JSOM Header

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.

Once you find an article in which you are interested, you may click on the title of that article to view the article in PDF format. You must have a Digital Journal subscription in order to view these articles. If you do not have access to the Digital Journal, you may subscribe here. Existing members will be asked to provide login credentials. You will also be provided a link at which you may purchase the individual article on our online store. On checkout, you will receive an email with a link where you can download the article.

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

Top

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

Abstract

-Frank Butler on serving the operational medicine community

Keywords:

"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."

Top

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

Abstract

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

Keywords:

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

Top

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

Keywords:

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

Top

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

Abstract

-Rob Miller on Changing Trauma Care

Keywords:

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

Top

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

Abstract

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

Keywords:

"It's What Color?"

Top

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

Buy Now

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

Top

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

Abstract

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

Keywords:

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

Top

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

Abstract

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

Keywords:

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

Top

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

Keywords:

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

Top

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

Keywords:

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

Top

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

Abstract

Ray Casillas on a Career in Operational Medicine

Keywords:

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

Top

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

Keywords:

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

Top

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

Keywords:

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

Top

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

Abstract

-Steve Rush on US Air Force Pararescue and Pararescuemen Today

Keywords:

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

Top

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

Keywords:

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

Top

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:

Buy Now

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

Top

Faudree LK. 10(1). 4 - 6. (Journal Article)

Keywords:

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

Top

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

Buy Now

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

Top

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:

Buy Now

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

Top

Hart RS, Detro JF. 09(1). 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:

A Case Of Tapework Infestation

Top

Kacoroski J, Bonk C, Gilpatrick S. 10(2). 46 - 48. (Case Reports)

Keywords:

A Case Study of MEDCANGRO Relative to RAND Conceptual Framework*

Top

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)

Buy Now

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

Top

Boedeker BH, Nicholas TA, Carpenter J, Leighton S, Bernhagen MA, Murray WB, Wadman MC. 11(2). 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

Buy Now

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

Top

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

Buy Now

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

Top

Mabry RL, Cuenca PJ. 08(3). 55 - 57. (Editorial)

Keywords:

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

Top

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

Buy Now

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

Top

Aberle SJ, Lohse CM, Sztajnkrycer MD. 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

Buy Now

A Herpes Zoster Outbreak on the Sinai Peninsula

Top

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

Buy Now

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

Top

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:

Buy Now

A Medical Training Event for Special Forces Medical Sergeants

Top

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

Buy Now

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

Top

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

Buy Now

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

Top

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

Buy Now

A New Look On Civil Military Operations

Top

Johnston M, Shearer J, Wilson W. 08(3). 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.

Keywords:

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

Top

Johnson TC. 11(3). 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:

Buy Now

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

Top

Nowrouzzadeh F. 07(3). 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.

Keywords:

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

Top

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

Buy Now

A Novel Ultrasound Transmission Gel for Resource-Constrained Environments

Top

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

Buy Now

A Painful Rash in an Austere Environment

Top

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

Buy Now

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

Top

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

Buy Now

A Prehospital Trauma Registry for Tactical Combat Casualty Care

Top

Kotwal RS, Montgomery HR, Mechler KK. 11(3). 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:

Buy Now

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

Top

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

Buy Now

A Review of Reduction Techniques for Anterior Glenohumeral Joint Dislocations

Top

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

Buy Now

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

Top

Arcure J, Harrison EE. 09(2). 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:

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

Top

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

Buy Now

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

Top

Lang G. 08(2). 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:

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

Top

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

Buy Now

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

Top

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

Buy Now

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

Top

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

Buy Now

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

Top

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

Buy Now

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

Top

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

Keywords:

Buy Now

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

Top

Butler FK, Kotwal RS, Buckenmaier CC, Edgar EP, O'Connor KC, Montgomery HR, Shackelford S, 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

Buy Now

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

Top

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

Buy Now

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

Top

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

Buy Now

Abdominal Aortic Tourniquet™ Use in Afghanistan

Top

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

Buy Now

Abdominal Pain

Top

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

Buy Now

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

Top

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

Buy Now

Acute Mountain Sickness Prophylaxis In The SOF Operator

Top

Pennardt A, Talbot T. 08(2). 65 - 66. (Editorial)

Keywords:

Acute Traumatic Wound Management in the Prolonged Field Care Setting

Top

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

Keywords:

Buy Now

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

Top

Walker TB, Lennemann LM, Anderson V, Lyons W, Zupan MF. 11(2). 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:

Buy Now

Adaptive Eyewear: Freeing The (visually) Oppressed

Top

DePold GD. 08(3). 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.

Keywords:

Addressing Maternal Healthcare Needs in the Counterinsurgency Environment

Top

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:

Buy Now

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

Top

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

Keywords:

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

Top

Mabry RL, Cuniowski P, Frankfurt A, Adams BD. 11(2). 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:

Buy Now

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

Top

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

Buy Now

Advancing The Art And Science Of Medical Plans

Top

Reed B. 09(3). 96 - 98. (Journal Article)

Keywords:

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

Top

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

Abstract

Timothy Floyd, MD
Artbook Press, 2010.

Keywords:

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

Top

Ervin MD. 08(1). 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).

Keywords:

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

Top

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

Buy Now

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

Top

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

Buy Now

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

Top

Brandon J, Hill GJ. 11(1). 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:

An Analysis of Battlefield Cricothyrotomy in Iraq and Afghanistan

Top

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:

Buy Now

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

Top

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

Buy Now

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

Top

Tien HC, Jung V, Rizoli SB, Acharya SV, MacDonald JC. 09(4). 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:

An Integrated Approach for Special Operations

Top

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

Buy Now

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

Top

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

Abstract

Interviewed by COL (Ret) Andre Pennardt, MD

Keywords: interviews; Viola, Steven

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

Top

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

Buy Now

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

Top

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

Buy Now

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

Top

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

Keywords:

Buy Now

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

Top

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

Buy Now

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

Top

Adkins DE, Mahon RT, Bennett S. 07(3). 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:

Analgesia and Sedation Management During Prolonged Field Care

Top

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

Keywords: sedation; analgesia; prolonged field care; guidelines

Buy Now

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

Top

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

Buy Now

Another Civilian Life Saved by Law Enforcement-Applied Tourniquets

Top

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

Buy Now

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

Top

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

Buy Now

Articulating Tractical Traction Splint Use on Pulseless Forearm Fracture

Top

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

Buy Now

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

Top

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

Buy Now

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

Top

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

Buy Now

Atlas of Conducted Electrical Weapon Wounds and Forensic Analysis

Top

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:

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

Top

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

Buy Now

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

Top

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

Buy Now

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

Top

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

Keywords:

Buy Now

Avoiding Program-Induced Cumulative Overload (PICO)

Top

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

Buy Now

Baseline Dissociation And Prospective Success In Special Forces Assessment And Selection

Top

Morgan CA, Hazlett G, Dial-Ward M, Southwick SM. 09(1). 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:

Basic Biostatistics and Clinical Medicine

Top

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

Keywords: biostatics, statistics; tests; specificity; sensitivity

Buy Now

Battlefield Analgesia: TCCC Guidelines Are Not Being Followed

Top

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

Buy Now

Battlefield Use Of Human Plasma By Special Operations Forces

Top

Murphy C. 08(3). 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:

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

Top

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:

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

Top

Asuku ME, Milner SM, Gerold KB. 11(4). 28 - 30. (Journal Article)

Keywords:

Buy Now

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

Top

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:

Buy Now

Biometrics in Support of Special Forces Medical Operations

Top

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:

Buy Now

Blast Traumatic Brain Injury - What Do We Know?

Top

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

Buy Now

Blood and Belonging: Journeys Into the New Nationalism

Top

Farr W. 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:

Blood Flow Restriction Rehabilitation for Extremity Weakness: A Case Series

Top

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

Buy Now

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

Top

Shearer D, Mahon RT. 09(2). 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.

Keywords:

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

Top

Hester RA. 11(3). 79 - 80. (Book Review)

Abstract

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

Keywords:

Caffeine and Performance

Top

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

Buy Now

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

Top

Taylor WM. 08(2). 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.

Keywords:

Canine Tactical Field Care Part Three - Thoracic and Abdominal Trauma

Top

Taylor WM. 10(4). 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.

Keywords:

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

Top

Taylor WM. 09(1). 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.

Keywords:

Care of the Burn Casualty in the Prolonged Field Care Environment

Top

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

Buy Now

Care Of The Military Working Dog By Medical Providers

Top

Vogelsang R. 07(1). 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.

Keywords:

Carfentanil: A New and Often Unrecognized Threat

Top

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.

Keywords:

Buy Now

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

Top

McLeroy RD, Ellis JL, Karnopp JM, Dellavolpe J, Gurney J, Keenan S, Powell D, Riesberg J, 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

Buy Now

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

Top

Delmonaco BL. 07(1). 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.

Keywords:

Case Report of an Anthrax Presentation Relevant to Special Operations Medicine

Top

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

Buy Now

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

Top

Thompson WD. 11(2). 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

Buy Now

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

Top

Hettich T, Whitfield E, Kratz K, Frament C. 10(3). 48 - 55. (Case Reports)

Keywords:

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

Top

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.

