the SOF Medic

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Cavett T, Solarczyk JK. 16(4). 33 - 39. (Journal Article)

Abstract

We propose that trigger-point dry needle (TrP-DN) therapy is an effective low-risk treatment for pain associated with myofascial trigger points (MTrP), and should be incorporated into the Special Operations Forces (SOF) Medic's scope of practice. Furthermore, TrP-DN therapy can be used as a treatment adjunct on the SOF continuum of care, providing analgesia and increased tolerance for rehabilitative therapy, thereby facilitating improved patient outcomes and faster return to operational readiness. The incidence of musculoskeletal injuries in the SOF community is discussed, as are available treatment options TrP-DN methods, a case study of a Soldier deployed to Afghanistan, the science behind the subject of MTrP and TrP-DN, and the risks associated with TrP-DN and how we can mitigate them effectively. Caution should be used in the interpretation of a body of literature based largely on case studies. Although the amount of published evidence in support of the potential benefits of TrP-DN is growing, larger, randomized, placebo-controlled trials and studies that evaluate the effects of TrP-DN in a methodologically rigorous and statistically significant way are needed. Based on anecdotal evidence of and personal experience with the success of the therapy, as well as its growing use within both civilian and military medicine, the possible therapeutic benefit of TrP-DN is relevant for the SOF community.

Keywords:

PMID: 28088815

DOI: 9S1K-PQVG

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Tularemia

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Burnett MW. 16(4). 71 - 73. (Journal Article)

Keywords: tularemia; Francisella tularensis

PMID: 28088821

DOI: MD7M-U4U1

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Tympanic Membrane Perforation In Ied Blasts

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Depenbrock P. 08(2). 51 - 54. (Journal Article)

Abstract

Traumatic tympanic membrane (TM) perforation is a common finding in victims of IED blasts. Frequently it goes undiagnosed by medical providers on initial evaluation. Hearing loss, tinnitus, and vertigo are common complaints from Soldiers who have experienced acoustic trauma. Although symptoms are usually transient, their persistence is a cause for concern. Treatment of a ruptured TM is usually expectant. In certain instances specialty consultation is required. Since primary blast and neurologic injuries can accompany traumatic TM perforation, physicians should maintain a high index of suspicion for their presence. This article aims to address the pathophysiology, diagnosis, treatment, and associated complications of blast-induced tympanic membrane perforation. Objectives 1. Understand the biophysics of primary blast injury and how to prevent blast-induced acoustic trauma. 2. Understand the common presenting signs and symptoms of tympanic membrane rupture. 3. Understand the treatment of tympanic membrane rupture and the indications for specialty referral. 4. Understand the long-term complications associated with traumatic tympanic membrane rupture.

Keywords:

DOI:

U.S. Military Experience With Junctional Wounds in War From 2001 to 2010

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Kragh JF, Dubick MA, Aden JK, McKeague AL, Rasmussen TE, Billings S, Blackbourne LH. 13(4). 76 - 84. (Journal Article)

Abstract

Background: In 2012, we reported on junctional wounds in war, but only of the few injuries that were critically severe. Objective: The purpose of the present study is to associate a wide range of junctional wounds and casualty survival over a decade in order to evidence opportunities for improvement in trauma care within a large healthcare system. Methods: We retrospectively surveyed data from a military trauma registry. We associated survival and injuries at the junction of the trunk and appendages in the current war (2001 to 2010). Results: The junctional injury rate rose 14-fold from 0%, its minimum in 2001, to 5%, its maximum in 2010. Of the 833 casualties with junctional injury in the study, the survival rate was 83%; its change was not statistically significant over time. Most casualties had severe extremity injuries and associated injuries of other body regions such as the face and head. Conclusions: Junctional injury is common, severe, disabling, and lethal. The findings of this study may increase awareness of junctional injury. Opportunities for improvement which we identified included further research on the future addition of junctional codes (such as neck diagnoses) in order to align research methods to clinical care.

Keywords: tourniquet; trauma; resuscitation; injuries; wounds

PMID: 24227565

DOI: 736K-8TI9

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Ultramobile Surgical Set for Austere Damage Control Surgery

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Lundy JB, Sparkman BK, Sleeter JJ, Steinberger Z, Remick KN. 21(4). 118 - 123. (Journal Article)

Abstract

The authors describe an equipment list for an ultramobile, surgeon-carried equipment set that is specifically designed for missions that require the extremes of constraints on personnel and resources conducted outside the ring of golden hour access to damage control surgery (DCS) capabilities.

Keywords: damage control surgery; damage control resuscitation; surgical equipment; austere; packing; pack; backpack; trauma; surgeon; surgery

PMID: 34969142

DOI: 2SXH-R9ZS

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Ultrasonography Performed by Military Nurses in Combat Operations: A Perspective for the Future?

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Balasoupramanien K, Comat G, Renard A, Meusnier J, Montigon C, Pitel A, Bascou M, Dubourg R, Cazes N. 22(3). 65 - 69. (Journal Article)

Abstract

Introduction: In current French military operations, it is not uncommon for military nurses (MNs) alone to be required to support soldiers in isolated areas. At a time when advanced practice nurses in the civilian sector develop extended skills, we asked MNs about their willingness to be trained in pointof- care ultrasound (POCUS). Methods: We conducted a webbased survey from 1 November 2018 to 1 December 2018, including all MNs deployed in Operation Barkhane. The questionnaire, sent by e-mail, aimed to describe the willingness of MNs to be trained in POCUS. Their opinion on the usefulness of this training, the situations, and ultrasound (US) targets that seemed most useful to them were also studied. Results: Thirty of 34 questionnaires were completed. On average, MNs had 7.4 years of practice and had been deployed three times for military operations. Five MNs reported having had informal training in clinical US by the military physicians (MPs) they work with and had performed POCUS in real-life situations; 24 (96%) of the untrained MNs wanted to be trained. Twenty- nine (96%) of the MNs felt that there was added value in knowing how to perform POCUS, especially in operations and in isolated posts without an MP. Focused assessment with sonography for trauma and pleural and renal US were the targets considered most useful to them, in that order. Conclusion: MNs are interested in learning POCUS and say it would be beneficial for the patient. Available scientific data tend to validate their ability after a brief training course to perform reliable, targeted US examinations in the field.

Keywords: ultrasonography; military medicine; military nurse

PMID: 35862838

DOI: X9TX-BLZQ

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Ultrasound Detection Of Pneumothorax With Minimally Trained Sonographers: A Preliminary Study

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Monti JD, Younggren B, Blankenship R. 09(1). 43 - 46. (Journal Article)

Abstract

Background: Prompt recognition and treatment of a tension pneumothorax is critical to reducing mortality in both military and civilian settings. Physician assistants, Special Operations Forces (SOF) and conventional force Medics are often the first medical providers to care for combat trauma patients with penetrating chest trauma and frequently have limited diagnostic capabilities available to them due to mission constraints. The purpose of this study is to examine the potential for non-physician providers to determine the absence or presence of a pneumothorax in a porcine model, with the use of a portable ultrasound machine, after receiving minimal training. Methods: Physician assistants, SOF and conventional force Medics, veterinary technicians, and food service inspectors, all naïve to ultrasound, were recruited for this study. Participants underwent a brief presentation on detection of a pneumothorax by ultrasound and were then asked to perform a thoracic ultrasound examination on euthanized, ventilated swine. Some of the swine were induced with a pneumothorax prior to these examinations, and all participants were blinded to the absence or presence of a pneumothorax. Results: Twenty-two participants examined a total of 44 hemithoraces. A total of 21 out of 22 pneumothoraces were correctly identified with one false-negative. All 22 normal hemithoraces were correctly identified for a sensitivity of 95.4% (95 % CI 0.75-0.99), and a specificity of 100% (95% CI 0.81-1.00), with PPV of 100%, NPV of 95.6%. Conclusions: Non-physician healthcare providers can accurately detect a pneumothorax with portable ultrasound after receiving minimal focused training.

Keywords: ultrasound; pneumothorax; military

PMID: 19813348

DOI: 9GWU-MQO4

Ultrasound In Special Operations Medicine: A Proposal For Applicatoin And Training

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Keenan S, Morgan AR, Blankenship R, Hubler DA. 08(4). 47 - 54. (Journal Article)

Abstract

Emergency ultrasound is gaining ground as a powerful diagnostic tool in the hospital setting. With ever-expanding indications, validated with scientific studies, it has become an accepted and relied-upon technology with daily use in emergency departments, and surgical and critical care settings around the world. Additionally, with the current worldwide combat operations and the resultant deployment of far-forward medical assets, the technology's use outside of the standard hospital setting has been demonstrated. This technology, however, has had limited use outside the forward surgical or medical officer-positioned assets, despite being standard equipment with some Special Operations units. We hope to stimulate discussion about its use in Special Operations medicine by educating the reader to the possibilities of this technology, and suggesting a reasonable training and fielding plan for its optimal use.

Keywords:

DOI:

Ultrasound Localization of Resuscitative Endovascular Balloon Occlusion of the Aorta in a Human Cadaver Model

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Lopachin T, Treager CD, Sulava EF, Stuart SM, Bohan ML, Boboc M, Fernandez P, Bianchi WD, McGowan AJ, Friedrich EE. 23(2). 73 - 77. (Journal Article)

Abstract

Objective: Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a method of gaining proximal control of noncompressible torso hemorrhage (NCTH). Catheter placement is traditionally confirmed with fluoroscopy, but few studies have evaluated whether ultrasound (US) can be used. Methods: Using a pressurized human cadaver model, a certified REBOA placer was shown one of four randomized cards that instructed them to place the REBOA either correctly or incorrectly in Zone 1 (the distal thoracic aorta extending from the celiac artery to the left subclavian artery) or Zone 3 (in the distal abdominal aorta, from the aortic bifurcation to the lowest renal artery). Once the REBOA was placed, 10 US-trained locators were asked to confirm balloon placement via US. The participants were given 3 minutes to determine whether the catheter had been correctly placed, repeating this 20 times on two cadavers. Results: Overall, US exhibited an average sensitivity of 83%, specificity of 76%, and accuracy of 80%. For Zone 1, US showed a sensitivity of 78% and specificity of 83%, and for Zone 3, a sensitivity of 88% and specificity of 76%. In addition, US exhibited a likelihood positive ratio (LR+) of 3.73 and a likelihood negative ratio (LR-) of 0.22 for either position, with similar numbers for Zone 1 (+4.57, -0.26) and Zone 3 (+3.16, -0.16). Conclusion: Ultrasound could prove to be a useful tool for confirming placement of a REBOA catheter, especially in austere environments.

Keywords: trauma; ultrasound; REBOA

PMID: 37169530

DOI: 8MDD-BY4I

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Ultrasound-Guided Airway Management in the Austere Setting

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Rapp J, Hampton K. 17(1). 130 - 130. (Journal Article)

Keywords: sonography; airway management

PMID: 28285491

DOI: 05XH-CMSK

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Ultrasound-Guided Triage

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Dare C, Hampton K. 16(4). 117 - 117. (Journal Article)

Keywords: ultrasound transfer; triage

PMID: 28088831

DOI: CCXG-RD3J

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Unconventional Resilience: A Strategic Framework

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Jeschke EA, Baker JB, Wyma-Bradley J, Dorsch J, Huffman SL. 23(3). 58 - 62. (Journal Article)

Abstract

This will be the second in a series of nine articles in which we discuss findings from our ethnographic study entitled "The Impact of Catastrophic Injury Exposure on Resilience in Special Operations Surgical Teams." Our goal in this article is to establish the practical importance of redefining resilience within a strategic framework. Our bottom-up approach to strategy development explores unconventional resilience as an integrated transformational process that promotes change-agency through the force of movement. Synthesis of empirical data derived from participant interviews and focus groups highlights conceptual attributes that make up the essential components of this framework. To achieve our goal, the authors (1) briefly remind readers how we have problematized conventional resilience; (2) explain how we analyzed qualitative quotes to extrapolate our definition of unconventional resilience; and (3) describe in detail our strategic framework. We conclude by gesturing to why this strategic framework is applicable to practical performance of all Special Operation Forces (SOF) medics.

Keywords: resilience; performance; strategic; SOF medic; transformational

PMID: 37169526

DOI: 2W3U-2XHB

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Unconventional Resilience: An Operational Model

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Jeschke EA, Baker JB, Wyma-Bradley J, Dorsch J, Huffman SL. 23(4). 64 - 68. (Journal Article)

Abstract

This is the third of nine planned papers drawn from the findings of our ethnographic study entitled "The Impact of Catastrophic Injury Exposure on Resilience in Special Operations Surgical Teams." Building from our strategic framework, this paper will establish that resilience is better understood as cohesive adaptation within a Special Operation Forces (SOF) cultural ecosystem. Exploring unconventional resilience as the inter-relationship across the organization, team, and individual, we will use qualitative quotes to describe the ecosystem of dynamic freedom of maneuver in ambiguity. To achieve our goals, we will: 1) compare conventional and unconventional resilience to operationalize the components of our strategic framework; 2) use qualitative quotes to show how the ecosystem of unconventional resilience functions at each level supporting our operational model; and 3) describe how the operational model of unconventional resilience links to tactical performance through five social determinants. We conclude by gesturing to how transformational change-agency applies to practical performance of all SOF medics.

