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Marchesini M, Ippolito C, Ambrosini L, Bignami EG, Fasani M, Abbenante D. 21(2). 67 - 71. (Journal Article)
Abstract
Background: Studies have highlighted the incidence and prevalence of chronic pain, which is an epidemic problem in all career sectors, as well as estimated the economic loss that follows its pathology. Several studies have indicated a high incidence of chronic osteoarticular pain in military service members, particularly in flight personnel. To date, no studies have estimated the incidence of pain pathology in the Italian military population, despite the implications related to flight qualification. Methods: A survey was conducted on helicopter flight personnel undergoing periodic annual evaluation. Results: A statistically significantly higher incidence of pain pathology than that reported in the global civilian population was demonstrated. More than 80% of the interviewed population reported moderate-to-severe back pain (45% in the lumbar tract and 38% in the cervical tract). Further, it was found that most staff with chronic pain do not use drugs or other treatments for severe pain because of concerns that such treatment approaches may compromise flight qualifications. Discussion: The present study observed a high incidence of pain in Italian military flight personnel and examined the degree to which this problem is undertreated in these individuals. To address this problem, further in-depth and larger investigations that include therapeutic protocols to resolve such pain pathologies should be conducted. Such investigations could help to reduce pain experienced by flight personnel and enhance the productivity of the Italian military forces while considering the pharmacologic limitations related to the task. Conclusion: Chronic lumbar and neck pain is more common in military helicopter crews than in the civilian population. The true figure is frequently underestimated because of staff concerns regarding the potential influence of therapies on work activity.
Keywords: pain, low back; pain, cervical back; helicopter crew, military; helicopter crew, Italian
Blaine C, Abbott M, Jacobson E. 18(3). 120 - 123. (Journal Article)
Abstract
The authors present their experience in emergency and longterm medical care by Special Operations Forces (SOF) medical providers in an austere environment. In this case, a Special Forces Operational Detachment-Alpha (SFOD-A) was deployed in support of Operation Inherent Resolve, partnered with indigenous combat forces.
Keywords: prolonged field care; indigenous combat forces; austere environments
Abdou H, Patel N, Edwards J, Richmond MJ, Elansary N, Du J, Poliner D, Morrison JJ. 21(4). 77 - 82. (Journal Article)
Abstract
Background: In locations in which access to resuscitative therapy may be limited, treating polytraumatized patients present a challenge. There is a pressing need for adjuncts that can be delivered in these settings. To assess these adjuncts, a model representative of this clinical scenario is necessary. We aimed to develop a hemorrhage and polytrauma model in the absence of fluid resuscitation. Materials and Methods: This study consisted of two parts: pulmonary contusion dose-finding (n = 6) and polytrauma with evaluation of varying hemorrhage volumes (n = 6). We applied three, six, or nine nonpenetrating captive bolt-gun discharges to the dose-finding group and obtained computed tomography (CT) images. We segmented images to assess contusion volumes. We subjected the second group to tibial fracture, pulmonary contusion, and controlled hemorrhage of 20%, 30%, or 40% and observed for 3 hours or until death. We used Kaplan-Meier analysis to assess survival. We also assessed hemodynamic and metabolic parameters. Results: Contusion volumes for three, six, and nine nonpenetrating captive bolt-gun discharges were 24 ± 28, 50 ± 31, and 63 ± 77 cm3, respectively (p = .679). Animals receiving at least six discharges suffered concomitant parenchymal laceration, whereas one of two swine subjected to three discharges had lacerations. Mortality was 100% at 12 and 115 minutes in the 40% and 30% hemorrhage groups, respectively, and 50% at 3 hours in the 20% group. Conclusion: This study characterizes a titratable hemorrhage and polytrauma model in the absence of fluid resuscitation. This model can be useful in evaluating resuscitative adjuncts that can be delivered in areas remote to healthcare access.
Keywords: Polytrauma model; pulmonary contusion; controlled hemorrhage; tibial fracture; delayed medical care; prolonged casualty care; prolonged field care
Aberle SJ, Lohse CM, Sztajnkrycer M. 15(2). 117 - 122. (Journal Article)
Abstract
Background: Law enforcement tactical incidents involve high-risk operations that exceed the capabilities of regular, uniformed police. Despite the existence of tactical teams for 50 years, little is known about the frequency or nature of emergency medical services (EMS) response to tactical events in the United States. The purpose of this study was to perform a descriptive analysis of tactical events reported to a national EMS database. Methods: Descriptive analysis of the 2012 National Emergency Medical Services Information System (NEMSIS) Public Release research data set, containing EMS emergency response data from 41 states. Results: A total of 17,479,328 EMS events were reported, of which 3,953 events were coded as "Activation-Tactical or SWAT Specialty Service/Response Team." The most common level of prehospital care present on scene was basic life support (55.2%). The majority (72.3%) of tactical incident activations involved a single patient; mass casualty incidents occurred in 0.5% of events. The most common EMS response locations were homes (48.4%), streets or highways (37.0%), and public buildings (6.3%). The mean age of treated patients was 44.1 years ± 22.0 years; 3.5% of tactical incident activation patients were aged 8 years or less. Injuries were coded as firearm assault in 14.8% and as chemical exposure in 8.9% of events. Cardiac arrest occurred in 5.1% of patients, with the majority (92.2%) occurring prior to EMS arrival. The primary symptoms reported by EMS personnel were pain (37.4%), change in responsiveness (13.1%), and bleeding (8.1%). Advanced airway procedures occurred in 30 patients. No patients were documented as receiving tourniquets or needle thoracostomy. Conclusion: Approximately 11 EMS responses in support of law enforcement tactical operations occur daily in the United States. The majority occur in homes and involve a single patient. Advanced airway procedures are required in a minority of patients. Cardiac arrest is rare and occurs prior to EMS response in the majority of cases. Better understanding of the nature and location of EMS responses to tactical incidents is required to develop consistent EMS policies in support of law enforcement tactical operations.
Keywords: TEMS; emergency medical services; tactical; SWAT
Lewis C, Nilan M, Srivilasa C, Knight RM, Shevchik J, Bowen B, Able T, Kreishman P. 20(2). 123 - 126. (Journal Article)
Abstract
We present the case of a severely injured Special Operations Servicemember whose care was remarkable for three unique interventions: the first use of a walking blood bank performed at the point of injury, prolonged permissive hypotension, and intermittent resuscitative endovascular balloon occlusion of the aorta (REBOA).
Keywords: resuscitative endovascular balloon occlusion of the aorta; intermittent REBOA; permissive hypotension; walking blood bank; buddy transfusion
Benjamin JM, Chippaux J, Jackson K, Ashe S, Tamou-Sambo B, Massougbodji A, Akpakpa OC, Abo BN. 19(2). 18 - 22. (Case Reports)
Abstract
A 20-year-old man presented to a rural hospital in Bembéréké, northern Benin, after a witnessed bite from a small, dark snake to his left foot that occurred 3 hours earlier. The description of the snake was consistent with several neurotoxic elapids known to inhabit the area in addition to various species from at least 10 different genera of non-front-fanged colubroid (NFFC) venomous snakes. The presentation was consistent with the early signs of a neurotoxic snakebite as well as a sympathetic nervous system stress response. Diagnosis was further complicated by the presence of a makeshift tourniquet, which either could have been the cause of local signs and symptoms or a mechanical barrier delaying venom distribution and systemic effects until removal. Systemic envenomation did not develop after the removal of the constricting band, but significant local paresthesias persisted for longer than 24 hours and resolved after the administration of a placebo injection of normal saline in place of antivenom therapy. This was an unusual case of snakebite with persistent neuropathy despite an apparent lack of envenomation and a number of snakebite- specific variables that complicated the initial assessment, diagnosis, and treatment of the patient. This case presentation provides clinicians with an opportunity to familiarize themselves with the differential diagnosis and approach to a patient bitten by an unidentified snake, and it illustrates the importance of symptom progression as a pathognomonic sign during the early stages of a truly serious snake envenomation. Treatment should be based on clinical presentation and evolution of symptoms rather than on snake identification alone.
Keywords: snakebite; envenomation; clinical diagnosis; non-front-fanged colubroid; antivenom; dry bite
Slish J, Hwang C, Holtsman L, Jones J, Stout D, Abo BN, Ryan M. 20(2). 104 - 109. (Journal Article)
Abstract
In summer of 2017 in Charlottesville, Virginia, white nationalists clashed with counterprotestors, ultimately leading to the death of three people and leaving 34 more injured. Soon after, the same group was granted permission to speak on the campus of the University of Florida in Gainesville, Florida. Despite our college town having limited resources and personnel, the comprehensive and extensive preparation preceding the event ensured a peaceful resolution for such a large and potentially volatile situation. The preparatory steps required joint efforts from local and state partners in law enforcement, emergency medical services, and emergency departments. We describe here the situation we faced, the pre-event preparations, the response in the field and in our emergency department, and the outcomes from an emergency and tactical medicine perspective. We hope our successful experience will impart knowledge for similar events.
Keywords: TCCC; TECC; mass-casualty event; event medicine; tactical medicine; National Incident Management System
Kester R, Abraham PA, Leggit JC, Harp JB, Kazman JB, Deuster PA, O'Connor FG. 24(1). 48 - 52. (Journal Article)
Abstract
Background: Among individuals with prior exertional heat illness (EHI), heat tolerance testing (HTT) may inform risk and return to duty/activity. However, little is known about HTT's predictive validity, particularly for EHI recurrence. Our project sought to demonstrate the predictive validity of HTT in EHI recurrence and HTT's utility as a diagnostic tool in exertional heat stroke (EHS). Methods: Participants with prior EHS were recruited for the study by a physician's referral and were classified as heat tolerant or intolerant after completing demographics and an HTT. Participants were further categorized as single/simple (SS) EHI or recurrent/complex (RC) EHI by conducting a retrospective record review of the following two years. We calculated the positive (PPV) and negative predictive values (NPV) of HTT. Results: The retrospective review of HTT records was used to categorize 44% of Servicemembers as RC, with 77% classified as heat tolerant, 14% as heat intolerant, and 9% as borderline. When borderline cases were classified as heat intolerant, HTT had a high NPV, indicating a high probability that heat-tolerant individuals did not have recurrent EHI. When borderline cases were classified as heat tolerant, NPV and sensitivity decreased while specificity increased. Conclusion: We demonstrated that the HTT had a 100% NPV for future EHI over two years of follow-up for Servicemembers with a history of recurrent heat injury and negative HTT results. An HTT can provide critical data points to inform return to duty decisions and timelines by predicting the risk of EHI recurrence.
Keywords: exertional heat stroke; heat stroke; heat tolerance testing; return to duty; heat tolerance; exertional heat illness; recurrent heat injury
Sell TC, Abt JP, Crawford K, Lovalekar M, Nagai T, Deluzio J, Smalley BW, McGrail MA, Rowe RS, Cardin S, Lephart SM. 10(4). 2 - 21. (Journal Article)
Abstract
Introduction: Physical training for United States military personnel requires a combination of injury prevention and performance optimization to counter unintentional musculoskeletal injuries and maximize warrior capabilities. Determining the most effective activities and tasks to meet these goals requires a systematic, research-based approach that is population specific based on the tasks and demands of the warrior. Objective: We have modified the traditional approach to injury prevention to implement a comprehensive injury prevention and performance optimization research program with the 101st Airborne Division (Air Assault) at Ft. Campbell, KY. This is Part I of two papers that presents the research conducted during the first three steps of the program and includes Injury Surveillance, Task and Demand Analysis, and Predictors of Injury and Optimal Performance. Methods: Injury surveillance based on a self-report of injuries was collected on all Soldiers participating in the study. Field-based analyses of the tasks and demands of Soldiers performing typical tasks of 101st Soldiers were performed to develop 101st-specific laboratory testing and to assist with the design of the intervention (Eagle Tactical Athlete Program (ETAP)). Laboratory testing of musculoskeletal, biomechanical, physiological, and nutritional characteristics was performed on Soldiers and benchmarked to triathletes to determine predictors of injury and optimal performance and to assist with the design of ETAP. Results: Injury surveillance demonstrated that Soldiers of the 101st are at risk for a wide range of preventable unintentional musculoskeletal injuries during physical training, tactical training, and recreational/sports activities. The field-based analyses provided quantitative data and qualitative information essential to guiding 101st specific laboratory testing and intervention design. Overall the laboratory testing revealed that Soldiers of the 101st would benefit from targeted physical training to meet the specific demands of their job and that sub-groups of Soldiers would benefit from targeted injury prevention activities. Conclusions: The first three steps of the injury prevention and performance research program revealed that Soldiers of the 101st suffer preventable musculoskeletal injuries, have unique physical demands, and would benefit from targeted training to improve performance and prevent injury.