Keywords:

Buy Now

Casualty Wounding Patterns In Special Operations Forces In Operation Iraqi Freedom

Top

Royal J. 08(1). 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.

Keywords:

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

Top

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

Buy Now

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

Top

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

Buy Now

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

Top

Kotwal RS, Butler FK, Murray CK, Hill GJ, Rayfield JC, Miles EA. 09(2). 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:

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

Top

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

Keywords:

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

Top

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

Buy Now

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

Top

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

Buy Now

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

Top

Harcke HT, Pearse LA, Levy AD, Getz JM, Robinson SR. 08(1). 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.

Keywords:

Chikungunya

Top

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

Buy Now

Cinnarizine for Sea Sickness During a Remote Pacific Ocean Rescue Mission

Top

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

Buy Now

Clinical Diagnoses In A Special Forces Group: The Musculoskeletal Burden

Top

Lynch JH, Pallis MP. 08(1). 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.

Keywords:

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

Top

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

Buy Now

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

Top

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

Buy Now

Clinical Image: Visual Estimation of Blood Loss

Top

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

Buy Now

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

Top

Gilpatrick S. 09(4). 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:

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

Top

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

Buy Now

Closing The Gap: Improving Trauma Care On The Ukrainian Battlefield

Top

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

Buy Now

Combat Ready Clamp Medic Technique

Top

Tovmassian RV, Kragh JF, Dubick MA, Baer DG, 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

Buy Now

Combat Trousers as Effective Improvised Pelvic Binders A Comparative Cadaveric Study

Top

Loftus A, Morris R, Friedmann Y, Pallister I, Parker P. 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

Buy Now

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

Top

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

Keywords:

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

Top

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:

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

Top

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

Keywords:

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

Top

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

Keywords:

Community Acquired Methicillin Resistant Staphylococcus Aureus

Top

Hammes JS. 07(2). 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:

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

Top

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

Buy Now

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

Top

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:

Buy Now

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

Top

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

Buy Now

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

Top

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:

Buy Now

Comprehensive Performance Nutrition for Special Operations Forces

Top

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

Buy Now

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

Top

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

Buy Now

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

Top

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

Buy Now

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

Top

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

Buy Now

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

Top

Caci JB. 11(1). 8 - 11. (Journal Article)

Keywords:

Crimean-Congo Hemorrhagic Fever

Top

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

Buy Now

C-TECC Update

Top

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

Keywords:

Cultural Competency and Patient-Centered Communication: A Study of an Isolated Outbreak of Urinary Tract Infections in Afghanistan

Top

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

Buy Now

Cultural Self-Awareness as a Crucial Component of Military Cross-Cultural Competence

Top

Pappamihiel CJ. 13(3). 62 - 69. (Journal Article)

Abstract

The military forces in the United States represent a unique culture that includes many subcultures within their own military society. Acculturation into the military often deemphasizes the influence of personal narrative and thereby establishes the primacy of military culture over personal cultural influences. The authors make the argument that military personnel need to further develop an understanding and appreciation of personal cultural narrative as well as organizational culture. The increased integration of military personnel with interagency partners, along with cooperative efforts between relief organizations, and nongovernmental organizations in politically/economically unstable areas around the globe serves to make cross-cultural interaction unavoidable in the future. Military medical personnel are especially likely to interact with others who have culturally different values. These interactions can occur between organizations as easily as they can during patient care. They must be able to step outside of their military culture and develop cross-cultural competence that is grounded in cultural self-awareness. Without an appropriate level of cultural self-awareness, military and medical personnel run the risk of being unable to communicate across dissimilar cultures or worse, alienating key stakeholders in collaborative operations between military services, coalition partners, and nonmilitary organizations. It is the authors' contention that unless military personnel, especially those in the medical arena, are able to appropriately self-assess situations that are impacted by culture, both their own and the other personnel involved, the resulting cultural dissonance is more likely to derail any significant positive effect of such collaborations.

Keywords: military cultural sensitivity; cultural awareness in the Armed Forces; cultural self-awareness

Buy Now

Cutaneous Leishmaniasis

Top

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

Buy Now

Cutaneous Leishmaniasis: The Efficacy of Nonantimony Treatment in the Austere Environment Using Cryotherapy, Thermotherapy, and Photodynamic Therapy as an Alternative Method of Treatment

Top

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

Buy Now

Damage Control and Point of Injury Care: Extending the Care Continuum to Military Prehospital Providers

Top

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:

Buy Now

Damage Control Resuscitation For The Special Forces Medic - Simplifying And Improving Prolonged Trauma Care: Part Two

Top

Hetzler MR, Risk G. 09(3). 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:

Damage Control Resuscitation For The Special Forces Medic: Simplifying And Improving Prolonged Trauma Care: Part One

Top

Risk G, Hetzler MR. 09(2). 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:

Dark Invasion - 1915: Germany's Secret War and the Hunt for the First Terrorist Cell in America

Top

Farr W. 14(2). 105 - 105. (Book Review)

Abstract

Howard Blum. New York: HarperCollins; 2014. 491 pages. ISBN: 978-0-06-23075-5.

Keywords:

Decompression Sickness Following Altitude-Chamber Training

Top

Studer NM, Hughes JR, Puskar J. 15(1). 11 - 15. (Journal Article)

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

Buy Now

Deconstructing the Definition of Prolonged Field Care

Top

Keenan S. 15(4). 125 - 125. (Journal Article)

Keywords:

Buy Now

Delayed Diagnosis of Pelvic hematoma without Fracture Due to Military Parachuting

Top

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

Buy Now

Dengue Infections

Top

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

Buy Now

Deployed Assessment and Management of mTBI Casualties

Top

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

Buy Now

Design and Demonstration of a Battery-Less Fluid Warmer for Combat

Top

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

Buy Now

Detection of Increased Intracranial Pressure by Ultrasound

Top

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:

Buy Now

Development of a Rugged handheld Device for Real-Time Analysis of heart Rate: Entropy in Critically Ill Patients

Top

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

Buy Now

Different Width and Tightening System: Emergency Tourniquets on Distal Limb Segments

Top

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

Buy Now

Differential Diagnosis Of Shoulder Pain Followed By Progressive Weakness: A Case Report

Top

Rosenthal MD. 09(4). 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:

Difficult Diagnoses in an Austere Environment: A Clinical Vignette-The Presentation, Diagnosis, and Management of Ichthyosis

Top

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:

Buy Now

Digital Intubation: The Two-Fingered Solution to Securing an Airway

Top

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

Buy Now

Dislocation Of The Knee: Imaging Findings

Top

Shearer D, Lomasney L, Pierce K. 10(4). 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:

Diving Medicine: A Review Of Current Evidence

Top

Lynch JH, Bove AA. 09(3). 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:

Don't Let the Word "Myopic" Blind You

Top

Callaway DW. 16(3). 120 - 122. (Classical Conference)

Keywords:

Drug-Induced Liver Injury Secondary to Testosterone Prohormone Dietary Supplement Use

Top

Hoedebecke KL, Rerucha C, Maxwell K, Butler J. 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

Buy Now

Early, Prehospital Activation of the Walking Blood Bank Based on Mechanism of Injury Improves Time to Fresh Whole Blood Transfusion

Top

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

Buy Now

Easy Scan and Easy Fix for the Shoulder Injury in a Difficult Environment

Top

Urbaniak M, Hampton K. 17(2). 150 - 150. (Journal Article)

Keywords:

Buy Now

Ebola Hemorrhagic Fever

Top

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

Buy Now

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"

Top

Myatt CA, Johnson DC. 09(2). 79 - 79. (Editorial)

Keywords:

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"

Top

Myatt CA, Johnson DC. 09(2). 80 - 80. (Editorial)

Keywords:

Effect of Hetastarch Bolus in Trauma Patients Requiring Emergency Surgery

Top

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

Buy Now

Effective Monitoring and Evaluation of Military Humanitarian Medical Operations

Top

Waller SG, Powell C, Ward JB, Riley K. 11(4). 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:

Buy Now

Effectiveness of Pulse Oximetry Versus Doppler for Tourniquet Monitoring

Top

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

Buy Now

Effects of a New Cooling Technology on Physical Performance in US Air Force Military Personnel

Top

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

Buy Now

Effects of Intraosseous and Intravenous Administration of Hextend® on Time of Administration and Hemodynamics in a Swine Model

Top

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

Buy Now

Embedded Fragment Removal and Wound Debridement in a Non-US Partner Force Soldier

Top

McLeroy RD, Spelman S, Jacobson E, Gurney J, Keenan S, Powell D, Riesberg J, 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

Buy Now

Emergency Cricothyroidotomy in Tactical Combat Casualty Care

Top

Mabry RL, Frankfurt A, Kharod C, Butler FK. 15(3). 11 - 19. (Journal Article)

Keywords:

Buy Now

Emergency Department Patients Support the Use of Combat Medics in Their Clinical Care

Top

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

Buy Now

Emergency Intraosseous Access: A useful, Lifesaving Device used in Afghanistan

Top

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:

Buy Now

Emergency Lateral Canthotomy And Cantholysis: A Simple Procedure To Preserve Vision From Sight Threatening Orbital Hemorrhage