Keywords: resilience; performance; operational model; SOF medic; ecosystem

PMID: 37972384

DOI: UOZ5-J9AH

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Unconventionally Acquired Brain Injury: Guidance and Instruction About an Emerging Challenge to Warfighter Brain Health

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Biggs AT, Henry SM, Johnston SL, Whittaker DR, Littlejohn LF. 21(2). 43 - 48. (Journal Article)

Abstract

Special Operations Forces have made brain health a medical priority in recent years, and new guidance identified a new challenge-unconventionally acquired brain injury (UBI). Although this emerging condition is described as a cluster of neurosensory and cognitive symptoms with unknown etiology/ origin, there remain critical questions about how this diagnosis differs from other brain injuries. More importantly, there are limited recommendations about how medical personnel should approach the problem. The current discussion will provide context and information about UBI based on higher guidance and will also review the scant literature to provide context. Foremost, UBI can be distinguished from traumatic brain injury (TBI) largely due to an unknown point of injury. The described symptoms otherwise appear to be largely the same as TBI. Likewise, the recommended course of treatment is to follow the Clinical Practice Guidelines for mild TBI/TBI even if the injury is an actual or suspected UBI. Personnel must be careful to avoid entering sensitive information into the medical record, which may be particularly challenging if identifying the cause involves classified information about an unconventional weapon. Finally, we briefly discuss the literature about several suspected incidents fitting UBI diagnostic criteria, and we conclude with five primary takeaways for medical personnel to follow.

Keywords: unconventional, acquired brain injury; traumatic brain injury; Havana syndrome; Special Operations; Frey effect

PMID: 34105120

DOI: GYL1-ZHBI

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Underneath The Unconventional: Philosophies And Paradigms Of Special Operations Forces Clinical Science

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Froede K. 11(4). 56 - 60. (Journal Article)

Abstract

Special Operations Forces (SOF) medical personnel (clinicians) directly impact their patients' outcomes, regardless if the patient is a Soldier, civilian, or indigenous person. Any health practitioner who specializes in trauma, Soldiers' healthcare, or tactical and/or operational healthcare must have a working knowledge of SOF medicine and its philosophical, political, and contextual origins. SOF clinical evidence and knowledge base is extensive and inextricably linked to SOF clinicians' underlying warrior philosophy and worldview. This submission will argue the point that SOF healthcare is a discipline and mature science in its own right, as evidenced by SOF's utilization and/or rejection of other disciplines' (nursing, medicine, conventional military) paradigms, community-wide adoption of its own specific paradigms, disciplinary matrix, and language. Peer-reviewed articles relevant to SOF and military healthcare from 2009-2011 are reviewed to determine possible philosophical frameworks, identify extant methodologies, and demonstrate underlying philosophical constructs.

Keywords:

PMID: 22173598

DOI: VVZR-PR2G

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Unforeseen Risk: Leptospirosis and the U.S. Special Operations Community

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Grambusch DM, Hoedebecke KL. 12(3). 36 - 42. (Journal Article)

Abstract

Leptospirosis is a bacterial zoonosis with worldwide distribution and is potentially lethal to those infected if left untreated. Due to the global posture of the U.S. Special Operations community, there is a seemingly perfect overlap of the regions in which they deploy and areas with concurrent endemic leptospirosis infection. Furthermore, Special Operations Forces (SOF) personel are known for working by, with, and through the host nation defense force, who tend to be commonly affected and often serve as a reservoir for this infection. Other risk factors including the usage of infected military working dogs, contaminated training sites, and certain recreational activities associated with water increase the danger of exposure for this cohort. Due to this increased risk of leptospirosis by U.S. Special Operations service members, medical providers within this community must understand and utilize proper preventive medicine, prophylaxis, early detection, diagnosis, and treatment for this potentially lethal infection.

Keywords: leptospirosis; operational medicine; adventure racing; zoonosis; zoonotic disease; spirochetes; working dogs; Special Operations

PMID: 23032318

DOI: 294L-QPQ1

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Unit Collective Medical Training in the 75th Ranger Regiment

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Gonzalez S, Vasquez PF, Montgomery HR, Conklin CC, Conaway ZA, Pate DM, Lopata JF, Kotwal RS. 22(4). 28 - 39. (Journal Article)

Abstract

The 75th Ranger Regiment's success with eliminating preventable death on the battlefield is innate to the execution of a continuous operational readiness training cycle that integrates individual and unit collective medical training. This is a tactical solution to a tactical problem that is solved by the entire unit, not just by medics. When a casualty occurs, the unit must immediately respond as a team to extract, treat, and evacuate the casualty while simultaneously completing the tactical mission. All in the unit must maintain first responder medical skills and medics must be highly proficient. Leaders must be prepared to integrate casualty management into any phase of the mission. Leaders must understand that (1) the first casualty can be anyone; (2) the first responder to a casualty can be anyone; (3) medical personnel manage casualty care; and (4) leaders have ownership and responsibility for all aspects of the mission. Foundational to training is a command-directed casualty response system which serves as a forcing function to ensure proficiency and mastery of the basics. Four programs have been developed to train individual and collective tasks that sustain the Ranger casualty response system: (1) Ranger First Responder, (2) Advanced Ranger First Responder, (3) Ranger Medic Assessment and Validation, and (4) Casualty Response Training for Ranger Leaders. Unit collective medical training incorporates tactical leader actions to facilitate the principles of casualty care. Tactical leader actions are paramount to execute a casualty response battle drill efficiently and effectively. Successful execution of this battle drill relies on a command-directed casualty response system and mastery of the basics through rehearsals, repetition, and conditioning.

Keywords: medical training; prehospital medicine; Tactical Combat Casualty Care; casualty response

PMID: 36525009

DOI: 8R6U-KY01

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United States Military Parachute Injuries. Part 1: Early Airborne History and Secular Trends in Injury Incidence

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Knapik JJ. 19(3). 110 - 115. (Journal Article)

Abstract

This article traces the early history of military airborne operations and examines studies that have provided overall incidences of parachute-related injuries over time. The first US combat parachute assault was proposed during World War I, but the war ended before the operation could be conducted. Experimental jumps were conducted near San Antonio, Texas, in 1928 and 1929, but it was not until 1939, spurred by the developments in Germany, that the US Army Chief of Infantry proposed the development of an "air infantry." An Airborne Test Platoon was instituted with 48 men at Fort Benning, Georgia, and mass training of paratroopers began in 1940. The US entered World War II in December 1941 with the attack on Pearl Harbor and declaration of war by Germany. In January 1942, US War Department directed that four parachute regiments be formed. The 509th Parachute Infantry Battalion made the first US Army combat jumps into Morocco and Algeria in November 1942. At the US Army Airborne School in the 1940-1941 period, the parachute-related injury incidence was 27 injuries/1000 jumps; by 1993 it was 10 injuries/1000 jumps and in 2005-2006, 6 injuries/1000 jumps. Analysis of time-loss injuries in operational units showed a decline in injuries from 6 injuries/1000 jumps to 3 injuries/1000 jumps to 1 injury/1000 jumps in the periods 1946-1949, 1956-1962, and 1962-1963, respectively. When all injuries (not just time-loss) experienced in operational units are considered, the overall injury incidence was about 8 injuries/1000 jumps in the 1993- 2013 period. In jump operations involving a larger number of risk factors (e.g., high winds, combat loads, rough drop zones) injury incidences was considerably higher. The few studies that have reported on parachute-related injuries in combat operations suggest injury incidence ranged from 19 to 401 injuries/ 1000 jumps, likely because of the number of known injury risk factors present during these jumps. Despite the limitations of this analysis stemming from different injury definitions and variable risk factors, the data strongly suggest that military parachute injuries have sharply declined over time. Part 2 of this series will discuss techniques and equipment that have likely improved the safety of parachute operations.

Keywords: injury incidence; parachute; history; risk factors

PMID: 31539444

DOI: Z8WL-VMS6

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United States Military Parachute Injuries: Part 2: Interventions Reducing Military Parachute Injuries in Training and Operations

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Knapik JJ. 19(4). 109 - 113. (Journal Article)

Abstract

This is part 2 of an article detailing the reduction in airbornerelated injuries over time. Part 1 examined the early history of airborne operations and provided evidence for the reduction in injuries over time; part 2 discusses interventions associated with the decline in injury rates. In 1943 at the United States (US) Army Airborne School, data showed that injuries were substantially reduced from 120 to 18 injuries/1000 trainees. Credit for the reduction was given to development of the parachute landing fall (PLF), better supervision of students while in initial airborne training, intensive ground training prior to actual jumping, and elimination of dangerous and unnecessary training procedures (like practice jumps from 11-foot heights). Compared to the older T-10 parachute introduced in the 1950s, the newer T-11 parachute introduced in 2010 reduced injuries by 43% in operational training (9.1 vs 5.2 injuries/1000 jumps). In aircraft with jump doors on both sides, alternating jumps between the doors so that the jumpers exit at slightly different times reduced high-altitude and mid-altitude entanglement injuries by 85% (0.13 to 0.02 injury/ 1000 jumps). Data from six scientific studies involving more than 1,300,000 jumps and two systematic reviews indicated that the parachute ankle brace (PAB) reduced ankle injuries and ankle fractures by about half with an estimated return on investment of at least $7 in medical and personnel costs for every $1 spent on the PAB. However, the PAB is not currently used or even well-known within the airborne community because of a lack of acceptance and promotion. While some airborne injury-reducing innovations are discussed here it is likely that there have been others that have not been documented. It is important to detail these interventions so future paratroopers and leaders can better understanding their rationale and effectiveness.

Keywords: T-10 parachute; T-11 parachute; parachute ankle brace; Controlled Alternating Parachute Exit System (CAPES); airborne school

PMID: 31910484

DOI: F7WX-VUG8

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Unstable Pelvic Fracture Reduction Under Ultrasonographic Control

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Goudard Y, Camus D, de Landevoisin ES, Dobost C, Domos P, Balandraud P. 19(1). 16 - 18. (Case Reports)

Abstract

Managing acute trauma cases in military and low-resource environments usually requires adapted medicosurgical protocols to achieve best medical results with limited technical capacity. We report a case of unstable pelvic fracture that needed ultrasonographic assessment for closed reduction before external stabilization. In our opinion, ultrasonographic control should be considered as a useful technique for unstable pelvic fracture reduction and an alternative to radiographic control.

Keywords: pelvic fracture; ultrasonography

PMID: 30859519

DOI: 74JP-8DOR

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Unwrapping a First Aid Tourniquet From Its Plastic Wrapper With and Without Gloves Worn: A Preliminary Study

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Kragh JF, Aden JK, Lambert CD, Moore VK, Dubick MA. 17(3). 25 - 34. (Journal Article)

Abstract

Background: The purpose of this study was to gather data about unwrapping a packaged limb tourniquet from its plastic wrapper while wearing different types of gloves. Because already unwrapped tourniquets require no time to unwrap, unwrapping data may provide insights into the issue of having tourniquets unwrapped when stowed in a first aid kit of a Serviceperson at war. Materials and Methods: In a laboratory setting, 36 tests of nine glove groups were performed in which four people, gloved and ungloved, unwrapped tourniquets. Other tourniquets were environmentally exposed for 3 months. Results: All the users successfully unwrapped each tourniquet. Mean times to unwrap by glove group were not significantly different (ρ = .0961). When mean values of eight experimental groups were compared with that of one control group (i.e., bare hands), results showed no significant difference (ρ > .07). Mean time was least for bare hands (12 seconds) and most for cold gloves layered under mittens (22 seconds). Among the 36 pairwise comparisons of difference between glove group means, after adjustment for multiple comparisons, no comparison was noted to be statistically significant (ρ > .052, all 36 pairs). Glove thickness ranged from 0 mm for bare hands to 2.5 mm for cold gloves layered under mittens. By glove group, the thickness-time association was moderate, as tested by linear regression (R2 = 0.6096). The tourniquets exposed to the environment had evidence of rapid photodegradation due to direct exposure to sunlight. Such exposure also destroyed the wrappers. Conclusion: In a preliminary study, different gloves performed similarly when wearers unwrapped a tourniquet from its wrapper. The tourniquet wrappers gave no visible protection from sunlight, and environmental exposure destroyed the wrappers.