Abt JP, Sell TC, Crawford K, Lovalekar M, Nagai T, Deluzio J, Smalley BW, McGrail MA, Rowe RS, Cardin S, Lephart SM. 10(4). 22 - 33. (Journal Article)
Abstract
Introduction: Physical training for United States military personnel requires a combination of injury prevention and performance optimization to counter unintentional musculoskeletal injuries and maximize warrior capabilities. Determining the most effective activities and tasks to meet these goals requires a systematic, research-based approach that is population specific based on the tasks and demands of the Warrior. Objective: The authors have modified the traditional approach to injury prevention to implement a comprehensive injury prevention and performance optimization research program with the 101st Airborne Division (Air Assault) at Fort Campbell, KY. This is second of two companion papers and presents the last three steps of the research model and includes Design and Validation of the Interventions, Program Integration and Implementation, and Monitor and Determine the Effectiveness of the Program. Methods: An 8-week trial was performed to validate the Eagle Tactical Athlete Program (ETAP) to improve modifiable suboptimal characteristics identified in Part I. The experimental group participated in ETAP under the direction of a ETAP Strength and Conditioning Specialist while the control group performed the current physical training at Fort Campbell under the direction of a Physical Training Leader and as governed by FM 21-20 for the 8-week study period. Results: Soldiers performing ETAP demonstrated improvements in several tests for strength, flexibility, performance, physiology, and the APFT compared to current physical training performed at Fort Campbell. Conclusions: ETAP was proven valid to improve certain suboptimal characteristics within the 8-week trial as compared to the current training performed at Fort Campbell. ETAP has long-term implications and with expected greater improvements when implemented into a Division pre-deployment cycle of 10-12 months which will result in further systemic adaptations for each variable.
Johnson AK, Royer SD, Ross JA, Poploski KM, Sheppard RL, Heebner NR, Abt JP, Winters JD. 21(4). 30 - 35. (Journal Article)
Abstract
Background: Servicemembers are required to operate at high levels despite experiencing common injuries such as chronic low back pain. Continuing high levels of activity while compensating for pain may increase the risk of musculoskeletal injuries. As such, the purpose of this project was to determine if servicemembers with chronic low back pain have reduced lower extremity performance, and if they use alternate strategies to complete a functional performance task as compared to healthy servicemembers. Methods: Of a total of 46 male United States Marine Corps Forces Special Operations Command (MARSOC) personnel, 23 individuals who suffered from chronic low back pain (age = 28.6 ± 4.4 years, weight = 84.2 ± 6.8 kg) and 23 healthy controls (age = 27.9 ± 3.8 years, weight = 83.8 ± 7.7 kg) completed a stop jump task. In this task, three-dimensional biomechanics were measured, and lower extremity and trunk strength were assessed. Results: The low back pain group exhibited higher vertical ground reaction force impulse on the dominant limb (0.26% body weight [BW]/s), compared to the nondominant limb (0.25% BW/s, p = .036). The control group demonstrated relationships between jump height and strength in both limbs (dominant: r = 0.436, p = .043; nondominant: r = 0.571, p = .006), whereas the low back pain group demonstrated relationships between jump height and dominant limb knee work (r = 0.470, p = .027) and ankle work (r = 0.447, p = .037). Conclusions: This study demonstrates that active-duty MARSOC personnel with a history of low back pain reach similar levels of jump height during a counter movement jump, as compared to those without a history of low back pain. However, the asymmetries displayed by the low back pain group suggest an alternate strategy to reaching similar jump heights as compared to healthy individuals.
Keywords: biomechanics; low back pain; asymmetries; jump height
Dilday J, Heidenreich B, Spitzer H, Abuhakmeh Y, Ahnfeldt E, Watt J, Mase VJ. 22(4). 41 - 45. (Journal Article)
Abstract
Background: Tube thoracostomy is the most effective treatment for pneumothorax, and on the battlefield, is lifesaving. In combat, far-forward adoption of open thoracostomy has not been successful. Therefore, the ability to safely and reliably perform chest tube insertion in the far-forward combat theatre would be of significant value. The Reactor is a hand-held device for tube thoracostomy that has been validated for tension pneumothorax compared to needle decompression. Here we investigate whether the Reactor has potential for simple pneumothorax compared to open thoracostomy. Treatment of pneumothorax before tension physiology ensues is critical. Methods: Simple pneumothoraces were created in 5 in-vivo swine models and confirmed with x-ray. Interventions were randomized to open technique (OT, n = 25) and Reactor (RT, n = 25). Post-procedure radiography was used to confirm tube placement and pneumothorax resolution. Video Assisted Thoracoscopic Surgery (VATS) was used to evaluate for iatrogenic injuries. 50 chest tubes were placed, with 25 per group. Results: There were no statistical differences between the groups for insertion time, pneumothorax resolution, or estimated blood loss (p = .91 and .83). Injury rates between groups varied, with 28% (n = 7) in the Reactor group and 8% (n = 2) the control group (p = .06). The most common injury was violation of visceral pleura (10%, n = 5, both groups) and violation of the mediastinum (8%, n = 4, both groups). Conclusion: The Reactor device was equal compared to open thoracostomy for insertion time, pneumothorax resolution, and injury rates. The device required smaller incisions compared to tube thoracostomy and may be useful adjunct in simple pneumothorax management.
Keywords: chest tube; thoracostomy; pneumothorax
Tien HC, Jung V, Rizoli SB, Acharya SV, MacDonald JC. 09(1). 65 - 68. (Previously Published)
Previously published in the Journal of the American College of Surgeons, Vol. 207, No. 2, August 2008. Republished in JSOM with permission
of Elsevier.
Abstract
Background: Tactical combat casualty care (TCCC) is a system of prehospital trauma care designed for the combat environment. Although widely adopted, very few studies have reported on how TCCC interventions are actually delivered on the battlefield, from a quality of care perspective. Study Design: This was a prospective study of all trauma patients treated at the Role 3 multinational medical unit (MMU) at Kandahar Airfield Base from February 7, 2006 to May 30, 2006. Primary outcomes were whether or not two TCCC interventions were underused, overused, or misused. Interventions studied were needle decompression of tension pneumothoraces and tourniquet application for exsanguinating extremity injuries. Results: One hundred thirty-four trauma patients were treated at the Role 3 MMU during the study period. Six patients had eight tourniquets applied. Five tourniquets were applied to four patients appropriately and saved their lives. There was one case of misuse where a venous tourniquet was applied. There was one case of overuse where one patient had two tourniquets placed for 4 hours on extremities with no vascular injury. There were seven cases where needle decompression was underused: Seven patients presented with vital signs absent with no needle decompression. There was one case of overuse of needle decompression. There were seven cases of misuse where the patients were decompressed too medially. Conclusions: Tourniquets save lives. Needle decompression can save lives, but is usually performed in patients with multiple critical injuries. TCCC instructors must reinforce proper techniques and indications for each procedure to ensure that the quality of care provided to injured soldiers on the battlefield remains high.
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
Cancio LC, Powell D, Adams B, Bull K, Keller A, Gurney J, Pamplin JC, Shackelford S, Keenan S. 16(4). 87 - 98. (Classical Conference)
Abstract
Rankin CJ, Fetherston T, Ballentine CD, Adams B, Long B, Carius BM. 22(2). 69 - 74. (Journal Article)
Abstract
The ongoing evolution of prehospital medical care continues to advance beyond immediate triage care. Prehospital care is even more important to consider in theaters with extended evacuation times and limited local medical assets. Although blood loss is often associated with settings of acute traumatic hemorrhage in military medicine, the possibility for other hematologic compromise necessitating urgent action requires medics operating in these environments to have a fundamental knowledge of the pathophysiology, manifestations, and stabilization measures of anemia to aid their patients prior to, or in lieu of, evacuation. Continued development of and access to point-of-care testing in increasingly forward-deployed settings further enable medics to perform these tasks. Here, we provide a brief review of hemoglobin function and composition, and presentation and management considerations of anemia, to assist medics in their treatment efforts. We also address specific concerns for battlefield and atraumatic presentations.
Keywords: hemoglobin; anemia; prehospital care; blood loss, hemorrhage; military; laboratory; malaria; hemolysis; bleeding; transfusion
DesRosiers TT, Anderson JL, Adams B, Carver RA. 22(2). 48 - 54. (Journal Article)
Abstract
Pain is one of the most common complaints of battlefield casualties, and unique considerations apply in the tactical environment when managing the pain of wounded service members. The resource constraints commonly experienced in an operational setting, plus the likelihood of prolonged casualty care by medics or corpsmen on future battlefields, necessitates a review of analgesia and sedation in the prehospital setting. Four clinical scenarios highlight the spectrum of analgesia and sedation that may be necessary in this prehospital and/or austere environment.
Keywords: traumatic brain injury; pathophysiology; prehospital management; critical care
Mabry RL, Cuniowski P, Frankfurt A, Adams BD. 11(3). 16 - 19. (Journal Article)
Abstract
Background: Optimal airway management protocols for the prehospital battlefield setting have not been defined. Airway management strategies in this environment must take into account the injury patterns, the environment and training requirements of military prehospital providers. Methods: This is a post-hoc, sub-group analysis of the Registry of Emergency Airways Arriving at Combat Hospitals or REACH database. This study examines only those patients who had advanced airways placed for trauma by an enlisted military medic at the point of injury. Results: Twenty (100%) of the patients had a traumatic injury, 19 (95%) were male, and 13 (65%) had a gun shot wounds (GSWs) as the mechanism of injury. The majority, 12 (60%) patients had an esophageal-tracheal airway device placed. Of the remaining patients, four (20%) underwent endotracheal intubation, three (15%) had a surgical cricothyroidotomy performed, and one (5%) had a Laryngeal Mask Airway (LMA) placed. Seventeen (85%) of the twenty patients were dead on arrival or died shortly after arrival at the Combat Support Hospital (CSH). All of the patients that died had a Glasgow Coma Scale (GCS) of three upon arrival. The Glasgow Coma Scale provides a score in the range 3-15; patients with scores of 3-8 are usually said to be in a coma. Three patients in this group survived to transfer from the CSH. Two of the transfers were lost to follow up, one with a GSW to the head and GCS of three, the other with a GCS of five from injuries sustained in an explosion. The third patient had a surgical cricothyroidotomy (SC) performed in the field for an expanding neck hematoma and recovered fully following surgery. Conclusions: Casualties that tolerate invasive airway management without sedation in the context of trauma prognosticates a very high mortality. Airway management algorithms for military providers should reflect the casualties encountered on the battlefield not patients in cardiac arrest which predominate in the civilian EMS airway management practice. Further data are needed to understand the injuries encountered on the battlefield and to develop airway management solutions that optimize outcomes of patients with battlefield trauma.
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
Tadlock M, Maves R, Flieger DM, Baldino TJ, Adams D, Riesberg JC, Kitchen LK, Brower JJ, Tripp MS. 24(2). 94 - 102. (Journal Article)
Abstract
During distributed maritime operations, individual components of the naval force are more geographically dispersed. As the U.S. Navy further develops this concept, smaller vessels may be operating at a significant time and distance away from more advanced medical capabilities. Therefore, during both current and future contested Distributed Maritime Operations, Role 1 maritime caregivers such as Independent Duty Corpsman will have to manage patients for prolonged periods of time. This manuscript presents an innovative approach to teaching complex operational medicine concepts (including Prolonged Casualty Care [PCC]) to austere Role 1 maritime caregivers using a hypothetical scenario involving a patient with sepsis and septic shock. The scenario incorporates the Joint Trauma System PCC Clinical Practice Guidelines (CPG) and other standard references. The scenario includes a stem clinical vignette, expected clinical changes for the affected patient at specific time points (e.g., time 0, 1, 2, and 48h), and expected interventions based on the PCC CPG and available shipboard equipment. Epidemiology of sepsis in the deployed environment is also reviewed. This process also identifies opportunities to improve training, clinical skills sustainment, and standard shipboard medical supplies.