Top

Ballard SR, Enzenauer RW, O'Donnell T, Fleming JC, Risk G, Waite AN. 09(2). 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:

Emergency Tourniquet Effectiveness in Four Positions on the Proximal Thigh

Top

Kragh JF, Wallum TE, Aden JK, Dubick MA, Baer DG. 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

Buy Now

Endovascular Resuscitation Techniques for Severe Hemorrhagic Shock and Traumatic Arrest in the Presurgical Setting

Top

Glassberg E, Nadler R, Dagan D. 13(3). 101 - 101. (Letter)

Keywords:

Endovascular Resuscitation Techniques for Severe Hemorrhagic Shock and Traumatic Arrest in the Presurgical Setting

Top

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

Buy Now

Erythema Ab Igne

Top

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

Buy Now

Erythema Multiforme

Top

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

Buy Now

Erythema Nodosum

Top

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

Buy Now

Establishing TEMS Training Standards for Patrol Officers and Initial Responders

Top

Pennardt A. 15(1). 146 - 146. (Journal Article)

Keywords:

Buy Now

Estimation of Dog-Bite Risk and Related Morbidity Among Personnel Working With Military Dogs

Top

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

Buy Now

Evaluating Alternatives to Traditional Cotton Laparotomy Sponges for Blood Absorption in the Austere and Mobile Surgical Environment

Top

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

Buy Now

Evaluation and Testing of Junctional Tourniquets by Special Operation Forces Personnel: A Comparison of the Combat Ready Clamp and the Junctional Emergency Treatment Tool

Top

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

Buy Now

Evaluation And Treatment Of Persistent Cognitive Dysfunction Following Mild Traumatic Brain Injury

Top

Cozzarelli TA. 10(4). 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:

Evaluation for Testosterone Deficiency

Top

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

Buy Now

Evaluation of a Removable Intraoral Soft Stabilization Splint for the Reduction of headaches and Nightmares in Military PTSD Patients: A Large Case Series

Top

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

Buy Now

Evaluation of Commercially Available Traction Splints for Battlefield Use

Top

Lee RW. 14(4). 95 - 97. (Letter)

Keywords:

Evaluation of Commercially Available Traction Splints for Battlefield Use

Top

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

Buy Now

Evaluation of Commercially Available Traction Splints for Battlefield Use: Response

Top

Studer NM, Grubb SM, Horn GT, Danielson PD. 14(4). 98 - 98. (Letter)

Keywords:

Evaluation of Contingency Telemedical Support to Improve Casualty Care at a Simulated Military Intermediate Resuscitation Facility: The EM-ANGEL Study

Top

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

Buy Now

Evaluation of Models of Pneumatic Tourniquet in Simulated Out-of-Hospital Use

Top

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

Buy Now

Evaluation of NuStat®, a Novel Nonimpregnated Hemostatic Dressing, Compared With Combat Gauze™ in Severe Traumatic Porcine Hemorrhage Model

Top

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

Buy Now

Evaluation of Two Junctional Tourniquets Used on the Battlefield: Combat Ready Clamp® versus SAM® Junctional Tourniquet

Top

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

Buy Now

Evaluation of XSTAT® and QuickClot® Combat Gauze® in a Swine Model of Lethal Junctional Hemorrhage in Coagulopathic Swine

Top

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

Buy Now

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

Top

Lutz RH, Kane S, Lay J. 10(4). 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:

Exertional Heat Illness Resulting in Acute Liver Failure and Liver Transplantation

Top

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

Buy Now

Exertional Heat Stroke: Clinical Significance and Practice Indications for Special Operations Medics and Providers

Top

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:

Buy Now

Exertional Rhabdomyolysis: Attrition Through Exercise, A Case Series and Review of the Literature

Top

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

Buy Now

Exertional Rhabdomyolysis: Epidemiology, Diagnosis, Treatment, and Prevention

Top

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

Buy Now

Experience in Treating Combat Burns in Afghanistan by Using Silver-Nylon Dressing

Top

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

Buy Now

Experience Of A US Air Force Surgical And Critical Care Team Deployed In Support Of Special Operations Command Africa

Top

Delmonaco BL, Baker A, Clay J, Kilbourn 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

Buy Now

Exploration Of Prehospital Vital Sign Trends For The Prediction Of Trauma Outcomes

Top

Chen L, Reisner AT, Gribok A, Reifman J. 10(2). 55 - 62. (Previously Published)

Reproduced with permission from Prehospital Emergency Care 2009, Vol. 13, No. 3, Pages 286294

Abstract

Objectives: We explored whether there are diagnostically useful temporal trends in prehospital vital signs of trauma patients. Methods: Vital signs were monitored during transport to a level I trauma center and electronically archived. Retrospectively, we identified reliable vital signs recorded from the 0- to 7-minute interval and from the 14 to 21-minute interval during transport, and, for each subject, we computed the temporal differences between the two intervals' vital signs, the intrasubject 95% data ranges, the values during the initial 2 minutes, and the 21-minute overall means. We tested for differences between subjects with major hemorrhage versus control subjects, and computed receiver operating characteristic (ROC) curves. We conducted sensitivity analyses, exploring alternative clinical outcomes, temporal windows, and methods of identifying reliable data. Results: Comparing major hemorrhage cases versus controls, there were no discriminatory differences in temporal vital sign trends. Hemorrhage cases had significantly wider intrasubject data ranges for systolic blood pressure (SBP), respiratory rate (RR), and shock index (SI) versus controls. All results were consistent in several sensitivity analyses. Conclusions: Our findings add to a growing body of evidence that prehospital vital sign trends over 21 minutes or less are unlikely to be diagnostically useful because of substantial nondirectional fluctuations in vital signs that would obscure any subtle, progressive temporal trends. SBP, RR, and SI values were significantly different for high-acuity patients, and had more variability. Taken together, these findings suggest that higher-acuity patients experience episodes of instability rather than gradual, steady decline. Measures that account for data variability, such as taking the average of multiple measurements, may improve the diagnostic utility of prehospital vital signs.

Keywords:

Extreme Conditioning Programs: Potential Benefits and Potential Risks

Top

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

Buy Now

Fascioliasis and Fasciolopsiasis: Similar Names, Similar Diseases?

Top

Bowden L. 08(4). 58 - 67. (Journal Article)

Abstract

This article reviews plant-borne helminth infections caused by Fasciola hepatica/gigantica and Fasciolopsis buski. Besides having similar names, both infections are caused by trematodes (flatworms or flukes). As with nearly all helminth infections, eosinophilia may be present, there is usually a delayed clinical presentation, and diagnosis is made with the proper identification of parasite eggs in the stool or serological testing. However, fascioliasis and fasciolopsiasis have more similarities including: egg morphology, parasite development, the involvement of aquatic plants and snails in the lifecycle, and preventive measures. Despite these similarities there are some important differences including: geographical distribution, definitive hosts, clinical presentation, and treatment. The SOF medical professional will have a greater understanding and be able to more easily identify both of these infections by being able to compare and contrast the two. Though these are not the most common helminth infections, these diseases are prevalent and may be of particular importance to providers working in Southeast Asia or South America.

Keywords:

Fast-Roping: Potential Consequences of Vibrations for Sensation and Regulation of Movement

Top

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

Buy Now

Faust's Gold: Inside the East German Doping Machine

Top

Farr W. 16(1). 125 - 125. (Book Review)

Abstract

Ungerleider, Steven. Faust's Gold. Inside the East German Doping Machine.
New York, NY: St. Martin's Press, 2001. 249 pages. ISBN 0-312-26977-3.

Keywords:

F-Cell World Drive 2011: Are Tactical Medicine Principles Applicable to a Civilian Scenario?

Top

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:

Buy Now

Feedback To The Field: An Assessment Of Sternal Intraosseous (io) Infusion

Top

Harcke HT, Crawley G, Ritter BA, Mazuchowski EL. 11(1). 23 - 26. (Journal Article)

Abstract

Intraosseous vascular infusion (IO) is a recognized alternative to peripheral intravenous infusion when access is inadequate. The sternum and proximal tibia are the preferred sites. A review of 98 cases at autopsy revealed successful sternal IO placement in 78 cases (80%). Assuming a worst case scenario for placement (pin mark and no tip in bone [17 cases] and tip present and not in the sternum [3 cases]), attempts were unsuccessful in 20 cases (20%). We draw no specific conclusions regarding sternal IO use, but hope that personnel placing these devices and those providing medical training can use the information.

Keywords:

Fentanyl For Pain Control In Special Operations

Top

Kacprowicz RF, Johnson TR, Mosely DS. 08(4). 48 - 53. (Journal Article)

Abstract

Opiate medications have been used for the control of severe pain due to combat trauma for hundreds of years. Morphine has long been the drug of choice for use on the battlefield, but it has several limitations which can make it difficult to use in modern warfare. Since its discovery in 1963, fentanyl has gradually emerged as one of the most effective alternatives to morphine. With fewer adverse effects and multiple routes of administration, fentanyl appears to be a very effective choice for the management of moderate to severe pain due to combat trauma. Available data support the use of fentanyl in Special Operations, but only after a thorough review of the pharmacology, adverse effects, dosing, and routes of administration.