Keywords: tourniquet; first aid methods; first aid device; hemorrhage prevention and control; shock; emergency medical services; military medicine; material science; environment; exposure

PMID: 28910464

DOI: 29KJ-6QTM

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Update on Minimalist Running Shoes

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Knapik JJ, Orr R, Pope R. 21(3). 107 - 110. (Journal Article)

Abstract

This article provides updated information comparing minimalist running shoes (MRS) to conventional running shoes (CRS). Our previous review found that, compared with running in CRS, transitioning to MRS resulted in lower energy cost and less ground contact occurring at the forefoot, resulting in lower impact forces. There was some increased risk of injury with MRS, although data were conflicting. A more recent 26-week study involved 30 trained runners using CRS and 31 using MRS. The proportion of training time in the assigned shoes increased by 5% each week. After the first 6 weeks of transition (35% of training time in the assigned shoe), energy cost was lower and 5-km running time faster in MRS compared with CRS. No further improvement occurred from weeks 6 to 26. There were no significant differences in injury incidence in the two groups (CRS = 37%, MRS = 52%; p = .24). Running-related pain was higher in the MRS group in the knee, shin, calf, and ankle and increased at these locations as running mileage increased. Risk of injury in MRS increased as participant body weight increased. These more recent data suggest that MRS can improve performance, but most runners should limit running in MRS to 35% of training time and in situations where optimal performance is desired (e.g., races, fitness tests).

Keywords: energy cost; running economy; injuries

PMID: 34529816

DOI: LWT4-DGIH

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Update: Five Years of Prolonged Field Care in Special Operations Medicine

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Riesberg JC, Loos PE. 19(2). 122 - 122. (Journal Article)

Abstract

This brief quarterly update from the SOMA Prolonged Field Care (PFC) Working Group focuses on the first of ten sequential reviews of the PFC Core Capabilities, starting with advanced airway management.

Keywords:

PMID: 31201765

DOI: IRW4-QS0G

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Update: SORTs, GHOST-Ts, New Guidelines, and Advanced Resuscitative Care

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Riesberg JC. 19(3). 116 - 116. (Journal Article)

Keywords:

PMID: 31539445

DOI: 3U17-IWBS

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Updated Considerations for the Use of Anesthesia Gas Machines in a Critical Care Setting During the Coronavirus Disease Pandemic

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Wickens CD, Delmonaco BL, Pelleg T. 21(4). 71 - 76. (Journal Article)

Abstract

The latest surge of the coronavirus disease 2019 (SARS-CoV-2 virus) pandemic continues to create an unprecedented need for mechanical ventilation in critically ill patients. The U.S. Food and Drug Administration (FDA) recognized that the additional need for ventilators, on March 22, 2020 and issued guidance outlining a policy intended to help increase availability of relevant technologies. The FDA included guidance for healthcare facilities facing shortages of mechanical ventilators to consider alternative devices capable of delivering breaths or pressure support including anesthesia machines. Anesthesia machine manufacturers have published guidelines for the off-label use of anesthesia machines in critical care settings. Capable of providing mechanical ventilation, anesthesia machines do not deliver ventilation modes and flow capabilities commonly used outside the operating room (OR). A paucity of published information exists to describe the operation of anesthesia machines, their technological and practical limitations, and special considerations to prevent harm when re-purposed. We provide technical information and practical guidance for the safe use of anesthesia machines in critically ill patients outside the OR.

Keywords: considerations; critical care; anesthesia

PMID: 34969130

DOI: CES2-JCVC

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Urban Shield 2016

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Mattison D. 16(3). 76 - 77. (Journal Article)

Keywords:

PMID: 27734448

DOI: H1GT-5GH6

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US Army Combat Medic Performance With Portable Ultrasound to Detect Sonographic Findings of Pneumothorax in a Cadaveric Model

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Meadows RM, Monti JD, Umar MA, Van Arnem KA, Chin EJ, Mitchell CA, Love S. 20(3). 71 - 75. (Journal Article)

Abstract

Background: Ultrasound, due to recent advances in portability and versatility, has become a valuable clinical adjunct in austere, resource-limited settings and is well demonstrated to be an accurate/efficient means to detect pneumothorax. The purpose of this study was to evaluate the impact of hands-on ultrasound training on ultrasound-naive US Army combat medics' ability to detect sonographic findings of pneumothorax with portable ultrasound in a cadaver model. Methods: Ultrasound-naive US Army combat medics assigned to conventional military units were recruited from a single US Army installation and randomized to receive either didactic training only, or "blended" (didactic and hands-on) training on ultrasound detection of pneumothorax. Blinded participants were asked to perform a thoracic ultrasound exam on ventilated human cadaver models. Primary outcome measured was sensitivity and specificity of detecting sonographic findings of pneumothorax between cohorts. Results: Forty-three participants examined a total of 258 hemithoraces. The didactic-only cohort (n = 24) detected sonographic findings of pneumothorax with a sensitivity of 68% and specificity of 57%. The blended cohort (n = 19) detected sonographic findings of pneumothorax with an overall sensitivity of 91% and specificity of 80%. Detection sensitivities were similar between B-mode versus M-mode use. Conclusion: US Army combat medics can use portable U/S to detect sonographic findings of pneumothorax in a human cadaver model with high sensitivity after a brief, blended (didactic and hands-on) training intervention.

Keywords: combat medic; ultraound; military; POCUS; pneumothorax; cadaver

PMID: 32969007

DOI: SOPZ-STAP

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US Military Dietary Protein Recommendations: A Simple But Often Confused Topic

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Pasiakos SM, Sepowitz JJ, Deuster PA. 15(4). 89 - 95. (Journal Article)

Abstract

Military recommendations for dietary protein are based on the recommended dietary allowance (RDA) of 0.8g of protein per kilogram of body mass (BM) established by the Food and Nutrition Board, Institute of Medicine (IOM) of the National Academies. The RDA is likely adequate for most military personnel, particularly when activity levels are low and energy intake is sufficient to maintain a healthy body weight. However, military recommendations account for periods of increased metabolic demand during training and real-world operations, especially those that produce an energy deficit. Under those conditions, protein requirements are higher (1.5-2.0g/kg BM) in an attempt to attenuate the unavoidable loss of muscle mass that occurs during prolonged or repeated exposure to energy deficits. Whole foods are recommended as the primary method to consume more protein, although there are likely operational scenarios where whole foods are not available and consuming supplemental protein at effective, not excessive, doses (20-25g or 0.25-0.3g/kg BM per meal) is recommended. Despite these evidence-based, condition-specific recommendations, the necessity of protein supplements and the requirements and rationale for consuming higher-protein diets are often misunderstood, resulting in an overconsumption of dietary protein and unsubstantiated health-related concerns. This review will provide the basis of the US military dietary protein requirements and highlight common misconceptions associated with the amount and safety of protein in military diets.

Keywords: military; US Army Special Operations Forces; sustained operations; whey protien; supplement; military dietary reference intakes

PMID: 26630101

DOI: J1H4-1EYT

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USASOC Division Of Science & Technology: What It Means For Special Operations Medicine

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Calvano CJ, Forman S, Osborn T, Gothard W. 16(1). 65 - 66. (Editorial)

Keywords:

PMID: 27045497

DOI: XT6R-SP9F

Use of a Pressure Cooker to Achieve Sterilization for an Expeditionary Environment

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Cook RK, McDaniel J, Pelaez M, Beltran T, Webb O. 21(1). 37 - 39. (Journal Article)

Abstract

Background: Sterilization of healthcare instruments in an expeditionary environment presents a myriad of challenges including portability, cost, and sufficient electrical power. Using pressure cookers to sterilize instruments presents a low-cost option for sterilization in prehospital settings. This project's objective was to determine if sterility can be achieved using a commercially available pressure cooker. Methods: Presto® 4-quart stainless steel pressure cookers were heated using Cuisinart® CB-30 cast-iron single burners. One 3M™ Attest™ 1292 Rapid Readout Biological Indicator and one 3M™ Comply™ SteriGage™ integrator strip were sealed in a Henry Schein® Sterilization Pouch and placed in a pressure cooker and brought to a pressure of 103.4kPa. Sterility was verified after 20 minutes at pressure. The Attest vials were incubated in a 3M Attest 290 Auto-Reader for 3 hours with a control vial. Results: Sterility using the pressure cooker was achieved in all tested bags, integrator strips, and Attest vials (n = 128). The mean time to achieve the necessary 103.4kPa was 379 seconds (standard deviation (SD) = 77). Neither the ambient temperature nor humidity were found to affect the pressure cooker's time to achieve adequate pressure, nor the achieved depth on the integrator strip (all p > .05). Conclusion: This study provides evidence that sterilization is possible with offthe- shelf pressure cookers. Though lacking US Food and Drug Administration (FDA) approval, the use of this commercially available pressure cooker may provide a method of sterilization requiring minimal resources from providers working in expeditionary environments.

Keywords: disinfection; sterilization; dental instruments; health professional

PMID: 33721304

DOI: WPGC-A599

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Use of a Removable Mandibular Neuroprosthesis for the Reduction of Posttraumatic Stress Disorder (PTSD) and Mild Traumatic Brain Injury/PTSD-Associated Nightmares, Headaches, and Sleep Disturbances

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Moeller DR, Duffey JM, Goolsby AM, Gallimore JT. 14(3). 64 - 73. (Journal Article)

Abstract

Introduction: Posttraumatic stress disorder (PTSD) has been associated with nighttime headaches (HAs), nightmares (NMs), and difficulty falling or staying asleep (sleep disturbances [SD]). The authors of the current study evaluated the correlative elements of using a removable mandibular neuroprosthesis (RMN) and the reduction of these symptoms in participants diagnosed with PTSD or mild traumatic brain injury (mTBI)/PTSD. The RMN device is a form of specialized dental splint that has a potential to reduce the painful stimuli of bruxing and potential upregulation of threat response systems that may occur during sleep. Method: A sample of 32 individuals was selected through random assignment from a volunteer base of 200 volunteers for examination by self-report according to an A-B-A-B design. The sample included 25 men and 7 women between the ages of 21 and 65; 21 had military experience and 11 were civilians. Participants were asked to rate the frequency and intensity of their HAs, NMs, and SD during each phase. Their responses were scored using a custom survey (equivalent forms reliability) that provides ratio-scaled results for symptom frequency and intensity. The original number of participants was 35 with three participants dropping out before the conclusion of the study. Results: Survey scores for PTSD-related sleep symptoms were relatively high at baseline (x̄ = 0.52) and significantly lower in the first experimental phase (x̄ = 0.20). Scores in the second experimental phase were likewise lower (x̄ = 0.38). Significant reductions in symptoms were reported across all three dimensions. Discussion: All participants reported some improvement in symptoms while using the device. No participants reported worsening of any symptoms as a result of using the RMN. Participants commonly reported that improvements in symptoms were immediate and did not diminish over time. Data indicate that there is a negative correlation between the use of an RMN and the reduction of HAs, NMs, and SD in persons diagnosed with PTSD or mTBI/PTSD.

Keywords: PTSD; mTBI; nightmares; headaches; sleep disturbances; DIMS; bruxism; bruxing; splint

PMID: 25344709

DOI: MHVO-MN5Q

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Use of a Tuning Fork for Fracture Evaluation: An Introduction for Education and Exposure

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Hetzler MR. 17(4). 130 - 132. (Journal Article)

Abstract

Radiographs, bones scans, and even ultrasound may be rare in the austere or acute environment for the evaluation of suspected musculoskeletal fractures. Having an easy, simple, and confident means of objective evaluation used in conjunction with the patient presentation, history, and physical findings may provide a more efficient and economical means of treatment. This introduction and review of selected literature are meant to provide a fuller understanding and consideration for the methods of using a tuning fork in fracture assessment.

Keywords: tuning fork; fracture; austere; operational medicine; primitive medicine

PMID: 29256212

DOI: AZ88-5FVB

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Use of Acetylsalicylic Acid in the Prehospital Setting for Suspected Acute Ischemic Stroke

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Levri JM, Ocon A, Schunk P, Cunningham CW. 17(3). 21 - 23. (Journal Article)

Abstract

Acute ischemic stroke (AIS) treatment guidelines include various recommendations for treatment once the patient arrives at the hospital. Prehospital care recommendations, however, are limited to expeditious transport to a qualified hospital and supportive care. The literature has insufficiently considered prehospital antiplatelet therapy. An otherwise healthy 30-year-old black man presented with headache for about 3 hours, left-sided facial and upper extremity numbness, slurred speech, miosis, lacrimation, and general fatigue and malaise. The presentation occurred at a time and location where appropriate resources to manage potential AIS were limited. The patient received a thorough physical examination and electrocardiogram. Acetylsalicylic acid (ASA) 325mg was administered within 15 minutes of history and examination. A local host-nation ambulance arrived approximately 30 minutes after presentation. The patient's neurologic symptoms had abated by the time the ambulance arrived. The patient did not undergo magnetic resonance imaging (MRI) until 72 hours after being admitted, owing to lack of neurology staff over the weekend. The MRI showed evidence of a left-sided, posteriorinferior cerebellar artery stroke. The patient was then taken to a different hospital, where he received care for his acute stroke. The patient eventually was prescribed a statin, ASA, and an angiotensin-converting enzyme inhibitor. The patient has no lingering symptoms or neurologic deficits.