Keywords: prolonged casualty care; Tactical Combat Casualty Care; maritime operations; critical care; sepsis; septic shock; appendicitis
Montgomery HR, Drew B, Torrisi J, Adams MG, Remley MA, Rich TA, Greydanus DJ, Shaw TA. 21(2). 122 - 127. (Classical Conference)
Abstract
Based on careful review of the Tactical Combat Casualty Care (TCCC) Guidelines, the authors developed a list of proposed changes and edits for inclusion in a comprehensive change proposal. To be included in the proposal, individual changes had to meet at least one of three criteria: 1. The change was primarily tactical, operational, or educational rather than clinical in nature. 2. The change was a minor modification to the language of an existing TCCC Guideline. 3. The change, though clinical, was straightforward and noncontentious. The authors initially presented their list to the TCCC Collaboration Group for review at the 11 August 2020 online virtual meeting of the Committee on Tactical Combat Casualty Care (CoTCCC). Based on discussions during the virtual meeting and following revisions, a second presentation of guideline modifications was presented during the CoTCCC session of the online virtual Defense Committee on Trauma meeting on 02 September 2020. The CoTCCC conducted voting on the guideline changes in early October 2020 with subsequent inclusion in the updated TCCC Guidelines published on 01 November 2020.1
Keywords: Tactical Combat Casualty Care; TCCC; guidelines; change proposal
Yue I, Allen DS, Chung J, Ruppert A, Papalski WN, Sons N, Zarow GJ, Good CJ, Devenny LE, Cady HJ, Sonntag EM, Adams RC, Hildreth AL. 24(3). 49 - 57. (Journal Article)
Abstract
Training needs of Special Operations Forces (SOF) medics were surveyed and new training initiatives have been created to meet their needs. SOF medics perform an array of medical procedures in austere environments with minimal supervision. Medical skills decay over time after initial training and the perceived training needs of active SOF medics were unclear. To fill this gap, active SOF medics (n=57) completed a survey that included confidence ratings and indications of whether additional training would make them more proficient in 70 medical knowledge and procedural skills, assembled into categories by a panel of experts (airway, trauma, neuro, differential diagnosis, administrative, infection, critical care, environmental, other). Data were analyzed with analysis of variance (ANOVA) and nonparametric statistics at P<.05. Confidence was highest in the trauma, administrative, and airway categories, and lowest in the infection, differential diagnosis, and neuro categories (P<.05 or less). Categories indicating the greatest need for additional training were environmental and critical care, while those indicating lowest need were the airway and trauma categories (P=.05). Additional training was endorsed by >75% of participants in each category. SOF medics also wanted additional training in all areas, preferably hands-on with live patients in realistic scenarios, taught by experienced medics. Findings highlight the training needs of SOF medics and demonstrate the value of bottom-up feedback toward optimizing sustainment training. Based on present findings, two TACMED (Tactical Medicine) Divisions at the SOF Echelon III level were created to meet the sustainment training needs of SOF medics
Keywords: special warfare; Special Operations; advanced tactical provider; medical sustainment program; medical training; TACMED
Kragh JF, Dubick MA, Aden JK, McKeague AL, Rasmussen TE, Billings S, Blackbourne LH. 13(4). 76 - 84. (Journal Article)
Abstract
Background: In 2012, we reported on junctional wounds in war, but only of the few injuries that were critically severe. Objective: The purpose of the present study is to associate a wide range of junctional wounds and casualty survival over a decade in order to evidence opportunities for improvement in trauma care within a large healthcare system. Methods: We retrospectively surveyed data from a military trauma registry. We associated survival and injuries at the junction of the trunk and appendages in the current war (2001 to 2010). Results: The junctional injury rate rose 14-fold from 0%, its minimum in 2001, to 5%, its maximum in 2010. Of the 833 casualties with junctional injury in the study, the survival rate was 83%; its change was not statistically significant over time. Most casualties had severe extremity injuries and associated injuries of other body regions such as the face and head. Conclusions: Junctional injury is common, severe, disabling, and lethal. The findings of this study may increase awareness of junctional injury. Opportunities for improvement which we identified included further research on the future addition of junctional codes (such as neck diagnoses) in order to align research methods to clinical care.
Keywords: tourniquet; trauma; resuscitation; injuries; wounds
Kragh JF, Wallum TE, Aden JK, Dubick MA, Billings S. 14(1). 26 - 29. (Journal Article)
Abstract
Objective: The purpose of the present study is to determine the performance of tourniquet use by the placement of the tourniquet's windlass on the extremity in four positions-medial, lateral, anterior, and posterior-to inform tourniquet instructors and develop best tourniquet practices. Methods: A HapMed™ Leg Tourniquet Trainer was used as a manikin to test the effectiveness of an emergency tourniquet, the Special Operations Forces Tactical Tourniquet. Two users made 10 tests, each in four positions. Results: Effectiveness rates of tourniquet use were 100% in all four positions. The two tourniquet users were both right-hand dominant and used their right hand to turn the windlass. One user turned the windlass clockwise, and the other turned it counterclockwise. The association between time to stop bleeding and tourniquet position was statistically significant but associations between time to stop bleeding and the user, user-by-position, and windlass turn number were not statistically significant. The association between tourniquet position and pressure under the tourniquet was statistically significant, and the association between user and pressure under the tourniquet was statistically significant, but the user-by-position and windlass turn number were not statistically significant. The associations between tourniquet position and blood loss volume, user and blood loss volume, and user-by-position and blood loss volume were statistically significant. Conclusions: The present study found that tourniquet effectiveness rates were uniformly 100% irrespective of whether the windlass position was medial, lateral, anterior, or posterior. These excellent clinical and statistical results indicate that users may continue to place the tourniquets as they prefer upon the proximal thigh.
Keywords: first aid; resuscitation; damage control; hematoma; trauma; shock
Kragh JF, Parsons DL, Kotwal RS, Kheirabadi BS, Aden JK, Gerhardt RT, Billings S, Dubick MA. 14(3). 58 - 63. (Journal Article)
Abstract
Background: Junctional hemorrhage is a common cause of death on the battlefield, but there is no documented direct comparison for the use of junctional tourniquet models by US medics. The purpose of this testing is to assess military medic experience with the use of junctional tourniquets in simulated out-of-hospital trauma care. Methods: Nine medics (seven men and two women) used four different junctional tourniquets: Combat Ready Clamp™ (CRoC™; http://www.combatmedicalsystems .com), Abdominal Aortic and Junctional Tourniquet™ (AAJT™; http://www.compressionworks.net), Junctional Emergency Treatment Tool (JETT™; http://www.narescue .com), and SAM Junctional Tourniquet® (SJT®; http:// www.sammedical.com/products). These medics also acted as simulated casualties. Effectiveness percentages, as measured by stopped distal pulse by Doppler auscultation, and time to effectiveness were recorded in two tests per tourniquet (72 total tests). Tourniquet users ranked their preference of model by answering the question: "If you had to go to war today and you could only choose one, which tourniquet would you choose to bring?" Results: All tourniquets used were safe under the conditions of this study. Both the SJT and the CRoC had high effectiveness percentages; their rate difference was not statistically significant. The SJT and the CRoC had fast times to effectiveness; their time difference was not statistically significant. Users preferred the SJT and the CRoC; their ranked difference was not statistically significant. Conclusion: The SJT and the CRoC were equally effective and fast and were preferred by the participants.
Keywords: tourniquet; hemorrhage; resuscitation; groin; inguinal; medical device; injuries; wounds
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
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
Kragh JF, Parsons DL, Kotwal RS, Kheirabadi BS, Aden JK, Gerhardt RT, Billings S, Dubick MA. 15(2). 96 - 96. (Letter)
Abstract
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
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
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
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
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
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
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
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
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
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
Kragh JF, Aden JK, Lambert CD, Moore VK, Dubick MA. 17(3). 25 - 34. (Journal Article)
Abstract
Background: The purpose of this study was to gather data about unwrapping a packaged limb tourniquet from its plastic wrapper while wearing different types of gloves. Because already unwrapped tourniquets require no time to unwrap, unwrapping data may provide insights into the issue of having tourniquets unwrapped when stowed in a first aid kit of a Serviceperson at war. Materials and Methods: In a laboratory setting, 36 tests of nine glove groups were performed in which four people, gloved and ungloved, unwrapped tourniquets. Other tourniquets were environmentally exposed for 3 months. Results: All the users successfully unwrapped each tourniquet. Mean times to unwrap by glove group were not significantly different (ρ = .0961). When mean values of eight experimental groups were compared with that of one control group (i.e., bare hands), results showed no significant difference (ρ > .07). Mean time was least for bare hands (12 seconds) and most for cold gloves layered under mittens (22 seconds). Among the 36 pairwise comparisons of difference between glove group means, after adjustment for multiple comparisons, no comparison was noted to be statistically significant (ρ > .052, all 36 pairs). Glove thickness ranged from 0 mm for bare hands to 2.5 mm for cold gloves layered under mittens. By glove group, the thickness-time association was moderate, as tested by linear regression (R2 = 0.6096). The tourniquets exposed to the environment had evidence of rapid photodegradation due to direct exposure to sunlight. Such exposure also destroyed the wrappers. Conclusion: In a preliminary study, different gloves performed similarly when wearers unwrapped a tourniquet from its wrapper. The tourniquet wrappers gave no visible protection from sunlight, and environmental exposure destroyed the wrappers.
Keywords: tourniquet; first aid methods; first aid device; hemorrhage prevention and control; shock; emergency medical services; military medicine; material science; environment; exposure
Kragh JF, Aden JK, Lambert CD, Moore VK, Dubick MA. 17(4). 29 - 36. (Journal Article)
Abstract
Background: The effects of users, glove types, and tourniquet devices on the performance of limb tourniquet use in simulated first aid were measured. Materials and Methods: Four users conducted 180 tests of tourniquet performance in eight glove groups compared with bare hands as a control. Results: Among tests, 99% (n = 179) had favorable results for each of the following: effectiveness (i.e., bleeding control), distal pulse stoppage, and tourniquet placement at the correct site. However, only 90% of tests ended with a satisfactory result, which is a composite outcome of aggregated metrics if all (patient status is stable, tourniquet placement is good, and pressure is good) are satisfactory. Of 18 unsatisfactory results, 17 (94%) were due to pressure problems. Most of the variance of the majority of continuous metrics (time to determination of bleeding control, trial time, overall time, pressure, and blood loss) could be attributed to the users (62%, 55%, 61%, 8%, and 68%, respectively). Glove effects impaired and slowed performance; three groups (cold gloves layered under mittens, mittens, and cold gloves) consistently had significant effects and five groups (examination gloves, flight gloves, leather gloves, glove liners, and glove liners layered under leather gloves) did not. For time to bleeding control and blood loss, performance using these same three glove groups had worse results compared with bare hands by 26, 18, and 17 seconds and by 188, 116, and 124mL, respectively. Device effects occurred only with continuous metrics and were often dominated by user effects. Conclusion: In simulated first aid with tourniquets used to control bleeding, users had major effects on most performance metrics. Glove effects were significant for three of eight glove types. Tourniquet device effects occurred only with continuous metrics and were often dominated by user effects.
Keywords: glove; mitten; manual skill; psychomotor performance; tourniquet; first aid; hemorrhage, prevention and control
Kragh JF, Newton NJ, Tan AR, Aden JK, Dubick MA. 18(2). 36 - 41. (Journal Article)
Abstract
Background: The performance of a new tourniquet model was compared with that of an established model in simulated first aid. Methods: Four users applied the Combat Application Tourniquet (C-A-T), an established model that served as the control tourniquet, and the new SAM Extremity Tourniquet (SXT) model, which was the study tourniquet. Results: The performance of the C-A-T was better than that of the SXT for seven measured parameters versus two, respectively; metrics were statistically tied 12 times. The degree of difference, when present, was often small. For pretime, a period of uncontrolled bleeding from the start to a time point when the tourniquet first contacts the manikin, the bleeding rate was uncontrolled at approximately 10.4mL/s, and for an overall average of 39 seconds of pretime, 406mL of blood loss was calculated. The mean time to determination of bleeding control (± standard deviation [SD]) was 66 seconds (SXT, 70 ± 30 seconds; C-A-T, 62 ± 18 seconds; p = .0075). The mean ease-of-use score was 4 (indicating easy) on a scale of 1 to 5, with 5 indicating very easy (mean ± SD: SXT, 4 ± 1; C-A-T, 5 ± 0; p < .0001). C-A-T also performed better for total trial time, manikin damage, blood loss rate, pressure, and composite score. SXT was better for pretime and unwrap time. All users intuitively self-selected the speed at which they applied the tourniquets and that speed was similar in all of the required steps. However, by time segments, one user went slowest in each segment while the other three generally went faster. Conclusions: In simulated first aid with tourniquets, better results generally were seen with the C-A-T than with the SXT in terms of performance metrics. However, the degree of difference, when present, was often small.
Keywords: tourniquet; manual skill; psychomotor performance; first aid device comparison/education/standards; hemorrhage prevention and control
Kragh JF, Tan AR, Newton NJ, Aden JK, Dubick MA. 18(3). 15 - 21. (Journal Article)
Abstract
Background: The purpose of this study was to survey the judgments of tourniquet users in simulation to discern opportunities for further study. Methods: The study design constituted two parts: questions posed to four tourniquet users and then their tourniquet use was surveyed in simulated first aid, where the users had to decide how to perform among five different cases. The questions addressed judged confidence, blood volumes, a reason bleeding resumes, regret of preventable death, hemorrhage assessment, need for side-by-side use of tourniquets, shock severity, predicting reliability, and difference in blood losses. The mechanical performance was tested on a manikin. Case 1 had no bleeding. Case 2 had limb-wound bleeding that indicated tourniquet use in first aid. Case 3 was like case 2, except the patient was a child. Case 4 was like case 2, except caregiving was under gunfire. Case 5 was like case 4, but two tourniquets were to be used side by side. Each user made tests of the five cases to constitute a block. Each user had three blocks. Case order was randomized within blocks. The study had 60 tests. Results: In answering questions relevant to first-aid use of limb tourniquets, judgments were in line with previous studies of judgment science, and thus were plausibly applicable. Mechanical performance results on the manikin were as follows: 38 satisfactory, 10 unsatisfactory (a loose tourniquet and nine incorrect tourniquet placements), and 12 not applicable (case 1 needed no mechanical intervention). For cases 1 to 5, satisfactory results were: 100%, 83%, 100%, 75%, and 58%, respectively. For blocks 1 to 3, satisfactory results were 50%, 83%, and 83%, respectively. Conclusion: For tourniquet use in simulated first aid, the results are plausibly applicable because user judgments were coherent with those in previous studies of judgment science. However, the opportunities for further studies were noted.