Keywords:

Fever and Thrombocytopenia in a Returning Soldier

Top

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

Buy Now

Field Diagnosis and Treatment of Ophthalmic Trauma

Top

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

Buy Now

Field Electronic Medical Records

Top

Cauchi T, Cameron O. 16(2). 69 - 70. (Journal Article)

Keywords:

Buy Now

Field Evaluation And Management Of Non-Battle Related Knee And Ankle Injuries By The Advanced Tactical Practitioner (ATP) In The Austere Environment - Part Two

Top

Hammesfahr R. 09(1). 2 - 12. (Journal Article)

Keywords:

Field Evaluation And Management Of Non-battle Related Knee And Ankle Injuries By The Advanced Tactical Practitioner In An Austere Environment: Part One

Top

Hammesfahr R. 09(4). 33 - 42. (Journal Article)

Keywords:

Field Evaluation And Management On Non-battle Related Knee And Ankle Injuries By The ATP In The Austere Environment

Top

Hammesfahr R. 09(2). 1 - 6. (Journal Article)

Keywords:

Field Sterilization in the Austere and Operational Environment A Literature Review of Recommendations

Top

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

Buy Now

Filling in the Gaps of Predeployment Fleet Surgical Team Training Using a Team-Centered Approach

Top

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

Buy Now

First Case Report of SAM® Junctional Tourniquet Use in Afghanistan to Control Inguinal Hemorrhage on the Battlefield

Top

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

Buy Now

Flank Pain

Top

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

Buy Now

Fluid Resuscitation for Hemorrhagic Shock in Tactical Combat Casualty Care: TCCC Guidelines Change 14-01 - 2 June 2014

Top

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

Buy Now

Force Health Protection In U.s. Army Special Operations Forces

Top

Forsyth L. 07(1). 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.

Keywords:

Force Health Protection Support Following a Natural Disaster: The 227th Medical Detachment's Role in Response to Superstorm Sandy

Top

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

Buy Now

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

Top

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

Keywords:

Buy Now

Foreign Language Short Course: Special Operations Clinical Research Fundamentals

Top

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

Buy Now

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

Top

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

Buy Now

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

Top

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

Buy Now

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

Top

Hubler DA, Lopez RA, Morgan AR, Vasios WN. 10(1). 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:

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

Top

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:

Buy Now

Fresh Whole Blood Transfusions In The Austere Environment

Top

Bowling F, Kerr W. 11(3). 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:

Buy Now

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

Top

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

Keywords:

Front Line Surgery A Practical Approach

Top

Farr W. 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.

Keywords:

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

Top

Bowles JM, Joas C, Head S. 15(3). 1 - 3. (Case Reports)

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

Buy Now

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

Top

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:

Buy Now

Functional Training Program Bridges Rehabilitation And Return To Duty

Top

Gross DL, Christopher GE, Faulk RT. 09(1). 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:

Fuzileiros Portugueses (Portuguese Marines)

Top

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

Keywords:

Buy Now

Garlic Burn to the Face

Top

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

Buy Now

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

Top

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

Buy Now

Giant Basal Cell Carcinoma

Top

Rivard SC, 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

Buy Now

Global Health Language and Culture Competency

Top

Beadling C, Maza J, Nakano G, Mahmood M, Jawad S, Al-Ameri A, Zuerlein S, Anderson W. 12(1). 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:

Buy Now

Global Health Language and Culture Competency

Top

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:

Buy Now

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

Top

Pueschel M. 11(4). 15 - 20. (Journal Article)

Keywords:

Buy Now

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

Top

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

Buy Now

Green Ghosts

Top

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

Abstract

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

Keywords:

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

Top

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

Abstract

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

Keywords:

Guerrilla Warfare on the Amber Coast

Top

Farr W. 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

Keywords:

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

Top

Hamid S. 11(2). 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:

Buy Now

Gunshot Wound to the Distal Phalanx: A Case Review

Top

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:

Buy Now

Gunshotwounds In Militaryworking Dogs

Top

Baker JL, Truesdale CA. 08(4). 120 - 121. (Journal Article)

Keywords:

Hazards Of Dietary Supplement Use

Top

Johnson AE, Haley CA, Ward JA. 07(4). 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.

Keywords:

Headache

Top

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

Keywords:

Buy Now

Hemorrhage Control Devices: Tourniquets and Hemostatic Dressings

Top

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

Keywords:

Buy Now

Hepatitis E

Top

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

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

Buy Now

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

Top

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

Buy Now

Hiv Postexposure Prophylaxis For Special Forces Soldiers

Top

Lutz RH, Carlton D, Taylor SF. 09(4). 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:

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

Top

LeClair TG. 11(3). 66 - 68. (Journal Article)

Keywords:

Buy Now

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

Top

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

Keywords:

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

Top

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

Buy Now

Humanitarian Struggle in Burma's Conflict Zones

Top

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

Buy Now

Hypertension And The Sofwarrior

Top

Horsley GW. 07(4). 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.

Keywords:

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

Top

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

Buy Now

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

Top

Farr W. 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.

Keywords:

Identification and Management of Bed Bug Infestations in Austere Environments

Top

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

Buy Now

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

Top

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

Buy Now

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

Top

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:

Buy Now

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

Top

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

Keywords:

Increasing Security through Public Health: A Practical Model

Top

Parker RD. 11(4). 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:

Buy Now

Infectious Diseases: Cholera

Top

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

Buy Now

Initial Tourniquet Pressure Does Not Affect Tourniquet Arterial Occlusion Pressure

Top

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

Buy Now

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

Top

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

Buy Now

Injuries And Footwear (Part 2): Minimalist Running Shoes

Top

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

Buy Now

Injuries and Injury Prevention During Foot Marching

Top

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

Buy Now

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

Top

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:

Buy Now

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

Top

Deaton TG, Roby JL. 10(1). 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:

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

Top

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

Buy Now

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

Top

Farr W. 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.

Keywords:

Integrated Education of All Responders

Top

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

Keywords:

Buy Now

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

Top

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

Buy Now

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

Top

Mueller G, Hunt B, Wall V, Rush R, 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

Buy Now

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

Top

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

Keywords:

Buy Now

Interest Survey And Guide To Medical Schooladmissions For SOF Medics

Top

True NA, Conway AC, Landis TM, Cairns CB, Cairns BA. 11(2). 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.

Keywords:

Buy Now

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

Top

Delmonaco BL, Andrews J, May A. 08(2). 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.

Keywords:

Internal Decapitation - High Ligamentus Cervical Injury

Top

Ben-Galim P. 10(1). 31 - 34. (Previously Published)

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

Keywords:

Internal Decapitation: Survival After Head To Neck Dissociation Injuries

Top

Ben-Galim P, Sibai TA, Hipp JA, Heggeness MH, Reitman CA. 10(1). 35 - 39. (Previously Published)

Previously published in Spine, Volume 33, Number 16, pp 17441749. 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

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

Top

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

Buy Now

Intra-articular Morphine versus Lidocaine for Acute Knee Pain

Top

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

Buy Now

Intraorbital Training Munition

Top

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

Buy Now

Introduction to the Unconventional Medicine Series

Top

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

Keywords:

Buy Now

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

Top

Bowman 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

Buy Now

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

Top

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

Buy Now

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

Top

Farr W. 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:

Japanese Encephalitis

Top

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

Keywords:

Buy Now

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

Top

Fletcher J, Dominguez J, Walker T, Gallaher P. 07(3). 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:

Journal Club: Ketamine in the Emergency Department

Top

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

Buy Now

Junctional Tourniquet Training Experience

Top

Kragh JF, Geracci JJ, Parsons DL, Robinson JB, Biever KA, Rein EB, Glassberg E, Strandenes G, Chen J, Benov A, Marcozzi D, Shackelford S, 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

Buy Now

Ketones and Human Performance

Top

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

Buy Now

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

Top

Johnson DC. 09(3). 110 - 112. (Journal Article)

Keywords:

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

Top

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

Buy Now

Knife Edge: Life as a Special Forces Surgeon

Top

Farr W. 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.

Keywords:

Laboratory Testing of Emergency Tourniquets Exposed to Prolonged Heat

Top

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

Buy Now

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

Top

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

Buy Now

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

Top

Burns GD, DeLellis SM. 08(4). 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.