Keywords: stroke, acute ischemic; prehospital treatment; acetylsalicylic acid; antiplatelet

PMID: 28910463

DOI: YR2M-G4N4

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Use of Atomized Intranasal Tranexamic Acid as an Adjunctive Therapy in Difficult-to-Treat Epistaxis

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Sarkar D, Martinez J. 19(2). 23 - 28. (Case Reports)

Abstract

There is a growing body of literature on the safe, effective use of tranexamic acid (TXA) for hemostasis in a variety of clinical settings. We present a case series of three patients with difficult-to-treat epistaxis where standard treatment methods were not effective. Using atomized intranasal TXA (ATXA) as part of a stepwise treatment approach, we were able to achieve hemostasis and manage all three cases independently, and we did so without major complications in our emergency department (ED). Given recent literature showing the underuse of TXA in combat casualties, ATXA, if formulated and delivered properly, may be of benefit for epistaxis and other significant hemorrhage cases. Further work must be done to elucidate the mechanism of action, specific dose, delivery method, use indications, and safety profile of ATXA.

Keywords: epistaxis; atomized; tranexamic acid; TXA; atomized intranasal TXA; intranasal

PMID: 31201748

DOI: CV5L-GVGA

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Use of Drone Technology for Delivery of Medical Supplies During Prolonged Field Care

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Mesar T, Lessig A, King DR. 18(4). 34 - 35. (Journal Article)

Abstract

Background: Care of trauma casualties in an austere environment presents many challenges, particularly when evacuation is not immediately available. Man-packable medical supplies may be consumed by a single casualty, and resupply may not be possible before evacuation, particularly during prolonged field care scenarios. We hypothesized that unmanned aerial drones could successfully deliver life-sustaining medical supplies to a remote, denied environment where vehicle or foot traffic is impossible or impractical. Methods: Using an unmanned, rotary- wing drone, we simulated delivery of a customizable, 4.5kg load of medical equipment, including tourniquets, dressings, analgesics, and blood products. A simulated casualty was positioned in a remote area. The flight was preprogrammed on the basis of grid coordinates and flew on autopilot beyond visual range; data (altitude, flight time, route) were recorded live by high-altitude Shadow drone. Delivery time was compared to the known US military standards for traversing uneven topography by foot or wheeled vehicle. Results: Four flights were performed. Data are given as mean (± standard deviation). Time from launch to delivery was 20.77 ± 0.05 minutes (cruise speed, 34.03 ± 0.15 km/h; mean range, 12.27 ± 0.07 km). Medical supplies were delivered successfully within 1m of the target. The drone successfully returned to the starting point every flight. Resupply by foot would take 5.1 hours with an average speed of 2.4km/h and 61.35 minutes, with an average speed of 12 km/h for a wheeled vehicle, if a rudimentary road existed. Conclusion: Use of unmanned drones is feasible for delivery of life-saving medical supplies in austere environments. Drones repeatedly and accurately delivered medical supplies faster than other methods without additional risk to personnel or manned airframe. This technology may have benefit for austere care of military and civilian casualties.

Keywords: drone; prolonged field care; medical supplies; delivery; austere environments

PMID: 30566722

DOI: M63P-H7DM

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Use of Intranasal Analgesia in French Armed Forces: A Cross-Sectional Survey

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Montagnon R, Cungi P, Aoun O, Morand G, Desmottes J, Pasquier P, Travers S, Aigle L, Dubecq C. 23(3). 39 - 43. (Journal Article)

Abstract

Background: Pain management is essential in military medicine, particularly in Tactical Combat Casualty Care (TCCC) during deployments in remote and austere settings. The few previously published studies on intranasal analgesia (INA) focused only on the efficacy and onset of action of the medications used (ketamine, sufentanil, and fentanyl). Side-effects were rarely reported. The aim of our study was to evaluate the use of intranasal analgesia by French military physicians. Methods: We carried out a multicentric survey between 15 January and 14 April 2020. The survey population included all French military physicians in primary-care centers (n = 727) or emergency departments (n = 55) regardless of being stationed in mainland France or French overseas departments and territories. Results: We collected 259 responses (33% responsiveness rate), of which 201 (77.6%) physicians reported being familiar with INA. However, regarding its use, of the 256 physicians with completed surveys, only 47 (18.3%) had already administered it. Emergency medicine physicians supporting highly operational units (e.g., Special Forces) were more familiar with this route of administration and used it more frequently. Ketamine was the most common medication used (n = 32; 57.1%). Finally, 234 (90%) respondents expressed an interest in further education on INA. Conclusion: Although a majority of French military physicians who replied to the survey were familiar with INA, few used it in practice. This route of administration seems to be a promising medication for remote and austere environments. Specific training should, therefore, be recommended to spread and standardize its use.

Keywords: Intranasal route; disaster medicine; emergency medicine; prehospital care; military medicine; analgesia; ketamine; Special Operations

PMID: 37169527

DOI: TBN6-NJSR

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Use of Knives and Multitools to Perform a Cadaveric Limb Amputation

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Baker RA, Worth K, Pourrajabi N, Martin J, Mitchell S, Baker S. 22(1). 71 - 75. (Journal Article)

Abstract

Background: An austere field amputation can be a life-saving procedure for an entrapped patient when standard equipment is not available or operable. The objective of this study was to use hand tools to perform cadaveric amputations in < 2 minutes. Methods: Timed guillotine amputation of the extremities on three cadavers was attempted using four available hand tools: a multitool, a rescue tool, a hunting knife, and a fixedblade knife. The primary outcome was successful amputation of the extremity in < 2 minutes. Results: Amputation success was different among the tools. The multitool amputated 78% of attempts; the hunting knife, 67%; the rescue knife, 56%; and the fixed-blade knife, 44%. The distal tibia/fibula and radius/ ulna were amputated successfully in 100% of attempts, whereas none of the tools could amputate the femur. The multitool received the best subjective ranking - 1.4 (p = .001) - by amputators, with the fixed-blade knife receiving the worst score. Conclusions: In the rare circumstance that an emergent field amputation requires a hand tool, the multitool is a capable instrument for a distal extremity amputation.

Keywords: amputation; knife; saw; prehospital; field; emergency

PMID: 35278317

DOI: Y31C-V4OI

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Use of Physical Therapists to Identify and Treat Musculoskeletal Injuries at "The Tip of the Trident"

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Shaw J, Brown L, Jansen B. 17(4). 45 - 48. (Journal Article)

Abstract

Musculoskeletal injuries continue to be the most common cause of decreased readiness and loss of productivity in all military environments. In commands with smaller footprints, such as Naval Special Warfare (NSW), every asset is critical for mission success. Studies have shown that early intervention by a medical provider can enhance healing and maintain unit readiness by preventing medical evacuations. Reports are limited with regard to Special Forces commands, especially during deployment. This article describes the injury characteristics and treatment of injuries seen by a physical therapist while deployed at forward operation commands embedded with NSW Group 2 Team 4. Over 4 months, 282 patients were evaluated and treated in southeast Afghanistan. In descending order, the three most common injured body regions were the lumbar/sacral spine (n = 82), shoulder (n = 59), and knee (n = 28). Therapy exercises (n = 461) were the most frequently performed treatment modality, followed by mobilization/manipulation (n = 394) and dry needling (n = 176). No patient evaluated was medically evacuated from the area or sent to an advanced medical site. Our data are similar to other published data reported on deployed units in terms of mechanisms and locations of injuries; thus, Special Forces commands do not appear to have unique injury patterns. These results support continued use of physical therapists in forward operations because of their ability to evaluate injuries and provide treatment modalities that help maintain the integrity of small commands at the site of injury.

Keywords: physical therapist; Naval Special Warfare; injuries, musculoskeletal

PMID: 29256193

DOI: W2I3-ICAW

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Use of the Intranasal Route for Administration of Ketamine by Special Operations Medical Personnel During Training Mishaps

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Montagnon R, Dubecq C, Pasquier P. 21(3). 96 - 97. (Letter)

Keywords:

PMID: 34529813

DOI: DV8T-KQO0

Use of the LMA Supreme in the Special Operations Environment: A Retrospective Comparison of the LMA Supreme and King LT-D

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Hamilton TJ, Maani CV, Redman TT. 13(4). 46 - 52. (Journal Article)

Abstract

The purpose of this study is to evaluate the use of the LMA Supreme® (LAM) as a combat supraglottic airway for U.S. Special Operations Forces (SOF). It is imperative to continuously evaluate and compare existing management options for airway control as requirements and technologies change. Providing our Special Operators with the most advanced and reliable medical equipment is of the utmost importance, and it is our intention here to compare the LMA Supreme with the currently fielded King LT-D® (King Systems) to determine whether the LMA Supreme may be a viable alternative supraglottic airway.

Keywords: supraglottic airway; LMA Supreme; King LT-D

PMID: 24227561

DOI: JETR-6ZB9

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Use of Topical Hemostatic Dressings in an Extended Field Care Model

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Welch M, Barratt J, Peters A, Wright C. 21(4). 63 - 65. (Journal Article)

Abstract

Background: We sought to test whether Celox topical hemostatic dressing (Medtrade Products) would maintain hemostasis in extended use. Methods: An anesthetized swine underwent bilateral arteriotomies and treatment with topical hemostatic dressings in line with the Kheirabadi method. The dressings were covered with standard field dressings, and these were visually inspected for bleeding every 2 hours until 8 hours, when the swine was euthanized. Results: There was no evidence of rebleeding at any point up to and including 8 hours. The Celox dressings maintained hemostasis in extended use. Conclusion: Celox topical hemostatic dressing is effective for extended use and maintains hemostasis. It should be considered for use in situations in which evacuation and definitive care may be delayed.

Keywords: hemostatic; trauma; prehospital; hemorrhage; military

PMID: 34969128

DOI: WTUP-GEE0

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Use Of Unapproved Products, Off-label Use, And Black-box warning... A variation Of Newton's Third Law Of The Practical Application Of The Rule Of Unintended Consequences... Considerations In Military Operational Medicine

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Pierson JF. 07(4). 50 - 60. (Journal Article)

Abstract

This article discusses the regulatory requirements for the use of unapproved drugs and off-label use of drugs and provides specific examples for military medicine. Additionally, it explains issues associated with standardization by the Service as a designated set, kit, or outfit as opposed to a general guidance. The former situation can be interpreted as a de facto policy whereas the latter is an adaptation of practice of medicine.

Keywords:

DOI:

Use of Walking Blood Bank at Point of Injury During Combat Operations: A Case Report

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Gaddy M, Fickling A, Hannick VC, Shackelford SA. 21(4). 94 - 98. (Journal Article)

Abstract

The US Military Tactical Combat Casualty Care guidelines recommend blood products as the preferred means of fluid resuscitation in trauma patients;, however, most combat units do not receive blood products prior to executing combat operations. This is largely due to logistical limitations in both blood supply and transfusion equipment. Further, the vast majority of medics are not trained in transfusion protocol. For many medics, the logistical constraints for cold-stored blood products favor the use of Walking Blood Bank (WBB), however few cases have been reported of WBB implementation at the point of injury during real world combat operations. This case report reviews one case of successful transfusion using WBB procedures at point of injury during combat. It highlights not only the feasibility, but also the necessity, for implementation of this practice on a larger scale.

Keywords: prehospital transfusion; fresh whole blood; walking blood bank

PMID: 34969135

DOI: V05K-FKXN

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Use Your Noodle to Simulate Tourniquet Use on a Limb With and Without Bone

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Kragh JF, Zhao NO, Aden JK, Dubick MA. 18(4). 57 - 63. (Journal Article)

Abstract

Background: The purpose of this study was to simulate first aid by mechanical use of a limb tourniquet on a thigh with and without bone to better understand best caregiving practices. Methods: Two investigators studied simulated first aid on a new pool "noodle," a plastic cylinder with a central air tunnel into which we inserted a wood dowel to simulate bone. Data were gathered by group (study and control, n = 12 each). The control group comprised data collected from simulated tourniquet use on the model with bone present. The study group comprised data from simulated tourniquet use on the model without bone. Results: Comparing compression with and without bone, the mean volumes of compressed soft tissues alone were 303mL and 306mL, respectively. When bone was present, the volume of soft tissues was squeezed more, yielding a smaller size by 3mL (1%). The bone had a volume of 41mL and pressed statically outward with an equal force oppositely directed to the inward compression of the overlying soft tissues. With bone removed and compression applied, the mean residual void was 16mL, because 25mL (i.e., 41mL minus 16mL) of soft tissues had collapsed inward. The volume of the limb under the tourniquet with and without bone was 344mL and 322mL, respectively. The collapse volume, 25mL, was 3mL more than the difference of the mean volume of the limb under the tourniquet. More limb squeeze (22mL) looked like better compression, but it was actually worse-an illusion created by collapse of the hidden void. Conclusion: In simulated first aid, mechanical modeling demonstrated how tourniquet compression applied to a limb squeezed the soft tissues better when underlying bone was present. Bone loss altered the compression profile and may complicate control of bleeding in care. This knowledge, its depiction, and its demonstration may inform first-aid instructors.