Keywords: psychomotor performance; practice-based learning; choice behavior; motivation; readiness
Zhao NO, Kragh JF, Aden JK, Jordan BS, Parsons DL, Dubick MA. 18(3). 22 - 27. (Journal Article)
Abstract
Background: Readiness to perform lifesaving interventions during emergencies is based on a person's preparation to proficiently execute the skills required. Graphically plotting the performance of a tourniquet user in simulation has previously aided us in developing our understanding of how the user actually behaves. The purpose of this study was to explore performance assessment and learning curves to better understand how to develop best teaching practices. Methods: These were retrospective analyses of a convenience sample of data from a prior manikin study of 200 tourniquet uses among 10 users. We sought to generate hypotheses about performance assessments relevant to developing best teaching practices. The focus was on different metrics of user performance. Results: When one metric was chosen over another, failure counts summed cumulatively over 200 uses differed as much as 12-fold. That difference also indicated that the degree of challenge posed to user performance differed by the metric chosen. When we ranked user performance with one metric and then with another, most (90%; nine of 10) users changed rank: five rose and four fell. Substantial differences in performance outcomes resulted from the difference in metric chosen, which, in turn, changed how the outcome was portrayed and thus interpreted. Hypotheses generated included the following: The usefulness of a specific metric may vary by the user's level of skill from novice to expert; demonstration of the step order in skill performance may suffice for initial training of novices; a mechanical metric of effectiveness, like pulse stoppage, may aid in later training of novices; and training users how to practice on their own and self-assess performance may aid their self-development. Conclusion: The outcome of the performance assessments varied depending on the choice of metric in this study of simulated use of tourniquets.
Keywords: education standards measures; implementation; individuality; choice behavior; first aid
Kragh JF, Zhao NO, Aden JK, Dubick MA. 18(4). 57 - 63. (Journal Article)
Abstract
Background: The purpose of this study was to simulate first aid by mechanical use of a limb tourniquet on a thigh with and without bone to better understand best caregiving practices. Methods: Two investigators studied simulated first aid on a new pool "noodle," a plastic cylinder with a central air tunnel into which we inserted a wood dowel to simulate bone. Data were gathered by group (study and control, n = 12 each). The control group comprised data collected from simulated tourniquet use on the model with bone present. The study group comprised data from simulated tourniquet use on the model without bone. Results: Comparing compression with and without bone, the mean volumes of compressed soft tissues alone were 303mL and 306mL, respectively. When bone was present, the volume of soft tissues was squeezed more, yielding a smaller size by 3mL (1%). The bone had a volume of 41mL and pressed statically outward with an equal force oppositely directed to the inward compression of the overlying soft tissues. With bone removed and compression applied, the mean residual void was 16mL, because 25mL (i.e., 41mL minus 16mL) of soft tissues had collapsed inward. The volume of the limb under the tourniquet with and without bone was 344mL and 322mL, respectively. The collapse volume, 25mL, was 3mL more than the difference of the mean volume of the limb under the tourniquet. More limb squeeze (22mL) looked like better compression, but it was actually worse-an illusion created by collapse of the hidden void. Conclusion: In simulated first aid, mechanical modeling demonstrated how tourniquet compression applied to a limb squeezed the soft tissues better when underlying bone was present. Bone loss altered the compression profile and may complicate control of bleeding in care. This knowledge, its depiction, and its demonstration may inform first-aid instructors.
Keywords: caregiver; choice behavior; public health; medical device; active learning; tourniquet; mechanics
Kragh JF, Aden JK, Dubick MA. 19(1). 35 - 43. (Journal Article)
Abstract
Background: A tourniquet's readiness during emergencies depends on how it is configured. We investigated configuration so ways of improving readiness can be developed. Methods: This study was conducted at the Institute of Surgical Research in 2018 as sequential investigations by one user of Combat Application Tourniquets (C-A-Ts) in a band-and-rod design. Results: Each tourniquet comes packaged with paper instructions for use, which include directions on how to configure it in preparation for caregiving. The paper and video instructions for use omit tensioning of the tourniquet in configuration, and the video misconfigured a time strap over the rod. In first-aid classrooms, we saw unwitting learners troubleshoot that misconfiguration. Problems with configuration were also seen in caregiving and with tourniquets stowed in kits. In deliberate practice, we self-applied a tourniquet to a thigh. In configuration after each of 100 uses, tourniquet elongation due to tensioning averaged 2.4 in was important for restoring the tourniquet to its full length. During configuration, if the C-A-T's stabilization plate slid along the band, out of position, the user slid the plate back into position. In various ways of testing other C-A-Ts, elongations averaged from 0.4 in to 0.9 in, depending on whether the tourniquet was self-applied or applied to a firm manikin. Elongation increments accrued as the tourniquet's band flattened. Configuration time averaged 22 seconds, and accrued experience improved the compactness of configuration. Conclusion: People are too often unreliable at putting C-A-Ts into the optimal configuration for use. That ready-to-use configuration includes the tourniquet being at its full length, having the stabilization plate positioned correctly along the band, and having the strap fastened to its clip of origin. When used, tourniquets had normal, small elongations in part due to band flattening. This tourniquet study showed the importance of optimal configuration to first-aid readiness practices.
Keywords: Combat Application Tourniquet; tourniquet configuration; limb tourniquet; Stop the Bleed; medical device; combat injury first aid; tourniquet band flattening; tourniquet elongation; use instruction; resuscitation; emergency
Schauer SG, Fisher AD, April MD, Carter R, Cunningham CW, Aden JK, Fernandez JD, DeLorenzo RA. 19(1). 70 - 74. (Journal Article)
Abstract
Background: Low rates of prehospital analgesia, as recommended by Tactical Combat Casualty Care (TCCC) guidelines, have been demonstrated in the Joint Theaters combat setting. The reasons for this remain unclear. This study expands on previous reports by evaluating a larger prehospital dataset for determinants of analgesia administration. Methods: This was part of an approved quality assurance project evaluating adherence to TCCC guidelines across multiple modalities. Data were from the Prehospital Trauma Registry, which existed from January 2013 through September 2014, and comprises data from TCCC cards, Department of Defense 1380 forms, and after-action reports to provide real-time feedback to units on prehospital medical care. Results: Of 705 total patient encounters, there were 501 documented administrations of analgesic medications given to 397 patients. Of these events, 242 (34.3%) were within TCCC guidelines. Special Operations Command had the highest rate of overall adherence, but rates were still low (68.5%). Medical officers had the highest rates of overall administration. The low rates of administration and adherence persisted across all subgroups. Conclusion: Rates of analgesia administration remained low overall and in subgroup analyses. Medical officers appeared to have higher rates of compliance with TCCC guidelines for analgesia administration, but overall adherence to TCCC guidelines was low. Future research will be aimed at finding methods to improve administration and adherence rates.
Keywords: analgesia; combat; compliance; military; pain; prehospital; Tactical Combat Casualty Care
Kragh JF, Wright-Aldossari B, Aden JK, Dubick MA. 19(2). 41 - 47. (Journal Article)
Abstract
Background: To investigate questions about application of emergency tourniquets in very young children, we investigated practices of Combat Application Tourniquet (C-A-T) use on a simulated infant-sized limb to develop ways to improve readiness for caregiving. Methods: This study was conducted as investigations of C-A-Ts used by two individuals in deliberate practice. The practice setup simulating a limb of infants aged 3-5 months included a handrail (circumference, 5.25 in.). This setup needed a specific modification to the instructions for use to adhere the band between the clips. Each user performed 100 practices. Results: With accrual of experience, application time was shorter for each user, on average in a power law of practice, and more ease was associated when less time was taken to apply the tourniquet. The ease of use was associated with accrued experience through deliberate practice of a tourniquet user while under coached learning. A check of tourniquet fit on a 4.25-in. limb also entailed the modification used in the 5.25-in. limb. However, an additional modification of wrapping the band in a figure-8 pattern around the rod was needed because the rod and clip could not meet. The fit on a 3.25-in. limb was impracticable for a workaround. Tourniquet use was harder for smaller limbs (i.e., 4.25 in. and 3.25 in.). A map of tourniquet fit was sketched of which sized limbs were too big, too small, within the fit zone, or at its borders. Conclusion: C-A-Ts mechanically fit the simulated limbs of infants aged 3-5 months, and C-A-T use was practicably easy enough to allow experienced users to fit tourniquets to limbs well using a specific modification of the routine technique. The findings and knowledge generated in this study are available to inform researches and developments in best preparation practices for instructing first aid.
Keywords: Combat Application Tourniquet; limb tourniquet; Stop the Bleed; medical device; combat injury first aid; use instruction; resuscitation; emergency
Schauer SG, April MD, Aden JK, Rowan M, Chung KK. 19(2). 77 - 80. (Journal Article)
Abstract
Background: The military is rapidly moving into a battlespace in which prolonged holding times in the field are probable. Ketamine provides hemodynamic support and has analgesic properties, but the safety of prolonged infusions is unclear. We compare in-hospital mortality between intubated burn intensive care unit (ICU) patients receiving prolonged ketamine infusion lasting =7 days or until death versus controls. Methods: We conducted a before/after cohort study of patients undergoing admission to a burn ICU with intubation within the first 24 hours as part of treatment for thermal burns. In January 2012, this ICU implemented a novel continuous ketamine infusions protocol. We performed a preintervention and postintervention cohort analysis. Results: We identified 2394 patients meeting our inclusion criteria-475 in the ketamine group and 1919 in the control group. Regarding burn total body surface area (TBSA) involvement, there were 1533 in the <10% group, 586 in the 11-30% group, and 281 in the >31% group. The median number of ventilator-free days within the first 30 days did not vary significantly between the ketamine group and the control group: 8.5 days (interquartile range [IQR] 1-16 days) versus 8 days (IQR 3-13 days, p = .442). Subjects receiving ketamine had higher mortality rates: 59.4% (n = 117) versus 40.6% (n = 80, p < .001), with an odds ratio for in-hospital mortality of 7.51 (95% CI 5.53-10.20, p < .001). When controlling for TBSA category, ventilator days and vasopressor administration, there was no association between ketamine and in-hospital mortality (0.66, 0.41-1.05, p = .08). Conclusions: When controlling for confounders, we found no difference in in-hospital mortality between the prolonged ketamine infusion recipients versus non-recipients.
Keywords: ketamine; prolonged; military; trauma; analgesia
Moore A, Aden JK, Curtis R, Umar M. 19(3). 71 - 75. (Journal Article)
Abstract
Background: The laryngeal handshake method (LHM) may be a reliable standardized method to quickly and accurately identify the cricothyroid membrane (CTM) when performing an emergency surgical airway (ESA). However, there is currently minimal available literature evaluating the method. Furthermore, no previous CTM localization studies have focused on success rates of military prehospital providers. This study was conducted with the goal of answering the question: Which method is superior, the LHM or the traditional method (TM), for identifying anatomical landmarks in a timely manner when performed by US Army combat medic trainees? Methods: This prospective randomized crossover study was conducted at Ft Sam Houston, TX, in September 2018. Two Army medic trainees with similar body habitus volunteered as subjects, and the upper and lower borders and midline of their CTMs were identified by ultrasound (US). The participants were also recruited from the medic trainee population. After receiving initial training on the LHM and refresher training on the TM, participants were asked to localize the CTMs of each subject with one method per subject. Success was defined as a marking within the borders and 5mm of midline within 2 minutes. Results: Thirty-two combat medic trainees participated; 78% (n = 25) successfully localized the CTM using the TM versus 41% (n = 13) using the LHM (p = .002). Conclusion: Findings of this study support that at present the TM is a superior method for successful localization of the CTM when performed by Army combat medic trainees.
Keywords: laryngeal handshake method; cricothyrotomy landmarks; cricothyroidotomy palpation; austere cricothyroidotomy
Kragh JF, Aden JK, Dubick MA. 19(3). 45 - 50. (Journal Article)
Abstract
Background: We sought opportunities to develop learning practices of individual first aid providers. In this study, we simulated deliberate practice in placing limb tourniquets. Methods: This study comprised tourniquet uses by two experienced persons. Their practice sessions focused on developing a motor skill with periodic coaching. The Combat Application Tourniquet is 1.5-inches wide and was used in a technique of loop passage around the end of the limb to place it 2-3 inches above the wound. The simulated limb was a Z-Medica Hemorrhage Control Trainer. Both users applied the tourniquet six times over 5 days to accrue 30 uses individually (N = 60 tourniquet applications for the study). Results: When represented as summary parameters, differences were small. For example, average ease of use was the same for both users, but such parameters only took a snapshot of performance, yielding a general assessment. However, for a learning curve by use number, a surrogate of experience accrual, application time revealed spiral learning. The amount that users compressed a limb averaged -15% compared with its unsqueezed state. Placement accuracy was classified relative to gap widths between the tourniquet and the wound, and of 60 performances, 55 were satisfactory and five were unsatisfactory (i.e., placement was <2 inches from the wound). When a tourniquet only overlaid the 2-inch edge of the placement zone (i.e., tourniquet was 2-3.5 inches away from the wound), no error was made, but errors were made in crossing that 2-inch edge. These gauging errors led us to create a template for learners to see and to demonstrate what the meaning of 2-3 inches is. Conclusion: Each metric had value in assessing first aid, but turning attention to gauging wound-tourniquet gaps revealed placement errors. Analysis of such errors uncovered what 2-3 inches meant in operation. Spiral learning may inform the development of best readiness practices such as coaching deliberate-practice sessions.