Keywords:

Learning Curves of Emergency Tourniquet Use Exploring for Utility in Training

Top

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

Buy Now

Left Hand Injury With Focal Swelling and Tenderness

Top

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

Keywords: sonography; injury, hand

Buy Now

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

Top

Winn AE, Rivard SC, 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

Buy Now

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

Top

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

Buy Now

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

Top

Hart D, McNeil M, Hegarty C, Rush R, 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

Buy Now

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

Top

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

Buy Now

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

Top

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

Buy Now

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

Top

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

Buy Now

Maggot Therapy for Wound Care in Austere Environments

Top

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

Buy Now

Management of Anaphylaxis in an Austere or Operational Environment

Top

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

Buy Now

Management of Burn Wounds Under Prolonged Field Care

Top

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:

Management of Crush Syndrome Under Prolonged Field Care

Top

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

Keywords:

Buy Now

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

Top

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

Buy Now

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

Top

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™

Buy Now

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

Top

Kotwal RS, Butler FK, Gross K, Kheirabadi BS, Baer DG, 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

Buy Now

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

Top

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:

Buy Now

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

Top

Butler FK, DuBose JJ, Otten EJ, Bennett DR, Gerhardt RT, Kheirabadi BS, Gross K, Cap AP, Littlejohn LF, Edgar EP, Shackelford S, 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

Buy Now

Management of Scalp hemorrhage and lacerations

Top

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:

Buy Now

Management of the Mangled Face by a Forward Surgical Team

Top

Brisson P, Woll M, Welden B. 11(4). 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:

Buy Now

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

Top

Smith CP, Sorrells A, Coburn M. 10(2). 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:

Manikin Human-Patient Simulator Training

Top

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

Buy Now

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

Top

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

Keywords:

Buy Now

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

Top

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

Buy Now

MEDEVAC Use of Ketamine for Postintubation Transport

Top

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

Buy Now

Medical Humanitarian Missions

Top

Mulvaney SW, Mcbeth MJ. 10(4). 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:

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

Top

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

Buy Now

Medical Operations of the 6th Ranger Infantry Battalion

Top

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

Buy Now

Medical Provider Ballistic Protection at Active Shooter Events

Top

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

Buy Now

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

Top

Becker T, Ray PD, Link M, Ziemba M. 11(2). 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:

Buy Now

Medical Seminars: A New Paradigm For SOF Counterinsurgency Medical Programs

Top

Alderman SM, Christensen J, Crawford I. 10(4). 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:

Meningococcal Disease

Top

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

Keywords: infection, meningococcal; disease, infectious

Buy Now

Middle East Respiratory Syndrome

Top

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

Buy Now

Mild Traumatic Brain Injury Literature Review and Proposed Changes To Classification

Top

Krainin BM, Forsten RD, Kotwal RS, Lutz RH, Guskiewicz KM. 11(3). 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:

Buy Now

Mild Traumatic Brain Injury: Situational Awareness for Special Operations Medical Providers

Top

Forsten RD, Roberts RJ, Stewart C, Solomon BE, Baggett MR. 08(2). 74 - 87. (Journal Article)

Keywords:

Military History of Increasing Survival: The U.S. Military Experience with Tourniquets and Hemostatic Dressings in the Afghanistan and Iraq Conflicts

Top

Butler FK. 15(4). 149 - 152. (Journal Article)

Keywords:

Buy Now

Military Static Line Parachuting Injuries Seen By The Airborne Battalion Provider

Top

Healy ML. 11(2). 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:

Buy Now

Mindfulness: A Fundamental Skill for Performance Sustainment and Enhancement

Top

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

Buy Now

Mitigating Exertional Heat Illness in Military Personnel: The Science Behind a Rice-Based Electrolyte and Rehydration Drink

Top

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.

Keywords:

Buy Now

Moderate To Severe Traumatic Brain Injury From The Battlefield To The Community

Top

Girard P, Helmick K, Parkinson G. 07(1). 56 - 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.

Keywords:

Modern Irregular Warfare in Defense Policy and as a Military Phenomenon

Top

Farr W. 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.

Keywords:

Monitoring Training for Human Performance Optimization

Top

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

Buy Now

Monkey Bite Exposure Treatment Protocol

Top

Newton F. 10(4). 48 - 49. (Journal Article)

Keywords:

Mosquito Soldiers: Malaria, Yellow Fever, and the Course of the American Civil War

Top

Gephart WJ. 11(2). 63 - 63. (Book Review)

Abstract

Andrew M. Bell
Louisiana State Univ Press, Baton Rouge, 2010. ISBN 978-0-8071-3561-7. Hardback,192 pages.

Keywords:

Mumps

Top

Burnett MW. 17(2). 117 - 119. (Journal Article)

Keywords: mumps; infectious disease

Buy Now

Nasal Foreign Body: Case Review For The Advanced Tactical Practitioner

Top

Paul J. 11(3). 69 - 71. (Journal Article)

Keywords:

Buy Now

National TEMS Initiative and Council NTIC Competency Domains/The TACMED Challenge!

Top

Pennardt A. 16(4). 132 - 132. (Classical Conference)

Keywords:

NATO SOF Transformation And The Development Of NATO SOF Medical Doctrine And Policy

Top

Wallace GR. 09(2). 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:

NATO Special Operations Forces Medical Engagements and Partnering Course: Initial Curriculum Recommendations from the NSHQ SOFMEP Committee

Top

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.

Keywords:

Buy Now

Necessity Of Medical Personnel On The Advance Party

Top

Horsley GW, Wilson K. 08(1). 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.

Keywords:

Needle Decompression

Top

Studer NM, Horn GT. 16(1). 72 - 73. (Editorial)

Keywords:

Buy Now

Needle Thoracentesis Decompression: Observations From Postmortem Computed Tomography and Autopsy

Top

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

Buy Now

Needle Thoracostomy In The Treatment Of A Tension Pneumothorax In Trauma Patients: What Size Needle?

Top

Zengerink I, Brink PR, Laupland KB, Raber EL, Zygun D, Kortbeek JB. 08(1). 92 - 95. (Previously Published)

Previously published in The Journal of Trauma Injury, Infection, and Critical Care. 2008;64:111114. 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.

Keywords:

No Ordinary Sleeper Cell: Managing the Varied Problems of Plasmodium vivax Malaria

Top

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

Buy Now

No Shit, There I Was: The Case for Narrative-Based Clinical Knowledge

Top

Froede K. 11(4). 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

Buy Now

No Slackers in Tourniquet Use to Stop Bleeding

Top

Polston RW, Clumpner BR, Kragh JF, Jones JA, Dubick MA, Baer DG. 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

Buy Now

OK, Doc . . . What Do I Really Have? Posttraumatic Stress Disorder Versus Traumatic Brain Injury

Top

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

Buy Now

Omega-3 Fatty Acid Ingestion as a TBI Prophylactic

Top

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:

Buy Now

One Up: A Woman in Action With the S.A.S.

Top

Farr W. 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.

Keywords:

Only Break Glass in Case of War? The Difficulty With Combat Medic Skills Sustainment Within Our Military Treatment Facilities

Top

Cunningham CW. 15(1). 90 - 92. (Letter)

Keywords:

Operation Sams

Top

Zimmerman DJ. 09(3). 80 - 83. (Previously Published)

Previously Published in The Year in Speical Operations 2009. Reprinted with Permission

Keywords:

Operational Point-of-Care Ultrasound Review: Low-Cost Simulators and Resources for Advanced Prehospital Providers

Top

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

Buy Now

Operational Stressors on Physical Performance in Special Operators and Countermeasures to Improve Performance: A Review of the Literature

Top

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

Buy Now

Operational Stressors on Physical Performance in Special Operators and Countermeasures to Improve Performance: A Review of the Literature

Top

Hoedebecke KL, Brink W. 14(2). 84 - 85. (Letter)

Keywords:

Operator Training and TEMS Support: A Survey of Unit Leaders in Northern and Central California

Top

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

Buy Now

Opposition to Soviet Rule in Lithuania, 1945-1980

Top

Farr W. 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:

Optimization of Simulation and Moulage in Military-Related Medical Training

Top

Petersen C, Rush SC, Gallo I, Dalere B, Staak B, 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

Buy Now

Optimizing Nutrition For Performance At Altitude: A Literature Review

Top

Kechijian D. 11(1). 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:

Optimizing the Use of Limb Tourniquets in Tactical Combat Casualty Care: TCCC Guidelines Change 14-02

Top

Shackelford S, 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

Buy Now

Oral Steroids for Dermatitis

Top

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

Buy Now

Overview Of Combat Trauma In Military Working Dogs In Iraq And Afghanistan

Top

Baker JL, Truesdale CA, Schlanser JR. 09(1). 105 - 108. (Previously Published)

Previously published in The United States Army Medical Department Journal / The Unites States Army Veterinary Corps January - March 2009.

Keywords:

Pain as a Barrier to Human Performance: A Focus on Function for Self-Reporting Pain With the Defense Veterans Pain Rating Scale

Top

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:

Buy Now

Pain Management In Current Combat Operations

Top

Black IH, McManus JG. 10(4). 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.

Keywords:

Pain Management In The Prehospital Environment

Top

McManus JG, Sallee DR. 08(4). 111 - 119. (Previously Published)

Previously published in Emerg Med Clin N Am 23 (2005) 415431. Permission granted to republish in the JSOM.