Keywords: caregiver; choice behavior; public health; medical device; active learning; tourniquet; mechanics

PMID: 30566724

DOI: 9P7J-HNEC

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Using Modeling To Predict Medical Requirements For Special Operations Missions

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Hill M, Nix R, Hopkins C, Konoske P, Pang G. 08(4). 38 - 46. (Journal Article)

Keywords:

DOI:

USSOCOM TCCC CASEVAC Set Program A Retrospective and Overview

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Gilpin J. 12(4). 79 - 85. (Journal Article)

Abstract

The United States Special Operations Command (USSOCOM) Tactical Combat Casualty Care (TCCC) Casualty Evacuation (CASEVAC) Set Program was initiated in 2006 as a three-step effort. The initial effort was to develop an improved Individual First Aid Kit (IFAK); this was followed by the development of a Medic bag and culminated with the CASEVAC Set. The intent of the Program is both standardizing the medical load out across SOF components and expanding the skill set of Special Operations Forces (SOF) medical practitioners by providing equipment and training outside the normal parameters of many units. Even though the Set is currently being fielded to a variety of units, there are still personnel unaware of the Set and its capabilities. The goal of this article is to increase awareness of the existence of the program and to promote thought/discussion regarding the expansion of the capabilities of the Advanced Tactical Practitioner (ATP) beyond traditional medical skills. This program is best understood by first looking back to where it originated, and then examining where it is at present.

Keywords:

PMID: 23536461

DOI: M1G4-53GV

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Vector-Borne Disease Surveillance in Puerto Rico: Pathogen Prevalence Rates in Canines - Implications for Public Health and the U.S. Military - Applying the One Health Concept

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Mccown M, Opel T, Grzeszak B. 13(2). 59 - 63. (Journal Article)

Abstract

Vector-borne diseases (VBDs) make up a large number of emerging infectious and zoonotic diseases. Vectors such as ticks, fleas, and mosquitoes parasitize dogs, thus making canine populations adequate reservoirs for infectious disease and zoonoses. The U.S. military deploys its personnel and Military Working Dogs (MWDs) throughout the world with possible risk of exposure to VBDs. Canine VBDs continue to have veterinary and public health significance for the host nations as well as for deployed U.S. personnel and MWDs. Thus, ongoing and consistent disease surveillance is an essential component to preserve health. The purpose of this study was to survey dogs from multiple cities and varying regions throughout Puerto Rico to determine the prevalence of ehrlichiosis (Ehrlichia canis), anaplasmosis (Anaplasma phagocytophilum), Lyme disease (Borrelia burgdorferi), and heartworm disease (Dirofilaria immitis) from May to July 2012. Canine blood samples (1-3 ml) from the cities of San Juan (n = 629), Guaynabo (n = 50), Ponce (n = 20) and Vieques Island (n = 53) were obtained and tested on-site using an IDEXX SNAP® 4Dx® (enzyme-linked immunosorbent assay) test kit. Prevalence for single or multiple disease status was calculated for each site. The overall period prevalence of VBD in Puerto Rico in the shelter population was 57.7% (71/123). In Guaynabo, the VBD prevalence was 30% (15/50); 2 (13%) of these positive dogs had VBD co-infection. In the coastal port city of Ponce, it was 60% (12/20); 6 (50%) dogs were infected by two or more VBDs. On Vieques Island, it was 83% (44/53); 27 (61%) dogs were coinfected. Conversely, samples collected at the Fort Buchanan Veterinary Clinic in the capitol city of San Juan resulted in a VBD prevalence of 8.9% (56/629). Lyme disease was not detected in any sample. This study showed the presence of D. immitis, E. canis, and A. phagocytophilum in all four sites of Puerto Rico, emphasizing the value of surveillance for VBDs to determine disease prevalence, complete risk assessments, and implement timely preventive medicine and other preventive measures. The lower VBD prevalence rate in the canine samples from Fort Buchanan demonstrates the value of responsible pet ownership and importance of preventive medicine and public health.

Keywords: zoonotic disease; parasites; ticks; vector-borne disease; dogs; public health; surveillance; One Health

PMID: 23817880

DOI: 98QX-CJUU

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Versatility With Far Forward Damage Control Surgery: Successful Resuscitative Thoracotomy in an HH-60 Black Hawk

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Pieper MA, Vonderharr MJ, Knutson TL, Sullivan JL, Allison CG, Englert Z. 19(1). 20 - 22. (Case Reports)

Abstract

The military conflicts of the past 17 years have taught us many lessons, including the evolution of the tiered trauma system with en route resuscitation. The evolution of the conflict has begun to limit the reach of this standard trauma system. Recent evidence suggests that 95% of early deaths resulting from traumatic injuries may be prevented if the patient can undergo damage control surgery within 23 minutes of injury. US Military Surgical Resuscitation Teams have been developed to shorten this time from injury to surgical care, as illustrated by this case report.

Keywords: en route surgery; resuscitative thoracotomy; HH-60; surgical resuscitation team

PMID: 30859520

DOI: Y3QJ-RS2M

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Veterans and Suicide: An Integrative Review of Risk Factors and Suicide Reduction Services

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Crawford S, Duffey JM, Doss KM. 22(1). 134 - 140. (Journal Article)

Abstract

Suicide has quickly risen to be among the top threats to humanity the world over, which is most certainly the case for American veterans. Literature has well documented that veterans are at increased suicide risk due to numerous factors associated with military culture. This article examines veterans' suicide reduction services by addressing the identification of veterans at elevated risk of suicide and assessing public-private partnership models that promote effective collaborative outreach and treatment. Essentially, this work appraises the development and procedures of multi-organization systems collaborating to impart novel and effective processes to eliminate suicide as intended by Past-President Trump's Executive Order No. 13,861.1 The essential risk factors associated with the identification of veterans at elevated risk of suicide are reviewed. Public-private partnership models that encourage collaborative and effective outreach and treatment are examined. The implications of this literature review will support mental health providers, researchers, and policymakers in innovative, collaborative, and effective suicide prevention and intervention practices for veterans. Directions for future research are identified to further contribute to efforts to empower veterans and eliminate suicide.

Keywords: suicide; risk reduction; veterans; Servicemembers; prevention; identification; intervention; partnerships

PMID: 35278330

DOI: T7F5-7MMP

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Veterinary Care System For Military Working Dogs - A Case Study

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Vogelsang R, Sofaly C, Richey M. 08(2). 61 - 67. (Case Reports)

Abstract

A previous JSOM article (Spring 2007) discussed military workings dogs (MWD) in SOF and their care by SOF medical personnel. MWDs are becoming more commonly utilized within SOF in current theaters and are subject to similar injuries and illnesses experienced by their human counterparts. SOF personnel can only provide basic care, as described in the earlier article, requiring more severely injured/ ill dogs be evacuated to a conventional veterinary treatment facility. This article discusses current conventional veterinary capability and utilizes a case study to help demonstrate the spectrum of veterinary care for MWDs, from point of injury, to CONUS rehabilitation and eventual return to duty. It is important that SOF medical and planning personnel understand what veterinary support exists, its capabilities and locations to ensure the best care possible can be provided to their dogs. OBJECTIVES 1) Understand conventional military veterinary support doctrine for working dog care. 2) Recognize potential problems/shortfalls within the veterinary care system. 3) Understand capabilities of conventional military veterinary care for the military working dog.

Keywords:

DOI:

Veterinary Public Health Essentials To Deployment Health Surveillance: Applying Zoonotic Disease Surveillance And Food/water Safety At Sof Deployment Sites

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McCown ME, Grzeszak B, Rada Morales JM. 09(4). 26 - 31. (Journal Article)

Keywords:

PMID: 20112645

DOI: 6UQF-ROX7

Victory I Consensus Document: Proposal for the Implementation of the Hartford Doctrine in the Spanish Context

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Martin L, Roca G, Hernandez JM, Fernandez S, Lynam B. 18(4). 27 - 29. (Letter)

Abstract

Several international recommendations advise adapting military healthcare response models to intentional mass casualty incidents (IMCIs) in civil environments. The IMCI experience and associated published research from the United States, where these situations are frequent and properly analyzed more often, are, unfortunately, not directly applicable to the Spanish model of emergency medical services (EMS), where each autonomous region has its own competencies and protocols. However, there is a series of common elements that served as a reference for the development of an effective, evidence- based, IMCI consensus response plan called Victoria I. In this plan, we have tried to define each intervening role during an IMCI, from the occasional first responder to the final hospital staff at the reference trauma centers. We believe that each professional role in this response chain, on and off the scene, must have a clear mission and function to improve victim survival.

Keywords: Victoria consensus; Hartford consensus; terrorist attack; intentional mass casualty incident; Spain

PMID: 30566720

DOI: TN52-5XEZ

Vietnam 1968-1969: A Battalion Surgeon's Journal

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Farr WD. 15(4). 126 - 126. (Book Review)

Abstract

Holley, Byron E. Vietnam 1968-1969. A Battalion Surgeon's Journal.
New York: Ivy Books, 1993. 211 pages. ISBN-10: 0804109346/ISBN-13: 978-0804109345.

Keywords:

DOI:

Vitamin A and Bone Fractures

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Knapik JJ, Hoedebecke SS. 21(1). 115 - 119. (Journal Article)

Abstract

Vitamin A is a generic term describing compounds that have the same biological activity as retinol. Dietary vitamin A can be obtained from "provitamin A" carotenoids (e.g., ß-carotene) found in plant foods such as carrots, cantaloupes, and sweet peppers, or as "preformed vitamin A" found in many dietary supplements, animal livers, and vitamin A-fortified foods, such as breakfast cereals, milk, cheese, and yogurt. Low consumption of vitamin A can cause night blindness, reduce immune function, and have detrimental developmental effects. Several lines of evidence suggest that excessive dietary intake of vitamin A might be associated with an increased risk of bone fractures. Meta-analysis of observational human studies that have examined vitamin A and fractures suggests that dietary consumption of large amounts of vitamin A in the form of ß-carotene likely has a protective effect, reducing the risk of fractures. On the other hand, meta-analyses that have specifically examined hip fractures have shown that total vitamin A (all types) or retinol consumption may increase the risk of hip fractures. Until more information is available, it is advisable to consume vitamin A primarily from plant sources, avoid excessive consumption from dietary supplements and animal sources, and lower consumption from fortified foods.

Keywords: beta-carotene; retinol; meta-analysis; hip fracture

PMID: 33721319

DOI: ETA1-NLQP

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Vitamin A and Bone Fractures: Systematic Review and Meta-Analysis

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Knapik JJ, Hoedebecke SS. 21(2). 100 - 107. (Journal Article)

Abstract

Vitamin A is a generic term for compounds that have biological activity similar to that of retinol and includes carotenoids like β-carotene and α-carotene. Some studies suggest high dietary intake of vitamin A can increase bone fracture risk. This investigation involved a systematic review and meta-analysis examining the association between vitamin A and fracture risk. Published literature was searched to find studies that (1) involved human participants, (2) had prospective cohort or case-control study designs, (3) contained original quantitative data on associations between dietary intake of vitamin A and fractures, and (4) provided either risk ratios (RRs), odds ratios (ORs), or hazard ratios (HRs) with 95% confidence intervals (95% CIs) comparing various levels of vitamin A consumption to fracture risk. Thirteen studies met the review criteria. Meta-analyses indicated that risk of hip fracture was increased by high dietary intake of total vitamin A (RR = 1.29; 95% CI = 1.07-1.57) or retinol (RR = 1.23; 95% CI = 1.02-1.48). Hip fracture risk was reduced by high dietary intake of total carotene (RR = 0.62; 95% CI = 0.42-0.93), β-carotene (RR = 0.72; 95% CI = 0.58-0.89), or α-carotene (RR = 0.81; 95% CI = 0.67-0.97). Total fracture risk was not associated with any vitamin A compound. High intake of total vitamin A or retinol increased hip fracture risk, while high intake of some carotenoids reduced hip fracture risk.

Keywords: retinol; β-carotine; α-carotene; B-cryptoxanthin; hip fracture; total fracture

PMID: 34105132

DOI: OGLF-K9ZU

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Walking Quadriplegic: Cervical Myelopathy in an Ambulating Combat Support Soldier

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Treyster DA, Riordan R, Rotello EN, Falcon J, Charny G. 22(3). 86 - 89. (Journal Article)

Abstract

We discuss a case of a 27-year-old male Soldier who presented with acute to subacute vague radicular complaints, which were atypical for and out of proportion to the imaging findings. Imaging demonstrated compressive cervical myelopathy at the levels of C3/C4 and C4/C5. Paradoxically, the patient's history revealed a remote nerve root compression, not cord compression, at the same levels. Identification and prompt surgical management led to the reversal of significant neurologic deficits that were present preoperatively. This case highlights the difficulty of identifying this rare condition among a plethora of otherwise benign and common cervical spondyloses seen in the Special Operations population. This study aims to bring to light the subtle history and physical characteristics that can assist Special Operations healthcare providers in making an otherwise elusive diagnosis. Last, it highlights a utility to documenting baseline spinal exam findings for the force to better identify subtle injuries.