Keywords: Combat Application Tourniquet; tourniquet placement; limb wound; Stop the Bleed; motor control and learning; loop-passage technique
Kragh JF, Aden JK, Dubick MA. 19(4). 51 - 57. (Journal Article)
Abstract
Background: We investigated interoperability for a first aid provider to perform simulated use of three tourniquet models of maximal, moderate, and minimal familiarity. Methods: The experiment was focused on the tourniquets used by an expert who rendered aid on a manikin by using three models of tourniquet with different extents of familiarity: The familiarity with Combat Application Tourniquet (C-A-T) was maximal; that for Special Operations Forces Tactical Tourniquet (SOFTT) was moderate, and that for Military Emergency Tourniquet (MET) was minimal. Each model had a band-and-rod design. Interoperability changes as intermodel differences were beneficial or costly in that performances were improved or impaired in units of time, ease, blood, and pressure. Each model had 10 tests, and test order was randomized by model. The HapMed Leg Tourniquet Trainer simulated a limb amputation. Results: In comparison of interoperability burdens, sums of 10 test durations by model for C-A-T, SOFTT, and MET were 38, 77, and 64 minutes, respectively; C-A-T was fastest (p ≤ .002, both). The sums of times to stop bleeding for C-A-T, SOFTT, and MET were 334, 953, and 826 seconds, respectively; C-A-T was fastest (p ≤ .0013, both). The sums of blood losses for C-A-T, SOFTT, and MET were 2105, 3287, and 4256mL, respectively; that for C-A-T was least (p ≤ .0005, both). The mean ease of use differed, with C-A-T being easiest (p ≤ .0046, both). The mean pressure differed, with C-A-T being higher than SOFTT (p = .0073). Conclusions: Timesaving strongly favored the model with which the user had maximal familiarity. In theory and simulation, interoperability bears costs in successfully attaining it, in maintaining it, and in failing either. The user's familiarity with tourniquet model was associated with improved interoperability as seen by improved performances. If multiple models are fielded, then organizations may plan on extra spending, supplying, training, and managing.
Keywords: tourniquet model; Combat Application Tourniquet (C-A-T); Special Forces Tactical Tourniquet (SOFTT); Military Emergency Tourniquet (MET); interoperability; manikin; emergency; first aid
Kragh JF, Aden JK, Dubick MA. 20(2). 20 - 21. (Journal Article)
Abstract
Kragh JF, Aden JK, Dubick MA. 20(2). 76 - 82. (Journal Article)
Abstract
Background: We sought new knowledge by further developing a model of using calculations in the simulation of a first-aid task. The purpose of this study was to develop the model to investigate the performance of tourniquet use in its component steps. Methods: We aimed to design an experiment on a desktop computer by mathematically manipulating simulated data in tourniquet use. A time factor of tourniquet use was ranged widely through time challenges in five degrees from ideal to worst performances. Redesigning the task was assessed by time costs and blood losses. Results: The step of tourniquet application took 17% of the trial time and securing the tourniquet after bleeding control took the longest amount of the trial time, 31%. A minority of the time (48% [17% + 31%] to apply tourniquet plus secure it) was spent after the tourniquet touched the patient, whereas most of the time (52%) was spent before the tourniquet touched the patient. The step of tourniquet application lost 14% of the total blood lost, whereas no blood was lost during securing the tourniquet, because that was the moment of bleeding control despite securing the tourniquet taking much time (31%). Most (86%) of blood lost occurred before the tourniquet touched the patient. But blood losses differed 10-fold, with a maximum of 2,434mL, which, when added to a pretask indication blood loss of 177mL, summed to 2,611mL. Before redesigning the task, costs of donning gloves and calling 9-1-1 included uncontrolled bleeding, but gloving mitigated risk of spreading pathogens among people. By step and person, redesigns of the task altered the risk-benefit profile. Conclusions: The model was useful because it simulated where most of the bleeding occurred before the tourniquet touched the patient. Modeling simulated redesigns of the task, which showed changes in the task's risk-benefit profile by step and among persons. The model generated hypotheses for future research, including the capability to screen candidate ideas among task designs.
Keywords: tourniquet; first aid; bleeding control and prevention; emergency; task deconstruction, simulation, modeling
Kragh JF, Aden JK, Dubick MA. 20(3). 44 - 51. (Journal Article)
Abstract
Background: Given little data to assess guidelines, we sought a way to exchange one type of intervention, field tourniquet use, for another, use of a pressure dressing. The study purpose was to test performance of controlling simulated bleeding with a stepwise procedure of tourniquet conversion. Methods: An experiment was designed to assess 15 tests of a caregiver making tourniquet-dressing conversions. Tests were divided into trials: tourniquet use and its conversion. In laboratory conditions, the tourniquet trial was care under gunfire; then, the conversion trial was emergency healthcare. A HapMed Leg Tourniquet Trainer simulated a limb amputation. An investigator provided healthcare. Results: Mean (± standard deviation [SD]) test time and blood loss were 9 ± 3.6 minutes and 334 ± 353.9mL, respectively. The first test took 17 minutes. By test number, times decreased; the last six took ≤7 minutes. All tourniquet trials controlled bleeding. Mean (±SD) tourniquet pressure and blood loss were 222 ± 18.0mmHg and 146 ± 40.9mL, respectively. Bleeding remained uncontrolled in one conversion. Initial attempts to wrap a dressing were effective in 73% of tries (n = 11 of 15). Four of 15 wrap attempts (27%) were repeated to troubleshoot bleeding recurrence, and the first three tests required a repetition. Mean (±SD) dressing pressures and blood losses were 141 ± 17.6mmHg and 188 ± 327.4mL, respectively. Unsatisfactory conversion trials had a dressing pressure <137mmHg. Dressings and wraps hid the wound to impair assessment of bleeding. Conclusions: In testing a method of converting a limb tourniquet to a pressure dressing, the caregiver performed faster with experience accrual. The tourniquet results were uniformly good, but conversion results were worse and more varied. Simulating conversion was disappointing on a manikin and indicated that its redesign might be needed to suit this method. The procedural method constituted a start for further development.
Keywords: bleeding control and prevention; bandage; dressing, emergency; skill; tourniquet
Nam JJ, McCravy MS, Haines KL, Thomas SB, Aden JK, Johnston LR, Mason PE, Gurney J, Sams VG. 22(4). 111 - 116. (Journal Article)
Abstract
Background: The purpose of our study was to assess risks/ outcomes of acute respiratory distress syndrome (ARDS) in US combat casualties. We hypothesized that combat trauma patients with ARDS would have worse outcomes based on mechanism of injury (MOI) and labs/vital signs aberrancies. Materials and Methods: We reviewed data on military Servicemembers serving in Iraq and Afghanistan from 1 January 2003 to 31 December 2015 diagnosed with ARDS by ICD-9 code. We extracted patient demographics, injury specifics, and mortality from the Department of Defense Trauma Registry (DoDTR). Results: The most common MOI was an explosion, accounting for 67.6% of all injuries. Nonsurvivors were more likely to have explosion-related injuries, have higher injury severity score (ISS), higher international normalized ratio (INR), lower platelet count, greater base deficit, lower temperature, lower Glasgow Coma Scale (GCS) score, and lower pH. There was no significant difference in deaths across time. Conclusion: By identifying characteristics of patients with higher mortality in trauma ARDS, we can develop treatment guidelines to improve outcomes. Given the high mortality associated with trauma ARDS and relative paucity of clinical data available, we need to improve battlefield data capture to better guide practice and ultimately improve care. The management of ARDS will be increasingly relevant in prolonged casualty care (PCC; formerly prolonged field care) on the modern battlefield.
Keywords: PCC; PFC; prolonged casualty care; prolonged field care; ARDS; acute respiratory distress syndrome; combat casualties; combat trauma; mechanism of injury
Johnston LR, Nam JJ, Nissen AP, Sleeter JJ, Aden JK, Mills AC, Sams VG. 23(1). 107 - 113. (Journal Article)
Abstract
Background: Patients with rib fractures are at high risk for morbidity and mortality. This study prospectively examines bedside percent predicted forced vital capacity (% pFVC) in predicting complications for patients suffering multiple rib fractures. The authors hypothesize that increased % pFVC is associated with reduced pulmonary complications. Methods: Adult patients with =3 rib fractures admitted to a level I trauma center, without cervical spinal cord injury or severe traumatic brain injury, were consecutively enrolled. FVC was measured at admission and % pFVC values were calculated for each patient. Patient were grouped by % pFVC <30% (low), 30-49% (moderate), and =50% (high). Results: A total of 79 patients were enrolled. Percent pFVC groups were similar except for pneumothorax being most frequent in the low group (47.8% vs. 13.9% and 20.0%, p = .028). Pulmonary complications were infrequent and did not differ between groups (8.7% vs. 5.6% vs. 0%, p = .198). Discussion: Increased % pFVC was associated with reduced hospital and intensive care unit (ICU) length of stay (LOS) and increased time to discharge to home. Percent pFVC should be used in addition to other factors to risk stratify patients with multiple rib fractures. Bedside spirometry is a simple tool that can help guide management in resource-limited settings, especially in large-scale combat operations. Conclusion: This study prospectively demonstrates that % pFVC at admission represents an objective physiologic assessment that can be used to identify patients likely to require an increased level of hospital care.
Keywords: chest trauma; rib fracture; forced vital capacity; pulmonary function test; risk stratification; prolonged casualty care; prolonged field care; bedside spirometry
Adhikari S, Koirala P, Kafle D. 18(3). 34 - 37. (Journal Article)
Abstract
Background: Anterior shoulder dislocation is a common sports-related musculoskeletal injury. Various methods have been described for reduction of the dislocation. A method that requires less sedation without compromising the success rate is likely to be highly useful in austere and prehospital settings. This study compares scapular manipulation with external rotation method for requirement of sedation and success rates. Methods: Forty-six patients with anterior shoulder dislocation were allocated alternatively to reduction using either scapular manipulation (SMM) or external rotation (ERM) techniques. The groups were compared for sedation requirements, pain scores, and success rates. Results: Reductions using SMM had fewer requirements for sedation (13% versus 39%; p < .05) and higher first-pass success rates (87% versus 61%; p < .05) as compared with ERM for anterior shoulder dislocation reduction. The numeric rating score of pain during reduction procedures was less in SMM (mean, 1.65 [standard deviation, 1.6]) than in ERM group (mean, 4.30 [standard deviation, 1.8]; p < .01). Conclusion: The SMM required less sedation and had higher first-pass success rates than ERM for reduction of anterior shoulder dislocation. The SMM is thus likely to be of advantage in resource-limited austere settings.
Keywords: shoulder reduction; scapular manipulation; external rotation
Adkins DE, Mahon RT, Bennett S. 07(4). 28 - 32. (Journal Article)
Abstract
Closed circuit underwater breathing apparatus (UBA) have gained popularity in recreational diving. Closed circuit UBAs carry a unique set of risks to the diver. We present the case of a diver who lost consciousness while diving and had pulmonary abnormalities. The case is illustrative of the diving related problems associated with closed circuit UBA that a physician may be faced with.
Fuse A, Schwartz RB, Saitoh D, Agawa S, Ohnishi M, Okumura T. 16(1). 140 - 141. (Journal Article)
Abstract
Washington M, Kajiura L, Leong MK, Agee W, Barnhill JC. 15(1). 100 - 104. (Journal Article)
Abstract
Staphylococcus sciuri is an emerging gram-positive bacterial pathogen that is infrequently isolated from cases of human disease. This organism is capable of rapid conversion from a state of methicillin sensitivity to a state of methicillin resistance and has been shown to express a set of highly effective virulence factors. The antibioticresistance breakpoints of S. sciuri differ significantly from the more common Staphylococcus species. Therefore, the rapid identification of S. sciuri in clinical material is a prerequisite for the proper determination of the antibiotic- resistance profile and the rapid initiation of antimicrobial therapy. Here, we present a brief literature review of S. sciuri and an entomological case study in which we describe the colonization of an American cockroach with this agent. In addition, we discuss potential implications for the distribution and evolution of antibiotic- resistant members of the genus Staphylococcus.