Keywords:

Parasitology Results From A Medcap In Africa

Top

Franklin B, Swierczewski B. 11(3). 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:

Buy Now

Pectoralis Major Injury During Basic Airborne Training

Top

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

Buy Now

Pediatric Trauma: Management From an Austere Prospective

Top

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

Buy Now

Performance Psychology as a Key Component of Human Performance Optimization

Top

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

Buy Now

Pertussis

Top

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:

Buy Now

Physical Therapy Treatment Of Chronic Neck Pain A Discussion And Case Study: Using Dry Needling And Battlefield Acupuncture

Top

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

Buy Now

Physiological And Psychological Characteristics Of Successful Combat Controller Trainees

Top

Walker TB, Lennemann LM, McGregor JN, Mauzy C, Zupan MF. 11(1). 39 - 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:

Pilot Ejection, Parachute, and Helicopter Crash Injuries

Top

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

Buy Now

Planning And Operational Consideration For Units Utilizing Military Working Dogs

Top

Royal J, Taylor JF. 09(4). 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:

Planning for Success: Desired Characteristics of Special Operations Surgeons, A Pilot Study

Top

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:

Buy Now

Point Prevalence Survey for Tick-Borne Pathogens in Military Working Dogs, Shelter Animals, and Pet Populations in Northern Colombia

Top

McCown ME, 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

Buy Now

Point-of-Care Coagulation Testing for Trauma Patients in a Military Setting: A Prospective Study

Top

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

Buy Now

Portable Ultrasound Empowers Special Forces Medics

Top

Crisp JD. 10(4). 59 - 62. (Journal Article)

Keywords:

Portuguese 2nd Parachute Battalion

Top

Ferreira B. 16(4). 122 - 124. (Journal Article)

Keywords:

Buy Now

Postural Stability of Special Warfare Combatant-Craft Crewmen With Tactical Gear

Top

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

Buy Now

Potential of Visual Sensory Screening, Diagnostic Evaluation, and Training for Treatment of Postconcussive Symptoms and Performance Enhancement for Special Forces Qualified Personnel

Top

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

Buy Now

POW and Detainee Operations: Lessons Unlearned

Top

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

Buy Now

Power To The People

Top

Schauer SG, Cunningham CW, DeLorenzo RA. 16(1). 69 - 71. (Editorial)

Keywords:

Buy Now

Pre-Deployment Training Recommendations for Special Forces Medical Sergeants Based on Recent Operation Enduring Freedom Experiences

Top

Hughes JR, Hughes T. 09(3). 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:

Predicting When to Administer Blood Products During Tactical Aeromedical Evacuation: Evaluation of a US Model

Top

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

Buy Now

Prehospital Administration of Tranexamic Acid by Ground Forces in Afghanistan: The Prehospital Trauma Registry Experience

Top

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

Buy Now

Prehospital Advances In The Management Of Severe Penetrating Trauma

Top

Mabry RL, McManus JG. 09(1). 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:

Prehospital Analgesia With Ketamine for Combat Wounds: A Case Series

Top

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

Buy Now

Prehospital and En Route Cricothyrotomy Performed in the Combat Setting: A Prospective, Multicenter, Observational Study

Top

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

Buy Now

Prehospital Cricothyrotomy Kits Used in Combat

Top

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

Buy Now

Prehospital Emergency Care: Evaluation of the Junctional Emergency Tourniquet Tool With a Perfused Cadaver Model

Top

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

Buy Now

Prehospital Use of Hemostatic Bandages and Tourniquets: Translation From Military Experience to Implementation in Civilian Trauma Care

Top

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

Buy Now

Preliminary Comparison of New and Established Tactical Tourniquets in a Manikin Hemorrhage Model

Top

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

Buy Now

Preliminary Comparison of Pneumatic Models of Tourniquet for Prehospital Control of Limb Bleeding in a Manikin Model

Top

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

Buy Now

Preliminary Measures of Instructor Learning in Teaching Junctional Tourniquet Users

Top

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

Buy Now

Preparedness for Resuscitation at a Geographically Isolated Army Troop Medical Clinic: Lessons From Camp Blanding, Florida

Top

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

Buy Now

Preparing for Operations in a Resource-Depleted and/or Extended Evacuation Environment

Top

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

Buy Now

Preparing Soldiers for the Stress of Combat

Top

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

Buy Now

Pressures Under 3.8cm, 5.1cm, and Side-by-Side 3.8cm-Wide Tourniquets

Top

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

Buy Now

Pretrauma Interventions in Force Health Protection: Introducing the "Left of Bang" Paradigm

Top

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

Prevalence of Posttraumatic Stress Disorder in Special Operations Forces

Top

Neller DJ, Butcher JJ. 13(1). 91 - 91. (Letter)

Keywords:

Preventing Ring Associated Injuries: Think Twice About Wearing That Ring

Top

Levy MJ, Gerold KB. 14(1). 93 - 95. (Journal Article)

Keywords:

Buy Now

Prevention of Foot Blisters

Top

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

Buy Now

Preventive Medicine and Its Role in the Special Operation Forces Medical Team

Top

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

Buy Now

Priorities for a 21st-Century Defense: Aligning U.S. Army Environmental Science and Engineering Officer Resources with the Department of Defense Strategic Guidance

Top

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

Buy Now

Proceedings From the 2016 Mid-Year Meeting of the Committee for Tactical Emergency Casualty Care (C-TECC) and Committee Updates

Top

Shapiro G, Tang N, Kamin R, Smith R. 17(1). 149 - 151. (Classical Conference)

Keywords:

Proceedings of the 2016 Spring/Summer Meeting of the Committee for Tactical Emergency Casualty Care

Top

Tang N, Shapiro G, Smith ER, Kamin R, Callaway DW. 16(2). 148 - 150. (Classical Conference)

Keywords:

Progress Of Tactical Emergency Medical Support In Japan

Top

Fuse A, Schwartz RB, Saitoh D, Agawa S, Ohnishi M, Okumura T. 16(1). 140 - 141. (Journal Article)

Keywords:

Buy Now

Prolonged Field Care for the Summer 2017 Edition

Top

Keenan S. 17(2). 131 - 131. (Journal Article)

Keywords:

Buy Now

Prolonged Field Care for the Winter 2016 Edition

Top

Keenan S. 16(4). 86 - 86. (Classical Conference)

Keywords:

Prolonged Field Care of a Casualty With Penetrating Chest Trauma

Top

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

Buy Now

Prolonged Field Care Working Group Fluid Therapy Recommendations

Top

Baker BL, Powell D, Riesberg J, 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

Buy Now

Prolonged Field Care Working Group Position Paper: Operational Context for Prolonged Field Care

Top

Mohr CJ, Keenan S. 15(3). 78 - 80. (Journal Article)

Keywords:

Buy Now

Prolonged Field Care Working Group Position Paper: Prolonged Field Care Capabilities

Top

Ball JA, Keenan S. 15(3). 76 - 77. (Journal Article)

Keywords:

Buy Now

Prolonged Field Care Working Group Update

Top

Keenan S. 16(2). 105 - 106. (Journal Article)

Keywords:

Buy Now

Providers Face Challenges Maintaining Deployment-Ready Skills at Garrison Hospitals

Top

Schauer SG, Varney SM. 15(4). 79 - 80. (Editorial)

Keywords:

Psoriasis

Top

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

Buy Now

Psychological Resilience And Postdeployment Social Support Protect Against Traumatic Stress And Depressive Symptoms In Soldiers Returning From Operations Enduring Freedom And Iraqi Freedom

Top

Myatt CA, Johnson DC. 09(3). 63 - 64. (Editorial)

Keywords:

Psychological Reslilence and Postdeployment Social Support Protect against Traumatic Stress and Depressive Symptoms In Soldiers Returning From Operation Enduring Freedom and Iraqi Freedom

Top

Pietrzak RH, Johnson DC, Goldstein MB, Malley JC, Southwick SM. 09(2). 67 - 73. (Previously Published)

Previously Published in Depression and Anxiety 0 : 17 (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:

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

Top

Pietrzak RH, Johnson DC, Goldstein MB, Malley JC, Rivers AJ, Morgan CA, Southwick SM. 09(2). 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:

PTSD: An Elusive Definition

Top

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:

Buy Now

Public Access Hemorrhage Control and the Stop the Bleeding Coalition

Top

Levy MJ. 15(3). 126 - 128. (Journal Article)

Keywords:

Buy Now

Public Health Foodborne Illness Case Study During A Special Operations Forces Deployment To South America

Top

McCown ME, Grzeszak B. 10(3). 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:

Public Health Operations In The JSOTF-P

Top

Rufolo D, Facciolla C. 11(1). 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:

Q Fever

Top

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

Buy Now

Quality of Care Assessment in Forward Detection of Extremity Compartment Syndrome in War

Top

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

Buy Now

QuikClot® Combat Gauze® Use by Ground Forces in Afghanistan The Prehospital Trauma Registry Experience

Top

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

Buy Now

Rabies

Top

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:

Buy Now

Rabies: 2015 Update

Top

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

Buy Now

Ranger First Responder And The Evolution Of Tactical Combat Casualty Care

Top

Veliz C, Montgomery HR, Kotwal RS. 10(2). 90 - 91. (Journal Article)

Keywords:

Rapid Reversal Ofwarfarin Toxicity Using Recombinant Factor Viia In A Deteriorating Patient With Left Hemothorax

Top

Samir H, Owens GP, Masud F. 07(2). 1 - 3. (Case Reports)

Keywords:

Rapid Vision Correction by Special Operations Forces

Top

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

Buy Now

Rationale for Use of Intravenous Acetaminophen in Special Operations Medicine

Top

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

Buy Now

Real-World Experience With Three Point-of-Care Blood Analyzers in Deployed Environments

Top

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

Buy Now

Recent Considerations in Tactical Medicine

Top

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

Buy Now

Recovery of Bacteria and Fungi From a Leg Wound

Top

Washington MA, 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

Buy Now

Red Rash

Top

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

Buy Now

Redefining Technical Rescue and Casualty Care for SOF: Part 1

Top

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:

Buy Now

Red-Green Versus Blue Tactical Light: A Direct, Objective Comparison

Top

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:

Buy Now

Regimented Techniques Facilitate a Rapid Ascent to Very High Altitude: A Controlled Study

Top

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

Buy Now

Regional Anesthetic Blocks For The Cure Of Minor Upper Extremity Wounds: Part One

Top

Arne BC. 10(2). 120 - 122. (Journal Article)

Keywords:

Regional Anesthetic Blocks Fot The Cure Of Minor Lower Extremity Wounds: Part Two

Top

Arne BC. 10(2). 123 - 125. (Journal Article)

Keywords:

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

Top

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

Buy Now

Remote Telementored Ultrasound-Directed Compression to Potentially Accelerate Hemostasis in Exsanguinating Junctional Vascular Injuries

Top

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

Buy Now

Replacement of Promethazine With Ondansetron for Treatment of Opioid- and Trauma-Related Nausea and Vomiting in Tactical Combat Casualty Care

Top

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.