Keywords: cervical spinal myelopathy; degenerative myelopathy; cervical spondylosis; military personnel; neurosurgery

PMID: 35862845

DOI: 1X9A-Q7Q7

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Walking the Plank

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Banting J, Meriano T. 16(3). 57 - 61. (Journal Article)

Abstract

Concepts and Objectives: 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: cervical spinal injury; Canadian C-spine rule, NEXUS Criteria; cervical collar

PMID: 27734444

DOI: SV2P-R8G4

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War in the Shadows: The Guerrilla in History

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Farr WD. 13(2). 75 - 76. (Book Review)

Abstract

Robert B. Asprey. War in the Shadows: The Guerrilla in History. Two volumes.
Garden City, NJ: Doubleday & Company; 1975. 1496 pages. ASIN: B002JNCB1C.

War in the Shadows: The Guerrilla in History. Two Thousand Years of the Guerrilla at War From Ancient Persia to the Present. Revised and updated. New York: William Morrow and Company; 1994.
1322 pages. ISBN 0-688-12815-7.

Keywords:

DOI:

War Reminiscences by the Surgeon of Mosby's Command

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Neal CA. 17(3). 152 - 153. (Book Review)

Abstract

Aristides Monteiro. War Reminiscences by the Surgeon of Mosby's Command. London, UK: Forgotten Books; 2015. 236 pp.

Keywords:

DOI:

War Time Medicine on a Peace Time Mission

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Reynolds S, Mclemore AN, Squires A. 12(4). 60 - 71. (Journal Article)

Abstract

As we realized the MEDEVAC from JTF-B was not going to happen, the words of instructors from the Joint Special Operations Medical Training Center (JSOMTC) echoed through my head, "Men, pay attention to this. There will be a day when you, as Deltas, will have to sustain a patient for hours, possibly days; this is what separates you from any other medical professional in the military, so shut up and stay awake." We had heard those words every time we started a new section of Special Forces Medical Sergeants (SFMS) course. Now those words were staring right back at us in the form of the patient's friends and family. We looked at our patient in the back of that beat up truck and knew we could keep our patient alive. We had the knowledge and the equipment; we just didn't know how much longer we would have to sustain him.

Keywords:

PMID: 23536459

DOI: 78YX-IPDC

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Warning: Tourniquets Risk Frostbite in Cold Weather

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Kragh JF, O'Conor DK. 23(1). 9 - 16. (Journal Article)

Abstract

We sought to better understand the frostbite risk during first-aid tourniquet use by reviewing information relevant to an association between tourniquet use and frostbite. However, there is little information concerning this subject, which may be of increasing importance because future conflicts against near-peer competitors may involve extreme cold weather environments. Historically, clinical frostbite cases with tourniquet use occurred in low frequency but in high severity when leading to limb amputation. The physiologic response of vasoconstriction to cold exposure leads to limb cooling and causes a reduction of limb blood flow, but cold-induced vasodilation ensues as periodic fluctuations that increase blood flow to hands and feet. In animal experiments, tourniquet use increased the development of frostbite. Evidence from human experiments also supports an association between tourniquet use and frostbite. Clinical guidance for caregiving to casualties at risk for frostbite with tourniquet use had previously been provided but slowly and progressively dropped out of documents. Conclusions: The cause of frostbite was deduced to be a sufficiently negative heat-transfer trend in local tissues, which tourniquet use may worsen because of decreasing tissue perfusion. An association between tourniquet use and frostbite exists but not as cause and effect. Tourniquet use increased the risk of the cold causing frostbite by allowing faster cooling of a limb because of reduced blood flow and lack of cold-induced vasodilation. Care providers above the level of the lay public are warned that first-aid tourniquet use in low-temperature (<0°C [<32°F]) environmental conditions risks frostbite.

Keywords: bleeding control and prevention; first aid; prehospital care; freezing cold injury; complication; wounds and injuries

PMID: 36854168

DOI: USQW-XVJH

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Warrior Model For Human Performacne And Injury Prevention: Eagle Tactical Athlete Program (ETAP) Part I

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Sell TC, Abt JP, Crawford K, Lovalekar M, Nagai T, Deluzio J, Smalley BW, McGrail MA, Rowe RS, Cardin S, Lephart SM. 10(4). 2 - 21. (Journal Article)

Abstract

Introduction: Physical training for United States military personnel requires a combination of injury prevention and performance optimization to counter unintentional musculoskeletal injuries and maximize warrior capabilities. Determining the most effective activities and tasks to meet these goals requires a systematic, research-based approach that is population specific based on the tasks and demands of the warrior. Objective: We have modified the traditional approach to injury prevention to implement a comprehensive injury prevention and performance optimization research program with the 101st Airborne Division (Air Assault) at Ft. Campbell, KY. This is Part I of two papers that presents the research conducted during the first three steps of the program and includes Injury Surveillance, Task and Demand Analysis, and Predictors of Injury and Optimal Performance. Methods: Injury surveillance based on a self-report of injuries was collected on all Soldiers participating in the study. Field-based analyses of the tasks and demands of Soldiers performing typical tasks of 101st Soldiers were performed to develop 101st-specific laboratory testing and to assist with the design of the intervention (Eagle Tactical Athlete Program (ETAP)). Laboratory testing of musculoskeletal, biomechanical, physiological, and nutritional characteristics was performed on Soldiers and benchmarked to triathletes to determine predictors of injury and optimal performance and to assist with the design of ETAP. Results: Injury surveillance demonstrated that Soldiers of the 101st are at risk for a wide range of preventable unintentional musculoskeletal injuries during physical training, tactical training, and recreational/sports activities. The field-based analyses provided quantitative data and qualitative information essential to guiding 101st specific laboratory testing and intervention design. Overall the laboratory testing revealed that Soldiers of the 101st would benefit from targeted physical training to meet the specific demands of their job and that sub-groups of Soldiers would benefit from targeted injury prevention activities. Conclusions: The first three steps of the injury prevention and performance research program revealed that Soldiers of the 101st suffer preventable musculoskeletal injuries, have unique physical demands, and would benefit from targeted training to improve performance and prevent injury.

Keywords:

PMID: 21442587

DOI: 556O-K7N2

Warrior Model For Human Performance And Injury Prevention: Eagle Tactical Athlete Program (ETAP) Part II

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Abt JP, Sell TC, Crawford K, Lovalekar M, Nagai T, Deluzio J, Smalley BW, McGrail MA, Rowe RS, Cardin S, Lephart SM. 10(4). 22 - 33. (Journal Article)

Abstract

Introduction: Physical training for United States military personnel requires a combination of injury prevention and performance optimization to counter unintentional musculoskeletal injuries and maximize warrior capabilities. Determining the most effective activities and tasks to meet these goals requires a systematic, research-based approach that is population specific based on the tasks and demands of the Warrior. Objective: The authors have modified the traditional approach to injury prevention to implement a comprehensive injury prevention and performance optimization research program with the 101st Airborne Division (Air Assault) at Fort Campbell, KY. This is second of two companion papers and presents the last three steps of the research model and includes Design and Validation of the Interventions, Program Integration and Implementation, and Monitor and Determine the Effectiveness of the Program. Methods: An 8-week trial was performed to validate the Eagle Tactical Athlete Program (ETAP) to improve modifiable suboptimal characteristics identified in Part I. The experimental group participated in ETAP under the direction of a ETAP Strength and Conditioning Specialist while the control group performed the current physical training at Fort Campbell under the direction of a Physical Training Leader and as governed by FM 21-20 for the 8-week study period. Results: Soldiers performing ETAP demonstrated improvements in several tests for strength, flexibility, performance, physiology, and the APFT compared to current physical training performed at Fort Campbell. Conclusions: ETAP was proven valid to improve certain suboptimal characteristics within the 8-week trial as compared to the current training performed at Fort Campbell. ETAP has long-term implications and with expected greater improvements when implemented into a Division pre-deployment cycle of 10-12 months which will result in further systemic adaptations for each variable.

Keywords:

PMID: 21442588

DOI: 42CI-ELHP

Warzone Stressor Exposure, Unit Support, and Emotional Distress Among U.S. Air Force Pararescuemen

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Armstrong EL, Bryan CJ, Stephenson JA, Bryan AO, Morrow CE. 14(2). 26 - 34. (Journal Article)

Abstract

Objectives: Combat exposure is associated with increased mental health symptom severity among military personnel, whereas unit support is associated with decreased severity. However, to date no studies have examined these relationships among U.S. Air Force pararescuemen (PJs), who have a unique and specialized career field that serves in both medical and combatant capacities. Design: Crosssectional self-report survey. Methods: Self-reported survey data regarding depression symptoms, posttraumatic stress disorder (PTSD) symptoms, perceived unit support, and exposure to traditional combat experiences (e.g., firefights) and medical consequences of combat (e.g., injuries and human remains) were collected from 194 PJs in seven rescue squadrons. Results: Levels of combat exposure were compared with previously published findings from combat units, and levels of medical exposure were compared with previously published findings among military medical professionals. Medical exposure intensity showed a stronger relationship with PTSD severity (ß = .365, p = .018) than with combat exposure intensity (ß = .136, ρ = .373), but neither combat nor medical exposure was associated with depression severity (ßs < .296, ρs > .164). Unit support was associated with less severe PTSD (ß = -.402, ρ < .001) and depression (ß = -.259, ρ = .062) symptoms and did not moderate the effects of combat or medical exposure. Conclusions: Medical stressors contribute more to PTSD among PJs than do traditional combat stressors. Unit support is associated with reduced PTSD and depression severity regardless of intensity of warzone exposure among PJs.

Keywords: unit support; military; trauma; combat exposure; pararescue; aftermath

PMID: 24952037

DOI: P7Z9-E8LW

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Watch Where You Point That: Pneumomediastinum From Pneumatic Nail Gun Injury to the Hand

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Nam JJ, Kelly WF. 21(1). 106 - 108. (Journal Article)

Abstract

Pneumatic nail guns are hand-held tools used in industrial and construction settings. Nail guns cause the most trauma with hospitalization among construction workers. To our knowledge, we report for the first time a case of pneumomediastinum from a nail gun injury to the hand. Our patient was a 40-year-old male construction worker who shot a nail gun into his hand. He became acutely dyspneic and was found to have a pneumomediastinum due to air insufflation. He later underwent tube thoracostomy and intubation. To our knowledge, this is the first report of pneumomediastinum from a nail gun injury to the hand.

Keywords: pneumatic nail guns; pneumomediastinum; nail gun injury

PMID: 33721316

DOI: 7R9Z-U2IE

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Water Decontamination Products for Wound Irrigation in Austere Environments: Benchtop Evaluation and Recommendations

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Holcomb I, Shiels S, Marsh N, Stinner D, McGwin G, Holcomb JB, Wenke JC. Ahead of Print. (Journal Article)

Abstract

Background: Irrigation is used to minimize infection of open wounds. Sterile saline is preferred, but potable water is becoming more widely accepted. However, the large volumes of water that are recommended are usually not available in austere environments. This study determined the long-term antimicrobial effectiveness of military purification powder compared with currently available civilian methods. The study also compared the physical characteristics and outcomes under the logistical constraints. Methods: Six commercially available water decontamination procedures were used to decontaminate five different sources of water (pond water, river water, inoculated saline, tap water, and sterile saline). Each product was evaluated based on six different parameters: bacterial culture, pH, turbidity, cost, flow rate, and size. Results: All methods of treatment decreased the bacterial count below the limit of detection. However, they had variable effects on pH and turbidity of the five water sources. Prices ranged from $7.95 to $350, yielding 10-10,000L of water, and weighing between 18 and 500g. Conclusion: In austere settings, where all equipment is carried manually, no single decontamination device is available to optimize all the measured parameters. Since all products effectively reduced microbial levels, their size, cost, and production capability should be evaluated for the intended application.

Keywords: infection; wound care; prehospital care

PMID: 38488823

DOI: 1FK6-PB2L

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We Cannot Afford to Lose the Lessons We Have Learned: COL (Ret) Rob Lutz's Reflections on a 20-Year SOF Medical Career

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Pennardt A. 17(3). 146 - 147. (Interview)

Keywords: interviews; Tactical Combat Casualty Care

PMID: 28910486

DOI: D054-Q4SH

What a Special Operations Cognitive Assessment Should Look Like

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Biggs A, Heller T, Colvin K, Wood D, Jewell JA, Littlejohn LF. 23(3). 18 - 23. (Journal Article)

Abstract

Special Operations organizations have recently demonstrated their commitment to enhanced cognitive functioning and improving brain health through the development of a Cognitive Domain. However, as this new enterprise becomes supported by more resources and personnel, a critical question involves what cognitive assessments should be conducted to evaluate cognitive functions. The assessment itself forms a crux in the Cognitive Domain that could mislead cognitive practitioners if not properly applied. Here, the discussion addresses the most important criteria to satisfy in the development of a Special Operations cognitive assessment, including operational relevance, optimization, and speed. Cognitive assessments in this domain must incorporate the following: (1) a task with clear operational relevance to ensure meaningful results, (2) no ceiling effects so that performance can support cognitive enhancement initiatives, and (3) the task itself should impose a minimal time requirement to avoid creating a substantial logistical burden. A dynamic threat assessment task supported by drift diffusion modeling can meet all requisite criteria, while also providing more insight into decision parameters of Special Operations personnel than any currently used test. The discussion concludes with a detailed description of this recommended cognitive assessment task, as well as the research and development steps needed to support its application.