Keywords: bacteriology; entomology; operating environment; preventive medicine
Walker S, Agree O, Harris R, DesRosiers TT. 23(2). 49 - 54. (Journal Article)
Abstract
Introduction: Timely vascular access is critical, as hemorrhage is the number one cause of death on the battlefield. Anecdotal evidence in the Military Health System identified an operationally relevant procedural skills gap in vascular access, and data exist in civilian literature showing high rates of iatrogenic injuries when lack of robust procedural opportunity exists. Multiple pre-deployment training courses are available for surgical providers, but no comprehensive pre-deployment vascular access training exists for non-surgical providers. Methods: This mixed-method review aimed to find relevant, operationally focused, vascular access training publications. A literature review was done to identify both relevant military clinical practice guidelines (CPGs) and full text articles. Reviewers also investigated available pre-deployment trainings for both surgeons and non-surgeons in which course administrators were contacted and details regarding the courses were described. Results: We identified seven full-text articles and four CPGs. Two existing surgical training programs and Army, Navy, and Air Force pre-deployment training standards for non-surgeons were evaluated. Conclusion: A cost-effective and accessible pre-deployment curriculum utilizing reviewed literature in a "learn, do, perfect" structure is suggested, building on pre-existing structures while incorporating remotely accessible didactics, hands-on practice with portable simulation models, and live-feedback training.
Keywords: vascular access; military medicine; arterial access; arterial line; central venous access; central line; IV; intravenous; literature review; training, military; deployed medicine; simulation training; austere environments; emergency medical care
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
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
Schauer SG, Naylor JF, Ahmed YM, Maddry JK, April MD. 20(3). 76 - 80. (Journal Article)
Abstract
Background: The United States (US) military utilizes combat wound medication packs (CWMP) to provide analgesia and wound prophylaxis in casualties who are still able to fight. We compared characteristics of combat casualties receiving CWMP to those not receiving CWMP. We also describe the proportions of casualties with injury patterns consistent with Tactical Combat Casualty Care (TCCC) guideline indications for CWMP use who received this intervention. Methods: This is a secondary analysis of Department of a Defense Trauma Registry (DODTR) dataset of US military personnel from January 2007 to August 2016. We searched for all subjects with documented use of at least one medication from the CWMP (acetaminophen, meloxicam, moxifloxacin). Results: Within our dataset, 11,665 casualties were US military Servicemembers. Overall, <1% (84) of our study population received the CWMP. The median age and mechanism of injuries were similar between CWMP nonrecipients versus recipients. Median composite injury scores were higher for nonrecipients than recipients (6 versus 4, P < .001). Proportions of casualties with injury patterns meeting TCCC guideline CWMP indications who received this intervention were low: gunshot wound, <1% (14 of 1805), tourniquet applied, <1% (11 of 1912), major amputation, <1% (5 of 803), and open fracture, <1% (10 of 2425). Based on serious injuries by body region, we had similar findings for the thorax (<1%; 3 of 1122), abdomen (<1%; 1 of 736), and extremities (<1%; 11 of 2699). Conclusions: Subjects receiving the CWMP were less severely injured compared to those who did not receive this intervention. The CWMP had very infrequent use among those casualties with injury patterns meeting indications specified in the TCCC Guidelines for use of this intervention.
Keywords: combat; pill; pack; military; pain; antibiotics
Dilday J, Heidenreich B, Spitzer H, Abuhakmeh Y, Ahnfeldt E, Watt J, Mase VJ. 22(4). 41 - 45. (Journal Article)
Abstract
Background: Tube thoracostomy is the most effective treatment for pneumothorax, and on the battlefield, is lifesaving. In combat, far-forward adoption of open thoracostomy has not been successful. Therefore, the ability to safely and reliably perform chest tube insertion in the far-forward combat theatre would be of significant value. The Reactor is a hand-held device for tube thoracostomy that has been validated for tension pneumothorax compared to needle decompression. Here we investigate whether the Reactor has potential for simple pneumothorax compared to open thoracostomy. Treatment of pneumothorax before tension physiology ensues is critical. Methods: Simple pneumothoraces were created in 5 in-vivo swine models and confirmed with x-ray. Interventions were randomized to open technique (OT, n = 25) and Reactor (RT, n = 25). Post-procedure radiography was used to confirm tube placement and pneumothorax resolution. Video Assisted Thoracoscopic Surgery (VATS) was used to evaluate for iatrogenic injuries. 50 chest tubes were placed, with 25 per group. Results: There were no statistical differences between the groups for insertion time, pneumothorax resolution, or estimated blood loss (p = .91 and .83). Injury rates between groups varied, with 28% (n = 7) in the Reactor group and 8% (n = 2) the control group (p = .06). The most common injury was violation of visceral pleura (10%, n = 5, both groups) and violation of the mediastinum (8%, n = 4, both groups). Conclusion: The Reactor device was equal compared to open thoracostomy for insertion time, pneumothorax resolution, and injury rates. The device required smaller incisions compared to tube thoracostomy and may be useful adjunct in simple pneumothorax management.
Keywords: chest tube; thoracostomy; pneumothorax
Montagnon R, Cungi P, Aoun O, Morand G, Desmottes J, Pasquier P, Travers S, Aigle L, Dubecq C. 23(3). 39 - 43. (Journal Article)
Abstract
Background: Pain management is essential in military medicine, particularly in Tactical Combat Casualty Care (TCCC) during deployments in remote and austere settings. The few previously published studies on intranasal analgesia (INA) focused only on the efficacy and onset of action of the medications used (ketamine, sufentanil, and fentanyl). Side-effects were rarely reported. The aim of our study was to evaluate the use of intranasal analgesia by French military physicians. Methods: We carried out a multicentric survey between 15 January and 14 April 2020. The survey population included all French military physicians in primary-care centers (n = 727) or emergency departments (n = 55) regardless of being stationed in mainland France or French overseas departments and territories. Results: We collected 259 responses (33% responsiveness rate), of which 201 (77.6%) physicians reported being familiar with INA. However, regarding its use, of the 256 physicians with completed surveys, only 47 (18.3%) had already administered it. Emergency medicine physicians supporting highly operational units (e.g., Special Forces) were more familiar with this route of administration and used it more frequently. Ketamine was the most common medication used (n = 32; 57.1%). Finally, 234 (90%) respondents expressed an interest in further education on INA. Conclusion: Although a majority of French military physicians who replied to the survey were familiar with INA, few used it in practice. This route of administration seems to be a promising medication for remote and austere environments. Specific training should, therefore, be recommended to spread and standardize its use.
Keywords: Intranasal route; disaster medicine; emergency medicine; prehospital care; military medicine; analgesia; ketamine; Special Operations
Montagnon R, Rouffilange L, Wagnon G, Balasoupramanien K, Texier G, Aigle L. 24(3). 44 - 48. (Journal Article)
Abstract
Introduction: A systematic radiological examination is needed for military airborne troops in order to detect subclinical medical contraindications for airborne training. Many potential recruits are excluded because of scoliosis, kyphosis, or spondylolisthesis. This study aimed to determine whether complementary radiological assessment excludes too many recruits and whether medical standards might be lowered without increasing medical risk to appointees. Methods: This retrospective, epidemiological, cross-sectional single-center study spanned 5 years at the French paratroopers' initial training center. We analyzed all medical files and full-spine X-ray results of all enlisted troops during this period. Secondary evaluation by an orthopedic surgeon enabled 23 enlisted personnel, deemed medically unacceptable because of X-ray findings, to be given waivers for airborne training. A follow-up review of their 23 files was conducted to determine whether static-line parachute jumps were hazardous to those who were initially declared medically unacceptable. Results: Of the 3,993 full-spine X-rays, 67.5% (2,695) were described as having normal alignment and structure; 21.8% (871) had lateral spinal deviation; and 10.7% (427) had scoliosis. Sixty-six recruits (1.6%) were deemed unfit because of findings that did not meet the standard on the fullspine X-ray: 53 enlisted personnel had scoliosis greater than 15°, and 13 had spondylolisthesis (grade II or III). Of the 23 patients granted waivers, 82.3% with scoliosis (14) and all patients with kyphosis had not declared any back pain after 5 years. Conclusion: The findings, supported by a literature review of foreign military data, suggest that spondylolisthesis above grade I and low back pain are more significant than scoliosis and kyphosis for establishing airborne standards.
Keywords: military medicine; airborne; scoliosis; kyphosis; spondylolisthesis
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
Schwartz RB, Shiver SA, Reynolds BZ, Lowry J, Holsten SB, Akers TW, Lyon M. 19(2). 69 - 72. (Journal Article)
Abstract
Background: Junctional hemorrhage is a potentially preventable cause of death. The Abdominal Aortic and Junctional Tourniquet (AAJT) compresses major vascular structures and arrests blood flow in exsanguinating hemorrhage. In a human model, the AAJT was effective in stopping blood flow in the femoral arteries via compression of the distal aorta. This study compares the ability of AAJT and Combat Gauze (CG) to stop hemorrhagic bleeding from a hemicorporectomy in a swine model. Method: Six anesthetized swine were used. Carotid arterial catheters were placed for continuous mean arterial pressure (MAP) readings. A hemicorporectomy was accomplished with a blade lever device by cutting the animal through both femoral heads transecting the proximal iliac arteries and veins. Hemorrhage control was attempted with the AAJT and regular Kerlix gauze or CG packing and direct pressure followed by Kerlix gauze placed over the CG. The primary outcome measure was survival at 60 minutes. Results: The 60-minute survival was 100% for the AAJT and 0% for the CG group. During the 60-minute monitoring period, only one CG animal achieved hemostasis. For the AAJT group, the mean time to hemostasis was 30 seconds. Initial MAP was higher in the AAJT group (mean, 87mmHg) than the CG group (mean, 70mmHg). The mean 60-minute MAP was 73mmHg for the AAJT group. Mean blood loss at 5 minutes and mean total blood loss were greater in the CG group than in the AAJT group. Conclusion: AAJT is superior to CG in controlling hemorrhage in a junctional wound in a swine model.
Keywords: junctional hemorrhage; gauze; tourniquet
Chitadze N, Gureshidze N, Rostiaschvili N, Danelia N, Dalakishvili K, Durglishvili L, Kuchukhidze R, Imnadze P, Chlikadze R, Betashvili M, Kuchuloria T, Akhvlediani N, Rivard R, Nikolich M, Bautista CT, Washington MA, Akhvlediani T. 18(2). 136 - 140. (Journal Article)
Abstract
Military personnel are at an increased risk for exposure to arthropod- borne and zoonotic pathogens. The prevalence of these pathogens has not been adequately described in the country of Georgia. As the Georgian military moves toward an increased level of capability and the adoption of European Union and North Atlantic Treaty Organization standards, international field exercises will become more frequent and will likely involve an increasing number of international partners. This study was undertaken with the goal of defining the arthropod-borne and zoonotic pathogen threat in Georgia so force health protection planning can proceed in a rational and data-driven manner. To estimate disease burden, blood was taken from 1,000 Georgian military recruits between October 2014 and February 2016 and screened for previous exposure to a set of bacterial and viral pathogens using a antibody-based, serologic procedure. The highest rate of exposure was to Salmonella enterica serovar Typhi, and the lowest rate of exposure was to Coxiella burnettii (the causative agent of Q fever). These data provide insight into the prevalence of arthropod-borne infections in Georgia, fill a critical knowledge gap, will help guide future surveillance efforts, and will inform force health protection planning.
Akhvlediani N, Walls S, Latif NH, Markhvashvili N, Javakhishvili N, Mitaishvili N, Marliani D, Hering K, Washington MA. 20(4). 100 - 103. (Journal Article)
Abstract
The coronavirus disease 2019 (COVID-19) pandemic has demonstrated that new and devastating respiratory pathogens can emerge without warning. It is therefore imperative that Special Operations medical personnel be aware of the presence of emerging pathogens within their area of operation. Human bocavirus (HBoV) is a newly described member of a family of viruses known as the Parvovirinae that are often associated with acute respiratory illness. The presence of HBoV in the country of Georgia has not been previously reported. Nasal and throat swabs were collected from 95 symptomatic members of the Georgian military. HBoV was detected in 11 of them (12%). To our knowledge, this is the first report of HBoV infection in the country of Georgia. This finding may have a significant impact on members of the Special Operations community who train in Georgia as more data concerning the transmission, pathogenesis, and treatment of HBoV are accumulated and the role of HBoV in human disease is more clearly defined.