Keywords:

Buy Now

Resourcing Interventions Enhance Psychology Support Capabilities in Special Operations Forces

Top

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)

Buy Now

ReSTART: A Novel Framework for Resource-Based Triage in Mass-Casualty Events

Top

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

Buy Now

Results Of Vietnamese Acupuncture Seen At The Second Surgical Hospital

Top

Rich NM, Dimond FC. 09(1). 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:

Resuscitation During Critical Care Transportation in Afghanistan

Top

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

Buy Now

Resuscitative Endovascular Balloon Occlusion of the Aorta: Pushing Care Forward

Top

Teeter WA, Romagnoli A, Glaser J, Fisher AD, Pasley J, 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

Buy Now

Rethinking Heat Injury in the SOF Multipurpose Canine: A Critical Review

Top

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:

Buy Now

Return to Duty After Severe Bilateral Lower Extremity Trauma

Top

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

Buy Now

Return to Full Duty After Anterior Cruciate Ligament Reconstruction: Is the Second Time More Difficult?

Top

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:

Buy Now

Review of 54 Cases of Prolonged Field Care

Top

DeSoucy E, 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

Buy Now

Review of Canine Deaths While in Service in US Civilian Law Enforcement (2002-2012)

Top

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

Buy Now

Review, Clinical Update, and Practice Guidelines for Excited Delirium Syndrome

Top

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

Buy Now

Rice-Based Electrolyte Drinks More Effective Than Water in Replacing Sweat Losses During Hot Weather Training and Operations

Top

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

Buy Now

Rigid Eye Shields: A Critical Gap in the Individual First Aid Kit

Top

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

Buy Now

Rigid Eye Shields: A Critical Gap in the Individual First Aid Kit Commentary

Top

Calvano CJ. 13(3). 29 - 30. (Journal Article)

Keywords:

Buy Now

Rise of the Warrior Cop: The Militarization of America's Police Forces

Top

Farr W. 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:

Risk Factors for Injuries During Airborne Static Line Operations

Top

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

Buy Now

Rocky Mountain Spotted Fever

Top

Burnett MW. 16(3). 63 - 64. (Journal Article)

Keywords:

Buy Now

Role Of Medicine In Supporting Special Forces Counter-insurgency Operations In Southern Afghanistan

Top

Keenan S. 07(4). 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).

Keywords:

Role of the Windlass in Improvised Tourniquet Use on a Manikin Hemorrhage Model

Top

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

Buy Now

Running A Local National Medical Clinic For Special Forces/special Operations Medical Personnel

Top

Blazier SJ, Leach RA, Perez G, Holmes BW, Blough RS, Keenan S. 07(4). 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:

Safety and Effectiveness Evidence of SAM® Junctional Tourniquet to Control Inguinal Hemorrhage in a Perfused Cadaver Model

Top

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

Buy Now

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

Top

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:

Buy Now

Salmonella Infections Including Typhoid Disease

Top

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

Buy Now

Sarcoidosis

Top

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

Buy Now

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)

Top

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:

Buy Now

Scapula Fracture Secondary To Static Line Injury In A 22 Year Old Active Duty Soldier

Top

Thompson WD. 10(3). 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

Schistosomiasis: Traverers in Africa

Top

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.

Buy Now

Sea State Green

Top

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

Buy Now

Searching for Sustainability: How Niger's CASEVAC Success Is Leading the African Continent and Educating the GHE/IHS Community

Top

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

Buy Now

Secession as an International Phenomenon: From America's Civil War to Contemporary Separatist Movements

Top

Farr W. 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:

Secondary Hypertension, Erythrocytosis, and Unilateral Renal Cystic Disease in a Submariner: A Case Report

Top

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

Buy Now

Seroprevalence of Dengue Fever in US Army Special Operations Forces: Initial Results and the Way Ahead

Top

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

Buy Now

Short Report Comparing Generation 6 Versus Prototype Generation 7 Combat Application Tourniquet® in a Manikin Hemorrhage Model

Top

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

Buy Now

Should We Teach Every Soldier How To Start An Iv?

Top

Mabry RL, Cuenca PJ. 09(2). 64 - 66. (Previously Published)

Previously published in Military Medicine,. 2009 Jun;174(6):iii-v. Permission granted to republish in the JSOM.

Keywords:

Significant Pressure Loss Occurs Under Tourniquets Within Minutes of Application

Top

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

Buy Now

Since When is a Calorie a Calorie?

Top

Reshel R. 12(1). 71 - 72. (Journal Article)

Keywords:

Buy Now

Singapore's Perspective, Little India Riot: An Impetus to Develop Tactical Medicine Among Medics in Singapore?

Top

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

Buy Now

Single versus Double Routing of the Band in the Combat Application Tourniquet

Top

Clumpner BR, Polston RW, Kragh JF, Westmoreland T, Harcke HT, Jones JA, Dubick MA, Baer DG, 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

Buy Now

Sleep As A Strategy For Optimizing Performance

Top

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

Buy Now

SOF Dentistry

Top

Harrington RD. 09(3). 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:

SOF Leadership in The Face Of Stress

Top

Bottoms M. 09(3). 107 - 109. (Journal Article)

Keywords:

SOLCUS After-Action Report: From Good Idea to the Largest Ultrasound Training Program in the Department of Defense

Top

Vasios WN. 16(1). 62 - 65. (Editorial)

Keywords:

Buy Now

SOLCUS: Update On Point-of-Care Ultrasound In Special Operations Medicine

Top

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

Buy Now

Soldiers Can Take It - A Conceptual Analysis Of Trauma

Top

Froede K. 11(1). 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:

Sore Throat

Top

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

Buy Now

SORT(ing) Out The Casualties: The Special Operations Resuscitation Team In Afghanistan

Top

Finlayson K. 09(1). 77 - 86. (Previously Published)

Previously published in Veritas Vol 5 No. 1 2009. Permission granted to republish in JSOM. in the JSOM.

Keywords:

Special Forces Medic (18d) And Medical Planning

Top

Ware OL. 10(1). 26 - 27. (Journal Article)

Keywords:

Special Forces Medical Sergeants' Perceptions and Beliefs Regarding Their Current Medical Sustainment Program: Implications for the Field

Top

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

Buy Now

Special Forces Medicine in Israel

Top

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

Buy Now

Special Forces: A Unique National Asset Through, With, and By

Top

Farr W. 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:

Special Operations Alumnus Starts New Challenge

Top

Green J. 14(1). 111 - 111. (Interview)

Keywords:

Special Operations Forces and Incidence of Post-Traumatic Stress Disorder Symptoms

Top

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:

Buy Now

Special Operations Individual Medical Equipment Part 2 - The In-use And Survival Medical Kits

Top

Geers D. 10(4). 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:

Special Operations Individual Medical Equipment Part I - The Major Trauma Kit

Top

Geers D. 09(3). 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:

Special Operations Medicine: A Federal Law Enforcement Perspective

Top

Schmidt DJ. 07(2). 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:

Special Operations Soldier With Cardiac Family History: Use of CCTA and Protein Biomarker Testing to Detect Risk of Heart Attack From Noncalcified Plaque

Top

Singh M, Kroman A, Singh J, Tariq H, Amin S, Morales-Pablon CA, Cahill KV, Harrison EE. 15(1). 7 - 10. (Journal Article)

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

Buy Now

Special Operator Level Clinical Ultrasound: An Experience In Application And Training

Top

Morgan AR, Vasios WN, Hubler DA, Benson PJ. 10(1). 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:

Spontaneous Pneumopericardium, Pneumomediastinum, And Subcutaneous Emphysema In A 22-year Old Active Duty Soldier

Top

Thompson D. 08(2). 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

Staphylococcus sciuri: An Entomological Case Study and a Brief Review of the Literature

Top

Washington MA, 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

Buy Now

Stress Fractures: Etiology, Epidemiology, Diagnosis, Treatment, and Prevention

Top

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

Buy Now

Surgery In Afghanistan: A Light Model For Field Surgery During War

Top

Fosse E, Husum H. 08(4). 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:

Surgical Instrument Sets for Special Operations Expeditionary Surgical Teams

Top

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)

Buy Now

Surveillance for Ehrlichia canis, Anaplasma phagocytophilum, Borrelia burgdorferi, and Dirofilaria immitis in Dogs From Three Cities in Colombia

Top

McCown ME, 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

Buy Now

Survey Of The Indications For Use Of Emergency Tourniquets

Top

Kragh JF, O'Neill ML, Beebe DF, Fox CJ, Beekley AC, Cain JS, Parsons DL, Mabry RL, Blackbourne LH. 11(1). 30 - 38. (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:

Suspected Dietary Supplement Injuries In Special Operations Soldiers

Top

Hughes JR, Shelton B, Hughes T. 10(2). 14 - 24. (Journal Article)

Keywords:

TacMed Updates: Building Community Resilience to Dynamic Mass Casualty Incidents: A Multiagency White Paper in Support of the First Care Provider

Top

Anonymous A. 15(4). 175 - 177. (Classical Conference)

Keywords:

TacMed Updates: Committee for Tactical Emergency Casualty Care (C-TECC) Update: Summer 2014

Top

Callaway DW, Smith R, Shapiro G, McKay SD. 14(3). 134 - 134. (Classical Conference)

Keywords:

TacMed Updates: Committee for Tactical Emergency Casualty Care Spring Update

Top

Shapiro G, Smith R, Callaway DW. 16(1). 137 - 139. (Classical Conference)

Keywords:

TacMed Updates: Development of a National Consensus for Tactical Emergency Medical Support (TEMS) Training Programs-Operators and Medical Providers

Top

Schwartz RB, Lerner B, Llewellyn C, Pennardt A, Wedmore I, Callaway DW, Wightman JM, Casillas R, Eastman A, 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:

TacMed Updates: K9 Tactical Emergency Casualty Care Direct Threat Care Guidelines

Top

Palmer LE, Yee A. 17(2). 174 - 187. (Classical Conference)

Keywords: canines; K9s; Operational K9s; Tactical Emergency Casualty Care

TacMed Updates: Spring Committee for Tactical Emergency Casualty Care (C-TECC) Update

Top

Smith R, Bobko JP, Shapiro G, Hartford B, Callaway DW. 15(1). 143 - 145. (Classical Conference)

Keywords:

TacMed Updates: Tactical Emergency Casualty Care (TECC) Update: Winter 2014

Top

Callaway DW, Smith R, Shapiro G. 14(4). 146 - 147. (Classical Conference)

Keywords:

TacMed Updates: TEMS v. 2014

Top

Carmona PA. 14(1). 116 - 117. (Classical Conference)

Keywords:

TacMed Updates: The Committee for Tactical Emergency Casualty Care (C-TECC): Summer Update

Top

Callaway DW, Smith R, Shapiro G, Hartford B, McKay SD, Kamin R. 15(2). 168 - 170. (Classical Conference)

Keywords:

TacMed Updates: The Committee for Tactical Emergency Casualty Care: Fall Update

Top

Callaway DW, Smith R, Shapiro G, McKay SD, Kamin R. 15(3). 148 - 152. (Classical Conference)

Keywords:

Tactical Combat Casualty Care In The Assault On Punta Paitilla Airfield

Top

Mucciarone JJ, Llewellyn C, Wightman JM. 08(4). 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:

Tactical Combat Casualty Care Updates

Top

Montgomery HR, Butler FK. 17(3). 154 - 154. (Classical Conference)

Keywords:

Tactical Combat Casualty Care: Top Lessons for Civilian EMS Systems from 14 Years of War

Top

Butler FK. 16(2). 120 - 137. (Classical Conference)

Keywords:

Tactical Emergency Casualty Care (TECC): Guidelines For The Provision Of Prehospital Trauma Care In High Threat Environments

Top

Callaway DW, Smith ER, Cain JS, Shapiro G, Burnett WT, McKay SD, Mabry RL. 11(3). 104 - 122. (Journal Article)

Keywords:

Buy Now

Tactical Emergency Casualty Care-Pediatric Appendix: Novel Guidelines for the Care of the Pediatric Casualty in the High-Threat, Prehospital Environment

Top

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

Buy Now

Tactical Evacuation: Extending Critical Care on Rotary Wing Platforms to Forward Surgical Facilities

Top

Tobin JM, Via DK, Carter T. 11(4). 43 - 44. (Journal Article)

Keywords:

Buy Now

Tactical Hemorrhage Control Case Studies Using a Point-of-Care Mechanical Direct Pressure Device

Top

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

Buy Now

Tactical Lighting in Special Operations Medicine: Survey of Current Preferences

Top

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

Buy Now

Tactical Lighting in Special Operations Medicine: Survey of Current Preferences

Top

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

Buy Now

Tactical Medicine in Response to Acts of Terrorism

Top

Tang N, Kelen GD. 13(4). 109 - 110. (Journal Article)

Keywords:

Buy Now

Tactical Physical Preparation: The Case for a Movement-Based Approach

Top

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:

Buy Now

Taser and Conducted Energy Weapons

Top

LeClair TG, Meriano T. 15(4). 83 - 88. (Journal Article)

Keywords: taser; conducted energy weapons

Buy Now

TCCC Guidelines Comprehensive Review and Update: TCCC Guidelines Change 16-03

Top

Montgomery HR, Butler FK, Kerr W, Conklin CC, Morissette DM, Remley MA, Shaw TA, Rich TA. 17(2). 21 - 38. (Classical Article)

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

TCCC Standardization: The Time Is Now

Top

Goforth C, Antico D. 16(3). 53 - 56. (Editorial)

Keywords:

TCCC Updates

Top

Anonymous A. 16(3). 99 - 119. (Classical Conference)

Keywords:

TCCC Updates

Top

Anonymous A. 14(3). 124 - 132. (Classical Conference)

Keywords:

TCCC Updates

Top

Butler FK. 16(1). 132 - 135. (Classical Conference)

Keywords:

TCCC Updates: Committee on Tactical Combat Casualty Care Meeting Minutes. Davis Conference Center, MacDill AFB, Fl 4-5 February 2014

Top

Anonymous A. 14(2). 113 - 120. (Classical Conference)

Keywords:

TCCC Updates: Committee on Tactical Combat Casualty Care Meeting: 3-4 February 2014, Atlanta, Georgia. Meeting Minutes: 17 April 2015

Top

Anonymous A. 15(2). 154 - 167. (Classical Conference)

Keywords:

TCCC Updates: CoTCCC Meeting 3-4 February 2015 Atlanta, Georgia

Top

Butler FK, Cordoni L. 15(1). 136 - 141. (Classical Conference)

Abstract

Selected Meeting Highlights

Keywords:

TCCC Updates: Tactical Combat Casualty Care Curriculum Annual Update 2014

Top

Giebner S. 14(4). 144 - 145. (Classical Conference)

Keywords:

TCCC Updates: Tactical Combat Casualty Care Guidelines for Medical Personnel: 3 June 2015

Top

Anonymous A. 15(3). 129 - 147. (Classical Conference)

Keywords:

TCCC Updates: TCCC Abstracts

Top

Anonymous A. 14(1). 113 - 115. (Classical Conference)

Keywords:

TCCC Updates: Translating Military Advances in Exdternal Hemorrhage Control to Law Enforcement

Top

Butler FK. 15(4). 167 - 174. (Classical Conference)

Keywords:

TCCC Updates: Two Decades of Saving Lives on the Battlefield: Tactical Combat Casualty Care Turns 20

Top

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:

Team of Teams: New Rules of Engagement for a Complex World

Top

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:

Teleconsultation in Prolonged Field Care Position Paper

Top

Vasios WN, Pamplin JC, Powell D, Loos PE, Riesberg J, Keenan S. 17(3). 141 - 144. (Journal Article)

Keywords:

Buy Now

Telemedicine to Reduce Medical Risk in Austere Medical Environments: The Virtual Critical Care Consultation (VC3) Service

Top

Powell D, McLeroy RD, Riesberg J, 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

Buy Now

Testing of Junctional Tourniquets by Medics of the Israeli Defense Force in Control of Simulated Groin Hemorrhage

Top

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

Buy Now

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

Top

Kragh JF, Parsons DL, Kotwal RS, Kheirabadi BS, Aden JK, Gerhardt RT, Baer DG, 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

Buy Now

Testing Tourniquet Use in a Manikin Model: Two Improvised Techniques

Top

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

Buy Now

The 10 Commandments of Nutrition: 2014

Top

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

Buy Now

The Agitated Patient

Top

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

Buy Now

The Application of Regional Anesthesia by the Special Forces Medical Sergeant

Top

Ho TT, Hall C. 13(4). 111 - 111. (Letter)

Keywords:

The Combat Medic Aid Bag: 2025 CoTCCC Top 10 Recommended Battlefield Trauma Care Research, Development, and Evaluation Priorities for 2015

Top

Butler FK, Blackbourne LH, Gross K. 15(4). 7 - 19. (Journal Article)

Keywords:

Buy Now

The Command Of Biotechnology And Merciful Conquest In Military Oppositions