Keywords: cognitive; assessment; Special Operations; drift diffusion; decisions

PMID: 37224387

DOI: UIMJ-G0CG

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What Can Be Done With Expired Pharmaceuticals? A Review Of Literature As It Pertains To Special Operations Force's Medics

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Culbertson NT. 11(3). 1 - 6. (Journal Article)

Abstract

Over the past decade, increasing evidence suggests that pharmaceuticals may continue to be potent beyond their date of expiration. Despite this evidence, we have not yet experienced a change in United States federal policy that would recommend usage of expired pharmaceuticals. While the scientific community and federal regulators continue to study the matter, the medical community is often guilty of misunderstanding the nuances of the issue. As a result, many healthcare professionals misinform their peers and their patients on either the appropriateness or inappropriateness of taking expired medications. Even though both the American Medical Association (AMA) and the Food and Drug Administration (FDA) do not recommend the dosing of expired pharmaceuticals at this time, discussion of the issue is warranted in order to understand the potential behind some expired drugs and to encourage further research. This discussion is particularly relevant to the Special Operations medical community, since Special Operations Force's (SOF) medic s frequently encounter expired medication overseas. Given thei r unique sk ill set and working environ ment, the SOF medic should be familiar with the potential applications of expired medications, including their drawbacks.

Keywords: date of expiration; expired pharmaceuticals; shelf-life extension

PMID: 21706454

DOI: 2YKV-VF0P

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What Every Sof Medic Should Know About Agroterrorism - Part I

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Farr KD. 07(4). 33 - 37. (Journal Article)

Abstract

Agroterrorism is "the deliberate introduction of a disease agent into livestock herds for the purposes of undermining socio-economic stability and/or generating fear." The threat of an agroterrorist attack on American soil is a growing concern. The financial, political, and social consequences of an attack are potentially enormous. This article will help SOF medics increase their understanding of the risks and consequences of agroterrorism and the foreign animal diseases that pose a threat.

Keywords:

DOI:

What Have We Done: The Moral Injury of Our Longest Wars

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Graverson SP. 22(2). 167 - 167. (Book Review)

Abstract

Wood D. What Have We Done: The Moral Injury of Our Longest Wars. Little, Brown Spark (November 1, 2016); 304 pages; ISBN 978-0-316-26414-3

Keywords:

What Is the Optimal Device Length and Insertion Site for Needle Thoracostomy in UK Military Casualties? A Computed Tomography Study

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Blenkinsop G, Mossadegh S, Ballard M, Parker PJ. 15(3). 60 - 65. (Journal Article)

Abstract

Significant lessons to inform best practice in trauma care should be learned from the last decade of conflict in Afghanistan and Iraq. This study used radiological data collated in the UK Military Hospital in Camp Bastion, Afghanistan, to investigate the most appropriate device length for needle chest decompression of tension pneumothorax (TP). We reviewed the optimal length of device and site needed for needle decompression of a tension pneumothorax in a UK military population and found no significant difference between sites for needle chest decompression (NCD). As a result, we do not recommend use of devices longer than 60mm for UK service personnel.

Keywords: decompression, chest; thoracostomy, needle; UK military

PMID: 26360355

DOI: 3G95-KN3U

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What the SOF Community Needs to Know About Dietary Supplements

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Deuster PA. 18(4). 131 - 136. (Journal Article)

Abstract

Dietary supplement (DS) use by military members and Special Operations Forces (SOF), in particular, is high. The "sports nutrition" market is expected to be one of the fastest growing segments because a "performance edge" is certainly desirable within the military. DS products are readily available in retail stores on military bases, over the Internet, and in niche stores near military bases. Thus, use of some DSs raises a number of unique concerns, particularly considering the potential for interactions among combinations of DS ingredients and concurrent medications taken under military operational conditions. All those who work with SOF should have a basic understanding of the DS world. This article briefly reviews selected DS regulations, identifies concerns and risks related to various DS products, and describes the purpose, functions, and resources of Operation Supplement Safety. Examples of regulatory concerns, adverse events, red flags, and tools are provided to help SOF communities sustain their health and performance.

Keywords: adulteration; human performance; new dietary ingredient; regulations; tainted products; supplements

PMID: 30566738

DOI: UR9N-LPVP

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What's in a Rash? Viral Exanthem Versus CBRNE Exposure: Teleconsultation Support for Two Special Forces Soldiers With Diffuse Rash in an Austere Environment

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Lee HD, Butterfield S, Maddry JK, Powell D, Vasios WN, Yun H, Ferraro D, Pamplin JC. 18(2). 133 - 135. (Journal Article)

Abstract

Objective: Review clinical thought process and key principles for diagnosing weaponized chemical and biologic injuries. Clinical Context: Special Operation Forces (SOF) team deployed in an undisclosed, austere environment. Organic Expertise: Two SOF Soldiers with civilian EMT-Basic certification. Closest Medical Support: Mobile Forward Surgical Team (2 hours away); medical consults available by e-mail, phone, or video-teleconsultation. Earliest Evacuation: Earliest military evacuation from country 12-24 hours. With teleconsultation, patients departed to Germany as originally scheduled without need for Medical Evacuation.

Keywords: telemedicine; chemical exposure; biologic exposure; military personnel; emergency treatment; patient transfer; prolonged field care

PMID: 29889970

DOI: 9NNM-E7J4

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When Minutes Matter: A Comparison of Whole Blood Collection Techniques

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Wier R, Walther S, Woodard C, Jordan CS, Matthews KJ, Deaton TG, Drew B, Byrne T, Zarow GJ. Ahead of Print. (Journal Article)

Abstract

Background: Fast and reliable blood collection is critical to emergency walking blood banks (WBB) because mortality significantly declines when blood is quickly administered to a warfighter with hemorrhagic shock. Phlebotomy for WBB is accomplished via either the "straight stick" (SS) or "ruggedized lock" (RL) method. SS comprises a 16-gauge phlebotomy needle connected to a blood collection bag via tubing. The RL device collects blood through the same apparatus, but has a capped, intravenous (IV) catheter between the needle and the donor's arm. This is the first study to compare these two methods in battlefield-relevant metrics. Methods: Military first responders and licensed medical providers (N=86) were trained in SS and RL as part of fresh whole blood training exercises. Outcomes included venipuncture success rates, time to IV access, blood collection times, total time, and user preferences, using a within-subjects crossover design. Data were analyzed using ANOVA and nonparametric statistics at p<0.05. Results: SS outperformed RL in first venipuncture success rates (76% vs. 64%, p=0.07), IV access times (448 [standard error of the mean; SE 23] vs. 558 [SE 31] s, p<0.01), and blood collection bag fill times (573 [SE 48] vs. 703 [SE 44] s, p<0.05), resulting in an approximate 3.5-minute faster time overall. Survey data were mixed, with users perceiving SS as simpler and faster, but RL as more reliable and secure. Conclusion: SS is optimal when timely collection is imperative, while RL may be preferable when device stability or replacing the collection bag is a consideration.

Keywords: phlebotomy; intravenous access; hemorrhagic shock; blood donation; walking blood bank; emergency donor panel; buddy transfusion; Tactical Combat Casualty Care

PMID: 38446068

DOI: N87K-W6BZ

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Where Do We Stand on "Buddy Transfusion" During Military Operations?

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Daniel Y, Derkenne C, Mahe P, Travers S, Martinaud C. 22(4). 46 - 49. (Journal Article)

Abstract

Warm fresh whole-blood transfusion between comrades on the battlefield, also known as "buddy transfusion," has been thrust back into the limelight for several years now. It means drawing blood on the battlefield, once a bleeding soldier needs a transfusion, from one of their uninjured companions and immediately infusing it. It is a lifesaving procedure, effective and hardy. This work aims to answer the main questions that military caregivers might have about it: interest of this procedure, donor and recipient safety, and hemostatic capacity of the blood collected this way.

Keywords: blood transfusion; war-related injuries; hemostasis; physical exertion; military deployment; thrombin; transfusions; buddy transfusions; whole blood

PMID: 36525011

DOI: J1X0-4X05

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Where There's a War, There's a Way: A Brief Report on Tactical Combat Casualty Care Training in a Multinational Environment

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Conyers K, Gillies AB, Sibley C, McMullen C, Remley MA, Wence S, Gurney J. 23(1). 130 - 133. (Journal Article)

Abstract

Background: With most combat deaths occurring in prehospital settings, the US Armed Forces focuses on life-threatening conditions at or near the point of injury. Tactical Combat Casualty Care (TCCC) guidelines are required for all US Servicemembers. Multinational militaries lack this requirement, and international partner forces often have limited prehospital medical training. Methods: From November 2019 to March 2020, military members assigned to the Role 2E at the Hamid Kazai International Airport (HKIA) North Atlantic Treaty Organization (NATO) base conducted multinational TCCC training. The standardized Joint Trauma System (JTS) TCCC curriculum consisted of two-day classroom instruction and situational training exercises. Competency was assessed through verbalized and demonstrated knowledge. After Action Reviews (AAR) were completed. Results: Twelve multinational TCCC training courses trained 590 military Servicemembers and civilians from 10 countries, ranging from 16 to 62 participants (avg class size = 35). Portugal and Turkey represented the two largest participating nations with 219 and 133, respectively. Student feedback determined optimal group ratios for instruction. AARs were reviewed to categorize best practices. Conclusion: Multinational TCCC standardization will save lives. Most nations lack TCCC training requirements. Thus, providing opportunities for standardized training for HKIA residents helped established a multinational baseline of medical interoperability. Utilizing this curriculum in multinational environments can replicate these results. International adoption of TCCC is dynamic and ongoing and should be promulgated to reduce preventable deaths.

Keywords: Tactical Combat Casualty Care; TCCC; training, trauma; MASCAL; mass casualty; deployed

PMID: 36800525

DOI: WKSE-6PVS

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Who Owns Battlefield Medicine?

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Kragh JF. 13(3). 112 - 112. (Interview)

Abstract

Bob Mabry on Being SOMA President and Being at Black Hawk Down

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PMID: 24049004

DOI: 1EQ4-YBSD

Whole Blood Storage Temperature Investigation in Austere Environments

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Avila CO, Sayson SC, Bennett B. 22(3). 19 - 21. (Journal Article)

Abstract

Introduction: Military medical research has affirmed that early administration of blood products and timely treatment save lives. The US Navy's Expeditionary Resuscitative Surgical System (ERSS) is a Role 2 Light Maneuver team that functions close to the point of injury, administering blood products and providing damage-control resuscitation and surgery. However, information is lacking on the logistical constraints regarding provisions for and the stability of blood products in austere environments. Methods: ERSS conducted a study on the United States Central Command (USCENTCOM) area of responsibility. Expired but properly stored units of stored whole blood (SWB) were subjected to five different storage conditions, including combinations of passive and active refrigeration. The SWB was monitored continuously, including for external ambient temperatures. The time for the SWB to rise above the threshold temperature was recorded. Results: The main outcome of the study was the time for the SWB to rise above the recommended storage temperature. Average ambient temperature during the experiment involving conditions 1 through 4 was 25.6°C (78.08°F). Average ambient temperature during the experiment involving condition 5 was 34.8°C (94.64°F). Blood temperature reached the 6°C (42.8°F) threshold within 90 minutes in conditions 1 and 2, which included control and chemically activated ice packs in the thermal insulated chamber (TIC). Condition 2 included prechilling the TIC in a standard refrigerator to 4°C (39.2°F), which kept the units of SWB below the threshold temperature for 490 minutes (approximately 8 hours). Condition 4 entailed prechilling the TIC in a standard freezer to 0.4°C (32.72°F), thus keeping the units of SWB below threshold for 2,160 minutes (i.e., 36 hours). Condition 5 consisted of prechilling the TIC to 3.9°C (39.02°F) in the combat blood refrigerator, which kept the SWB units below the threshold for 780 minutes (i.e., 13 hours), despite a higher average ambient temperature of almost +10°C (50°F). Conclusion: Combining active and passive refrigeration methods will increase the time before SWB rises above the threshold temperature. We demonstrate an adaptable approach of preserving blood product temperature despite refrigeration power failure in austere settings, thereby maintaining mission readiness to increase the survival of potential casualties.

Keywords: stored whole blood; forward deployed surgical team; austere environments; walking blood bank; fresh whole blood; Role 2 care; blood transfusion; Golden Hour Offset Surgical Team

PMID: 35862848

DOI: Z785-2PXQ

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Why Civil Resistance Works: The Strategic Logic of Nonviolent Conflict

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Farr WD. 14(4). 139 - 139. (Book Review)

Abstract

Chenoweth, Erica, and Stephan, Maria J. Why Civil Resistance Works: The Strategic Logic of Nonviolent Conflict. West Sussex, England: Columbia University Press; 2011.
Paperback, 320 pages, 11 figures, 19 tables. ISBN: 978-0-231-15683-7. $22.00/£15.00.