Keywords: coronavirus disease 2019; COVID-19; respiratory pathogens; bocavirus; human bocavirus
Chitadze N, Gureshidze N, Rostiaschvili N, Danelia N, Dalakishvili K, Durglishvili L, Kuchukhidze R, Imnadze P, Chlikadze R, Betashvili M, Kuchuloria T, Akhvlediani N, Rivard R, Nikolich M, Bautista CT, Washington MA, Akhvlediani T. 18(2). 136 - 140. (Journal Article)
Abstract
Military personnel are at an increased risk for exposure to arthropod- borne and zoonotic pathogens. The prevalence of these pathogens has not been adequately described in the country of Georgia. As the Georgian military moves toward an increased level of capability and the adoption of European Union and North Atlantic Treaty Organization standards, international field exercises will become more frequent and will likely involve an increasing number of international partners. This study was undertaken with the goal of defining the arthropod-borne and zoonotic pathogen threat in Georgia so force health protection planning can proceed in a rational and data-driven manner. To estimate disease burden, blood was taken from 1,000 Georgian military recruits between October 2014 and February 2016 and screened for previous exposure to a set of bacterial and viral pathogens using a antibody-based, serologic procedure. The highest rate of exposure was to Salmonella enterica serovar Typhi, and the lowest rate of exposure was to Coxiella burnettii (the causative agent of Q fever). These data provide insight into the prevalence of arthropod-borne infections in Georgia, fill a critical knowledge gap, will help guide future surveillance efforts, and will inform force health protection planning.
Benjamin JM, Chippaux J, Jackson K, Ashe S, Tamou-Sambo B, Massougbodji A, Akpakpa OC, Abo BN. 19(2). 18 - 22. (Case Reports)
Abstract
A 20-year-old man presented to a rural hospital in Bembéréké, northern Benin, after a witnessed bite from a small, dark snake to his left foot that occurred 3 hours earlier. The description of the snake was consistent with several neurotoxic elapids known to inhabit the area in addition to various species from at least 10 different genera of non-front-fanged colubroid (NFFC) venomous snakes. The presentation was consistent with the early signs of a neurotoxic snakebite as well as a sympathetic nervous system stress response. Diagnosis was further complicated by the presence of a makeshift tourniquet, which either could have been the cause of local signs and symptoms or a mechanical barrier delaying venom distribution and systemic effects until removal. Systemic envenomation did not develop after the removal of the constricting band, but significant local paresthesias persisted for longer than 24 hours and resolved after the administration of a placebo injection of normal saline in place of antivenom therapy. This was an unusual case of snakebite with persistent neuropathy despite an apparent lack of envenomation and a number of snakebite- specific variables that complicated the initial assessment, diagnosis, and treatment of the patient. This case presentation provides clinicians with an opportunity to familiarize themselves with the differential diagnosis and approach to a patient bitten by an unidentified snake, and it illustrates the importance of symptom progression as a pathognomonic sign during the early stages of a truly serious snake envenomation. Treatment should be based on clinical presentation and evolution of symptoms rather than on snake identification alone.
Keywords: snakebite; envenomation; clinical diagnosis; non-front-fanged colubroid; antivenom; dry bite
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
Beadling C, Maza J, Nakano G, Mahmood M, Jawad S, Al-Ameri A, Zuerlein S, Anderson W. 12(3). 10 - 16. (Journal Article)
Abstract
This article presents findings from a survey conducted to examine the availability of foreign language and culture training to Civil Affairs health personnel and the relevance of that training to the tasks they perform. Civil Affairs forces recognize the value of cross-cultural communication competence because their missions involve a significant level of interaction with foreign governments' officials, military, and civilians. Members of the 95th Civil Affairs Brigade (Airborne) who had a health-related military occupational specialty code were invited to participate in the survey. More than 45% of those surveyed were foreign language qualified. Many also received predeployment language and culture training specific to the area of deployment. Significantly more respondents reported receiving cultural training and training on how to work effectively with interpreters than having received foreign language training. Respondents perceived interpreters as important assets and were generally satisfied with their performance. Findings from the survey highlight a need to identify standard requirements for predeployment language training that focuses on medical and health terminology and to determine the best delivery platform(s). Civil Affairs health personnel would benefit from additional cultural training that focuses on health and healthcare in the country or region of deployment. Investing in the development of distance learning capabilities as a platform for delivering health-specific language and culture training may help ease the time and resources constraints that limit the ability of Civil Affairs health personnel to access the training they need.
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.
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
Luk JH, Chang BF, Albus ML, Morgan SA, Szymanski TJ, Hamid OS, Keller L, Daher AF, Sheele JM. 21(4). 66 - 70. (Journal Article)
Abstract
Background: Emergency medical services (EMS) providers are at high risk for occupational violence, and some tactical EMS providers carry weapons. Methods: Anonymous surveys were administered to tactical and nontactical prehospital providers at 180 prehospital agencies in northeast Ohio between September 2018 and March 2019. Demographics were collected, and survey questions asked about workplace violence and comfort level with tactical EMS carrying weapons. Results: Of 432 respondents, 404 EMS providers (94%) reported a history of verbal or physical assault on scene, and 395 (91%) reported working in a setting with a direct active threat at least rarely. Of those reporting a history of assault on scene, 46.5% reported that it occurred at least sometimes. Higher rates of assault on scene were associated with being younger, white, or an emergency medical technician-paramedic, working in an urban environment, having more frequent direct active threats, and having more comfort with tactical EMS carrying firearms (p ≤ .03). Most respondents (306; 71%) reported that they were prepared to defend themselves from someone who originally called for help. Most (303; 70%) reported a comfort level of 8 or higher (from 1, not comfortable to 10, completely comfortable) with tactical EMS providers carrying weapons. Comfort with tactical EMS providers carrying weapons was associated with being white, not having a bachelor's degree, and feeling prepared to defend oneself from a patient (p ≤ .02). Conclusion: EMS providers in the survey report high rates of verbal and physical violence while on scene and are comfortable with tactical EMS providers carrying weapons.
Keywords: assault; emergency medical services; EMS; firearm; safety; Special Weapons and Tactics; SWAT; tactical EMS; weapon
Levy MJ, Straight KM, Marino MJ, Alcorta RL. 16(1). 98 - 102. (Journal Article)
Abstract
Childers W, Alderete JF, Eliason TD, Goldman SM, Nicolella DP, Pierrie SN, Stark GE, Studer NM, Wenke JC, Wilson JB, Dearth CL. 23(3). 91 - 100. (Journal Article)
Abstract
The potential for delayed evacuation of injured Service members from austere environments highlights the need to develop solutions that can stabilize a wound and enable mobility during these prolonged casualty care (PCC) scenarios. Lower extremity fractures have traditionally been treated by immobilization (splinting) followed by air evacuation - a paradigm not practical in PCC scenarios. In the civilian sector, treatment of extremity injuries sustained during remote recreational activities have similar challenges, particularly when adverse weather or terrain precludes early ground or air rescue. This review examines currently available fracture treatment solutions to include splinting, orthotic devices, and biological interventions and evaluates their feasibility: 1) for prolonged use in austere environments and 2) to enable patient mobilization. This review returned three common types of splints to include: a simple box splint, pneumatic splints, and traction splints. None of these splinting techniques allowed for ambulation. However, fixed facility-based orthotic interventions that include weight-bearing features may be combined with common splinting techniques to improve mobility. Biologically-focused technologies to stabilize a long bone fracture are still in their infancy. Integrating design features across these technologies could generate advanced treatments which would enable mobility, thus maximizing survivability until patient evacuation is feasible.
Keywords: prolonged casualty care; combat fractures; lower extremity; mobility; splinting; wilderness
Alderman SM, Christensen JB, Crawford I. 10(1). 16 - 22. (Journal Article)
Abstract
Medical programs are valuable tools when they properly align with operational objectives. In counterinsurgency operations, the medical program should promote the capacity of the host nation government and lead to greater self-sufficiency. The Medical Civic Action Program (MEDCAP) often fails to fully integrate host nation providers and officials which may undermine local medical infrastructure and rarely provides sustainable improvement. The Medical Seminar (MEDSEM) was developed during Operation Enduring Freedom- Philippines to address the shortcomings of the traditional MEDCAP. The MEDSEM greatly enhanced the MEDCAP by adding education to the venue, thereby promoting self reliance and improving the sustainability of medical interventions. Furthermore, the MEDSEM forged relationships and promoted interoperability through collaboration between local medical providers, governmental leaders, host nation forces, and U.S. Special Operations Forces.
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.
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.
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
Gattere M, Scaffei N, Gozzetti L, Alessandrini M. 21(1). 120 - 123. (Journal Article)
Abstract
As a result of the increasing use and application of military tourniquets in civilian settings, it is necessary to evaluate the size and effectiveness of the equipment on patients that differ from the military-aged population for whom the devices have been primarily created. This case report describes the application of a tourniquet on a pediatric patient while also profiling a common situation in which the Combat Application Tourniquet GEN 7 (C-A-T Resources) might be used in civilian care systems. The case is that of a 14-month-old child who suffered a limb amputation secondary to a road accident in Italy and the ensuing life-saving treatment. The intervening nurse at the scene had been trained on the use of hemorrhage-control devices through the American College of Surgeons "Stop the Bleed" campaign.
Keywords: tourniquet; hemorrhage; child; pediatric; military personnel; accidents; amputation; Stop the Bleed; NATO Special Operations Combat Medic; NSCOM
Alexander DW. 20(3). 109 - 112. (Journal Article)
Abstract
The SOCOM Spiritual Fitness Scale (SSFS) enables religious support teams and other spiritual fitness/performance (SF/SP) stakeholders in the Special Operations Forces community to reliably measure both "horizontal" and "vertical" dimensions of spirituality, as defined by the chairman of the Joint Chiefs of Staff Instruction on SF. The SSFS's three subscales relate to core attributes of SF/SP, which were identified through factor analysis during the iterations of the tool's development. The SSFS is capable of generating baseline assessments for research related to SF/SP. It is also capable of generating unique SF/SP profiles for individuals and groups, which can shape programs and inform tailored coaching for optimized performance.
Keywords: spirituality; spiritual metric; spiritual fitness; human performance optimization; total force fitness
Alexander DW, Deuster PA. 21(1). 109 - 112. (Journal Article)
Abstract
The United States Special Operations Command (SOCOM)'s Preservation of the Force and Family Program (POTFF) identifies spiritual performance (SP) as a key pillar for holistically caring for and optimizing the performance of all Special Operations Forces (SOF) and their families. Enhancing SP is key to sustaining core spiritual beliefs, values, awareness, relationships and experiences. The SOCOM Spiritual Fitness Scale (SSFS) enables religious support teams in SOF communities and beyond to reliably measure SP according to POTFF's definition of SP and the Chairman of the Joint Chiefs of Staff Instruction (CJCSI) on Spiritual Fitness (SF). The three subscales of the SSFS relate to core attributes of SP/SF, which were identified through factor analysis during iterations of the tool's development. Directly aligning SP/SF programs with the core attributes of SSFS will allow chaplains to support both theists and nontheists and to retain certain traditional chaplain activities which no longer have universal connection to religious ministry in the public discourse. Chaplains are also empowered to immediately begin conducting relevant and spiritual assessments. We will illustrate how a chaplain can align SP initiatives with the three core attributes of SP/SF and leverage the SSFS to assess baseline unit needs, conceive and develop evidence-based initiatives, conduct rolling program assessments, and articulate program efficacy to key leaders and collaborators.
Keywords: spiritual metric; spiritual fitness; human performance optimization; total force fitness; program evaluation
White LA, Maxey BS, Solitro GF, Conrad SA, Davidson KP, Alhaque A, Alexander JS. 24(3). 9 - 17. (Journal Article)
Abstract
Background: In emergency casualty and evacuation situations, manual ventilation using self-inflating bags remains a critical skill; however, significant challenges exist in ensuring safety and effectiveness, since inaccurate manual ventilation is associated with life-threatening risks (e.g., gastric insufflation with aspiration, barotrauma, and reduced venous return). Methods: This study assessed the impact of audiovisual feedback from the bag-valve-mask (BVM) emergency narration guided instrument (BENGI), a handheld manual ventilation guidance device, on improving performance and safety, immediately and 2 weeks after, with no additional manual ventilation training. In a crossover manikin simulation study with 20 participants, BENGI immediately and significantly improved tidal volume and respiratory rate accuracy. Results: Intraand inter-participant variations were lower with BENGI, with Poincaré plot analysis showing improved performance that remained for at least 2 weeks following BENGI training. Conclusion: BENGI's audiovisual feedback improves manual immediately and persistently, making it invaluable for training and clinical use in diverse scenarios, from battlespace to civilian emergencies.
Keywords: ventilator; emergency; simulation; lung; tidal volume; monitoring
Vallier DJ, Anderson WJ, Snelson JV, Yauger YJ, Felix JR, Alford KI, Bermoy WA. 22(4). 9 - 13. (Journal Article)
Abstract
US Army Forward Surgical Elements (FSEs) are highly mobile teams that provide damage control surgery (DCS) and damage control resuscitation (DCR) in austere locations that often lack standard hospital utilities (electricity, heat, food, and water). FSEs rely on portable battery-operated intravenous (IV) fluid warmers to remain light and mobile. However, their ability to warm blood in a massive resuscitation requires additional analysis. The purpose of this literature review is to examine the three most common battery-operated IV fluid warmers as determined by type and quantity listed on the Mission Table of Organization and Equipment (MTOE) of organic mobile medical units. These include the Buddy Lite, enFlow, and Thermal Angel, which are available to deployed US Army FSEs for blood resuscitation therapy. Based on limited available evidence, the enFlow produced higher outlet temperatures, effectively warmed greater volumes, reached the time to peak temperature faster, and produced greatest flow rates, with cool saline (5-10°C), compared to the Thermal Angel and Buddy Lite. However, recently the US Food and Drug Administration (FDA) issued a Class 1 recall on enFlow cartridges. Testing demonstrated aluminum elution from enFlow cartridges into IV solutions, thereby exposing patients to potentially unsafe aluminum levels. The authors recommend FSE units conduct a 100% enFlow cartridge inventory and seek an alternative IV fluid warming system prior to enFlow cartridge disposal. If an alternative does not exist, or the alternative warming system does not fit mission requirements, then medical personnel must carefully weigh the risks and benefits associated with the enFlow delivery system.