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Willingness of Emergency Medical Services Professionals to Respond to an Active Shooter Incident

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Chovaz M, Patel RV, March JA, Taylor SE, Brewer KL. 18(4). 82 - 86. (Journal Article)

Abstract

Background: Historically, staging of civilian emergency medical services (EMS) during an active shooter incident was in the cold zone while these professionals awaited the scene to be completely secured by multiple waves of law enforcement. This delay in EMS response has led to the development of a more effective method: the Rescue Task Force (RTF). The RTF concept has the second wave of law enforcement escorting civilian EMS into the warm zone, thus decreasing EMS response time. To our knowledge, there are no data regarding the willingness of EMS professionals to enter a warm zone as part of an RTF. In this study, we assessed the willingness of EMS providers to respond to an active shooter incident as part of an RTF. Methods: A survey was distributed at an annual, educational EMS conference in North Carolina. The surveys were distributed on the first day of the conference at the beginning of a general session that focused on EMS stress and wellness. Total attendance was measured using identification badges and scanners on exiting the session. Data were assessed using χ2 analysis, as were associations between demographics of interest and willingness to respond under certain conditions. A p value < .01 indicated statistical significance. Results: The overall response rate was 76% (n = 391 of 515 session attendees). Most surveys were completed by paramedics (74%; n = 288 of 391). Most EMS professionals (75%; n = 293 of 391) stated they would respond to the given active shooter scenario as part of an RTF (escorted by the second wave of law enforcement) if they were given only ballistic gear. However, most EMS professionals (61%; n = 239 of 391) stated they would not respond if they were provided no ballistic gear and no firearm. Those with tactical or military training were more willing to respond with no ballistic gear and no firearm (49.6%; n = 68 of 137) versus those without such training (31%; n = 79 of 250; odds ratio, 2.2; 95% confidence interval, 1.4-3.3; p < .001). Conclusion: EMS professionals are willing to put themselves in harm's way by entering a warm zone if they are simply provided the proper training and ballistic equipment.

Keywords: emergency medical services; EMS; active shooter incident; Rescue Task Force

PMID: 30566728

DOI: RQN5-WWBY

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Winged Scalpel: A Surgeon at the Frontline of Disaster

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Farr WD. 15(2). 147 - 147. (Book Review)

Abstract

Villar, Richard. Winged Scalpel. A Surgeon at the Frontline of Disaster.
Barnsley, South Yorkshire, United Kingdom: Pen and Sword Book Limited; 2013.
Hardcover, 224 pages. ISBN-10: 1781591687 ; ISBN-13: 978-1781591680.

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WITHDRAWN: The 'BATH' Assessment Algorithm No Longer Meets the Needs of American Law Enforcement

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George T, Nealy W, Scott ME. Ahead of Print. (Editorial)

Abstract

This article has been witdrawn at the request of the author(s). The Publisher apologizes for any inconvenience this may cause.

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PMID: 38278771|REJECTED: Cannot Replace Article: Replacement file must use the original ArticleIds

DOI: XCXL-JVFE

Without Jumping to Conclusions

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Hampton K. 19(2). 127 - 127. (Journal Article)

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PMID: 31201767

DOI: 8PEU-949F

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Women in US Military History

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Garceau-Kragh G. 22(3). 75 - 83. (Editorial)

Keywords: women; military; history

PMID: 36122556

DOI: Z2WS-HWCX

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Workload of Swedish Special Forces Operators Experienced During Stressful Simulation Training: A Pilot Study

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Hindorf M, Berggren P, Jonson C, Lundberg L, Jonsson A. 22(3). 42 - 48. (Journal Article)

Abstract

Introduction: Stress week was included during training of Special Forces (SF) Operators in Sweden to test their ability and limits for handling stress in different unknown situations and environments at a military training facility in Sweden. The aim of the study was to examine the effects of stress and workload experienced in various tasks during firefighting and military medicine simulation training. Methods: This pilot study was performed during the second day of stress week. The National Aeronautics and Space Administration Task Load Index (NASA-TLX) is a validated, subjective, and multidimensional assessment tool for rating perceived workload with six subscales: mental demand, physical demand, temporal demand, performance, effort, and frustration. These subscales were used as an indicator of stress experienced. The different tasks were assessed by the SF Operators by rating the NASA-TLX subscales for each task, which were then analyzed and compared using ANOVA. Results: There was a significant difference between the two simulation exercises assessed by the participants and instructors, and both groups considered firefighting to be more demanding than medical. The participants perceived the mental and physical demands as more demanding in the firefighting exercises, as well as for the level of frustration and effort. However, no differences regarding performance or temporal demands between the simulation exercises were found. Conclusion: The principle "train as you fight" implies difficult and demanding situations. When exposing Swedish SF Operators to challenging situations, assessment of perceived stress and performance are possible.

Keywords: military training; stress; simulation; NASA-TLX

PMID: 35862842

DOI: UDGU-Q4OW

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Worldwide Case Reports Using the iTClamp for External Hemorrhage Control

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McKee JL, Kirkpatrick AW, Bennett BL, Jenkins DA, Logsetty S, Holcomb JB. 18(3). 39 - 44. (Journal Article)

Abstract

Background: Historically, hemorrhage control strategies consisted of manual pressure, pressure dressings, gauze with or without hemostatic ingredients for wound packing, or the use of tourniquets. The iTClamp is a relatively new alternative to stop external bleeding. Methods: An anonymous survey was used to evaluate the outcomes of the iTClamp in worldwide cases of external bleeding. Results: A total of 245 evaluable applications were reported. The iTClamp stopped the bleeding in 81% (n = 198) of the cases. Inadequate bleeding control was documented in 8% (n = 20) and in the remaining 11% (n = 27), bleeding control was not reported. The top three anatomic body regions for iTClamp application were the scalp, 37% (n = 91); arm, 20% (n = 49); and leg, 19% (n = 46). In 26% of the reported cases (direct pressure [23% (n = 63)] and tourniquets [3% (n = 8]), other techniques were abandoned in favor of the iTClamp. Conversely, the iTClamp was abandoned in favor of direct pressure 11 times (4.4%) and abandoned in favor of a tourniquet three times (1%). Conclusion: The iTClamp appears to be a fast and reliable device to stop external bleeding. Because of its function and possible applications, it has potential to lessen the gap between and add to the present selection of devices for treatment of external bleeding.

Keywords: trauma; bleeding control; emergency medical services; iTClamp

PMID: 30222835

DOI: ZIY0-8LIH

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You Never Know, Until You Know, and Then You Know: An Interview With COL (Ret) John F. Kragh Jr, MD

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Pennardt A. 18(1). 147 - 148. (Interview)

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PMID: 29533452

DOI: 3LR9-9AFJ

Your Metric Matters! Choose Wisely to Assess User Performance With Tourniquets in Simulated First Aid

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Zhao NO, Kragh JF, Aden JK, Jordan BS, Parsons DL, Dubick MA. 18(3). 22 - 27. (Journal Article)

Abstract

Background: Readiness to perform lifesaving interventions during emergencies is based on a person's preparation to proficiently execute the skills required. Graphically plotting the performance of a tourniquet user in simulation has previously aided us in developing our understanding of how the user actually behaves. The purpose of this study was to explore performance assessment and learning curves to better understand how to develop best teaching practices. Methods: These were retrospective analyses of a convenience sample of data from a prior manikin study of 200 tourniquet uses among 10 users. We sought to generate hypotheses about performance assessments relevant to developing best teaching practices. The focus was on different metrics of user performance. Results: When one metric was chosen over another, failure counts summed cumulatively over 200 uses differed as much as 12-fold. That difference also indicated that the degree of challenge posed to user performance differed by the metric chosen. When we ranked user performance with one metric and then with another, most (90%; nine of 10) users changed rank: five rose and four fell. Substantial differences in performance outcomes resulted from the difference in metric chosen, which, in turn, changed how the outcome was portrayed and thus interpreted. Hypotheses generated included the following: The usefulness of a specific metric may vary by the user's level of skill from novice to expert; demonstration of the step order in skill performance may suffice for initial training of novices; a mechanical metric of effectiveness, like pulse stoppage, may aid in later training of novices; and training users how to practice on their own and self-assess performance may aid their self-development. Conclusion: The outcome of the performance assessments varied depending on the choice of metric in this study of simulated use of tourniquets.

Keywords: education standards measures; implementation; individuality; choice behavior; first aid

PMID: 30222832

DOI: QCIU-59MA

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Yugoslav Guerrilla Hospital Design Features and Operation in World War II

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Colesar MT, Baker JB. 23(3). 24 - 31. (Journal Article)

Abstract

In the most austere combat conditions, Yugoslav guerillas of World War II (WWII) demonstrated an innovative and effective hospitalization system that saved countless lives. Yugoslav Partisans faced extreme medical and logistical challenges that spurred innovation while waging a guerrilla war against the Nazis. Partisans used concealed hospitals ranging between 25 to 215 beds throughout the country with wards that were often subterranean. Concealment and secrecy prevented discovery of many wards, which prototypically contained two bunk levels and held 30 patients in a 3.5 × 10.5-meter space that included storage and ventilation. Backup storage and treatment facilities provided critical redundancy. Intra-theater evacuation relied on pack animals and litter bearers while partisans relied on Allied fixed wing aircraft for inter-theater evacuation.

Keywords: Yugoslavia; warfare; hospital design and construction; military personnel; military health; military medicine; war-related injuries; armed conflicts; World War II

PMID: 37224389

DOI: T4A2-PY3C

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Zika Virus

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Burnett MW. 16(1). 86 - 87. (Journal Article)

Keywords: Zika Virus

PMID: 27045503

DOI: SHFO-PY0C

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Zoonotic And Infectious Disease Surveillance In Central America: Honduran Feral Cats Positive For Toxoplasma, Trypanosoma, Leishmania, Rickettsia, And Lyme Disease

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McCown ME, Grzeszak B. 10(3). 41 - 43. (Journal Article)

Abstract

A recent zoonotic and infectious disease field surveillance study in Honduras resulted in the discovery of Toxoplasma, Trypanosoma, Leishmania, Rickettsia, and Lyme disease with significantly high prevalence rates in a group of feral cats. All five diseases - toxoplasmosis,trypanosomiasis, leishmaniasis, rickettsiosis, and Lyme disease - were confirmed in this group of cats which maintained close contact to local civilians and U.S. personnel. These diseases are infectious to other animals and humans primarily through vector transmission or ingestion. In the austere Central and South American sites that Special Operations Forces (SOF) medics are deployed, the living conditions and close quarters are prime environments for the potential spread of infectious and zoonotic disease. This study's findings, as with previous veterinary disease surveillance studies, emphasize the critical need for continual and aggressive surveillance for zoonotic and infectious disease presence within animals in specific areas of operation (AO). The importance to SOF is that a variety of animals may be sentinels, hosts, or direct transmitters of disease to civilians and servicemembers. These studies are value-added tools to the U.S. military, specifically to a deploying or already deployed unit. The SOF medic must ensure that this value-added tool is utilized and that findings are applied to assure Special Forces Operational Detachment - Alpha (SFOD-A) health and, on a bigger scale, U.S. military force health protection and local civilian health.

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PMID: 21049434

DOI: 13SQ-OK4V

Zoonotic And Infectious Disease Surveillance In Ecuador: Ehrlichia Canis, Anaplasma Phagocytophilum, Borrelia Burgdorferi, And Dirofilaria Immitis Prevalence Rates In Canines

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Mccown M, Monterroso VH, Grzeszak B. 11(4). 61 - 65. (Journal Article)

Abstract

Vector-borne diseases (VBD) make up a large number of emerging infectious and zoonotic diseases. Ticks, fleas, and mosquitoes are effective vectors parasitizing canines, making dogs adequate reservoirs for zoonoses. The U.S. military deploys personnel and government- owned animals around the world with possible risk of exposure to VBD. Canine VBD have veterinary and public health significance for the host nations as well as for the U.S. troops and its working animals deployed in the theater of operations. These factors make disease surveillance a great importance. The objective of this work was to survey canines from the cities of Manta and Guayaquil in Ecuador to determine prevalence of heartworm disease (D. immitis), ehrlichi os is (E. canis), Lyme disease (B. burgdorf eri), and anapl asmosis (A. phagocytophilum). Canine blood samples (1-3ml) collected from the cities of Manta (n=50) and Guayaquil (n=50) were tested on site using a SNAP® 4Dx® Test Kit. Prevalence for single or multiple disease status was calculated for each city. In the city of Manta the overall prevalence of diseases was 78%; 52% for E. canis alone, and 26% for co-infection with E. canis and A. phagocytophilum. The overall prevalence for the city of Guayaquil was 88%; 40% for E. canis alone, 22% for A. phagocytophilum alone, and 26% for co-infection with E. canis and A. phagocytophilum. Neither heartworm disease nor Lyme disease was detected in any samp le. In conclusion, this study showed the extensive presence of E. canis and A. phagocytophilum in both cities in Ecuador, emphasizing the value of surveillance for zoonotic diseases to determine disease prevalence and risk assessments, as well as to implement control measures.

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PMID: 22173599

DOI: 9U3U-BCIZ

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