Keywords: Thermal Angel; enFlow; Buddy Lite; fluid warmer; intravenous fluids, IVF; cartridge
White LA, Maxey BS, Solitro GF, Conrad SA, Davidson KP, Alhaque A, Alexander JS. 24(3). 9 - 17. (Journal Article)
Abstract
Background: In emergency casualty and evacuation situations, manual ventilation using self-inflating bags remains a critical skill; however, significant challenges exist in ensuring safety and effectiveness, since inaccurate manual ventilation is associated with life-threatening risks (e.g., gastric insufflation with aspiration, barotrauma, and reduced venous return). Methods: This study assessed the impact of audiovisual feedback from the bag-valve-mask (BVM) emergency narration guided instrument (BENGI), a handheld manual ventilation guidance device, on improving performance and safety, immediately and 2 weeks after, with no additional manual ventilation training. In a crossover manikin simulation study with 20 participants, BENGI immediately and significantly improved tidal volume and respiratory rate accuracy. Results: Intraand inter-participant variations were lower with BENGI, with Poincaré plot analysis showing improved performance that remained for at least 2 weeks following BENGI training. Conclusion: BENGI's audiovisual feedback improves manual immediately and persistently, making it invaluable for training and clinical use in diverse scenarios, from battlespace to civilian emergencies.
Keywords: ventilator; emergency; simulation; lung; tidal volume; monitoring
Mccown M, Alleman A, Sayler KA, Chandrashekar R, Thatcher B, Tyrrell P, Stillman B, Beall M, Barbet AF. 14(4). 81 - 85. (Journal Article)
Abstract
Background: Based on the high tick-borne pathogen results from a 2011 surveillance study in three Colombian cities, an in-depth point prevalence survey was conducted to determine the seroprevalence of tick-borne pathogens at a specific point in time in 70 working dogs, 101 shelter dogs, and 47 client-owned dogs in Barranquilla, Colombia. Results: Of the 218 serum samples, 163 (74%) were positive for Ehrlichia canis and 116 (53%) for Anaplasma platys. Exposure to tick-borne pathogens was highest in shelter and working dogs where more than 90% of the samples were seropositive or positive on polymerase chain reaction for one or more organisms as compared to 51% in client-owned animals. Conclusion: Surveillance for exposure to tickborne pathogens provides vital information necessary to protect and conserve the health of local humans and animals, deployed military service members, and working dogs in various parts of the world. This study and resultant data demonstrate the value of following a broadbased surveillance study with a more specific, focused analysis in an area of concern. This area's high levels of exposure warrant emphasis by medical planners and advisors on precautionary measures for military dogs, Special Operations Forces personnel, and the local public.
Keywords: tick-borne pathogens; point prevalence; surveillance; US Military SOF; military working dogs; Colombia
Yue I, Allen DS, Chung J, Ruppert A, Papalski WN, Sons N, Zarow GJ, Good CJ, Devenny LE, Cady HJ, Sonntag EM, Adams RC, Hildreth AL. 24(3). 49 - 57. (Journal Article)
Abstract
Training needs of Special Operations Forces (SOF) medics were surveyed and new training initiatives have been created to meet their needs. SOF medics perform an array of medical procedures in austere environments with minimal supervision. Medical skills decay over time after initial training and the perceived training needs of active SOF medics were unclear. To fill this gap, active SOF medics (n=57) completed a survey that included confidence ratings and indications of whether additional training would make them more proficient in 70 medical knowledge and procedural skills, assembled into categories by a panel of experts (airway, trauma, neuro, differential diagnosis, administrative, infection, critical care, environmental, other). Data were analyzed with analysis of variance (ANOVA) and nonparametric statistics at P<.05. Confidence was highest in the trauma, administrative, and airway categories, and lowest in the infection, differential diagnosis, and neuro categories (P<.05 or less). Categories indicating the greatest need for additional training were environmental and critical care, while those indicating lowest need were the airway and trauma categories (P=.05). Additional training was endorsed by >75% of participants in each category. SOF medics also wanted additional training in all areas, preferably hands-on with live patients in realistic scenarios, taught by experienced medics. Findings highlight the training needs of SOF medics and demonstrate the value of bottom-up feedback toward optimizing sustainment training. Based on present findings, two TACMED (Tactical Medicine) Divisions at the SOF Echelon III level were created to meet the sustainment training needs of SOF medics
Keywords: special warfare; Special Operations; advanced tactical provider; medical sustainment program; medical training; TACMED
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
Paquette R, Quinene M, Blackbourne LH, Allen PB. 21(3). 78 - 85. (Journal Article)
Abstract
Background: Penetrating thoracic injuries account for an essential subset of battlefield and civilian injuries that result in death. Current recommendations are to use commercially available nonocclusive chest seals. We review current evidence for which chest seal(s) is likely to be the most effective in treating open pneumothoraces. Methods: A systematic review was conducted in accordance with the PRIMSA 2009 standard systematic review methodology, except where noted. The databases Pubmed, MEDLINE, CINAHL, Scopus, and gray sources were searched for all English-language, full-manuscript, experimental, quantitative studies of humans and animals concerning seal adherence or their efficacy at preventing tension pneumothoraces published between 1990 and 2020. A numerical analysis was used to provide the consensus recommendation. Results: Of 683 eligible identified articles [PubMed 528 (77.3%), Scopus 87 (12.7%), CINAHL 67 (9.8%), one (0.1%) unpublished], six (0.9%) articles were included. Synthesis of all studies' results suggests a consensus recommendation for the Hyfin Vent Chest Seal and Russell Chest Seal. These two were the most effective chest seals, as previously investigated in a quantifiable, experimental study. Conclusion: While chest seals are recommended in civilian and military prehospital medicine to improve patient survival, current evidence concerning the individual device's efficacy is limited. Further scientific, quantitative research is needed to clarify which commercially available chest seals are most effective and provide patients with penetrating chest trauma the best possible method for preventing or mitigating tension pneumothoraces.
Keywords: pneumothorax; chest seal; chest trauma; Tactical Combat Casualty Care; advanced trauma life support; systematic review
Hiller HM, Hill GJ, Shea S, Fernandes J, Earl K, Knight J, Schaffrinna A, Donham B, Allen PB. 22(3). 37 - 41. (Journal Article)
Abstract
Units within the Special Operations Forces (SOF) community require medically competent and operationally proficient medical providers (physicians, physician assistants, and nurse practitioners, among others) to support complex mission sets. The expectations placed on providers who successfully assess for and are selected into these units are high. These providers are not only expected to be experts in their respective subspecialities, but also to serve as staff officers, provide medical direction for SOF medics, serve as medical advisors to the command team, and provide direct medical support for kinetic operations. They are expected to perform these functions with little oversight and guidance and when geographically separated from higher units. Graduates from military Graduate Medical Education (GME) programs are extremely well-educated and can provide high quality medical care. However, they often find themselves ill-prepared for the extra demands placed upon them by the Special Operations community due to a lack of operational exposure. The authors of this paper recognized this gap and propose that the Joint Emergency Medicine Exercise (JEMX) model can help augment the body of knowledge required to perform well as a provider in a Special Operations unit.
Keywords: military graduate medical education; Special Operations; joint emergency medicine exercise
Pieper MA, Vonderharr MJ, Knutson TL, Sullivan JL, Allison CG, Englert Z. 19(1). 20 - 22. (Case Reports)
Abstract
The military conflicts of the past 17 years have taught us many lessons, including the evolution of the tiered trauma system with en route resuscitation. The evolution of the conflict has begun to limit the reach of this standard trauma system. Recent evidence suggests that 95% of early deaths resulting from traumatic injuries may be prevented if the patient can undergo damage control surgery within 23 minutes of injury. US Military Surgical Resuscitation Teams have been developed to shorten this time from injury to surgical care, as illustrated by this case report.
Keywords: en route surgery; resuscitative thoracotomy; HH-60; surgical resuscitation team
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
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
Alterie J, Dennis AJ, Baig A, Impens A, Ivkovic K, Joseph KT, Messer TA, Poulakidas S, Starr FL, Wiley DE, Bokhari F, Nagy KK. 18(3). 71 - 74. (Journal Article)
Abstract
Background: One of the greatest conundrums with tourniquet (TQ) education is the use of an appropriate surrogate of hemorrhage in the training setting to determine whether a TQ has been successfully used. At our facility, we currently use loss of audible Doppler signal or loss of palpable pulse to represent adequate occlusion of vasculature and thus successful TQ application. We set out to determine whether pain can be used to indicate successful TQ application in the training setting. Methods: Three tourniquet systems (a pneumatic tourniquet, Combat Application Tourniquet® [C-A-T], and Stretch Wrap and Tuck Tourniquet™ [SWAT-T]) were used to occlude the arterial vasculature of the left upper arm (LUA), right upper arm (RUA), left forearm (LFA), right forearm (RFA), right thigh (RTH), and right calf (RCA) of 41 volunteers. A 4MHz, handheld Doppler ultrasound was used to confirm loss of Doppler signal (LOS) at the radial or posterior tibial artery to denote successful TQ application. Once successful placement of the TQ was noted, subjects rated their pain from 0 to 10 on the visual analog scale. In addition, the circumference of each limb, the pressure with the pneumatic TQ, number of twists with the C-A-T, and length of TQ used for the SWAT-T to obtain LOS was recorded. Results: All 41 subjects had measurements at all anatomic sites with the pneumatic TQ, except one participant who was unable to complete the LUA. In total, pain was rated as 1 or less by 61% of subjects for LUA, 50% for LFA, 57.5% for RUA, 52.5% RFA, 15% for RTH, and 25% for RCA. Pain was rated 3 or 4 by 45% of subjects for RTH. For the C-A-T, data were collected from 40 participants. In total, pain was rated as 1 or less by 57.5% for the LUA, 70% for the LFA, 62.5% for the RUA, 75% for the RFA, 15% for the RTH, and 40% for the RCA. Pain was rated 3 or 4 by 42.5%. The SWAT-T group consisted of 37 participants for all anatomic locations. In total, pain was rated as 1 or less by 27% for LUA, 40.5% for the LFA, 27.0% for the RUA, 43.2 for the RFA, 18.9% for the RTH, and 16.2% for the RCA. Pain was rated 5 by 21.6% for RTH application, and 3 or 4 by 35%. Conclusion: The unexpected low pain values recorded when loss of signal was reached make the use of pain too sensitive as an indicator to confirm adequate occlusion of vasculature and, thus, successful TQ application.
Keywords: tourniquet; pain; vasculature occlusion
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
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
Rush S, Lauria MJ, DeSoucy ES, Koch EJ, Kamler JJ, Remley MA, Alway N, Brodie F, Barendregt P, Miller K, Hines R, Champagne M, Paladino L, Shackelford SA, Miles EA, Dorlac WC, Gurney J, Robb D, Kue RC. 24(3). 24 - 29. (Journal Article)
Abstract
Herein, we present a simplified approach to prehospital mass casualty event (MASCAL) management called "Move, Treat, and Transport." Prior publications demonstrate a disconnect between MASCAL response training and actions taken during real-world incidents. Overly complex algorithms, infrequent training on their use, and chaotic events all contribute to the low utilization of formal triage systems in the real world. A review of published studies on prehospital MASCAL management and a recent series of military prehospital MASCAL responses highlight the need for an intuitive MASCAL management system that accounts for expected resource limitations and tactical constraints. "Move, Treat, and Transport" is a simple and pragmatic approach that emphasizes speed and efficiency of response; considers time, tactics, and scale of the event; and focuses on interventions and evacuation to definitive care if needed.
Keywords: MASCAL; mass casualty incident; prehospital care; triage; emergency preparedness
Rush S, Lauria MJ, DeSoucy ES, Koch EJ, Kamler JJ, Remley MA, Alway N, Brodie F, Foudrait A, Barendregt P, Atkins M, Miller K, Hines R, Champagne M, Paladino L, Shackelford SA, Miles EA, Obiajulu J, Dorlac WC, Gurney J, Robb D, Kue RC. 24(3). 62 - 66. (Case Reports)
Abstract
Introduction: Mass casualty events (MASCALs) in the combat environment, which involve large numbers of casualties that overwhelm immediately available resources, are fundamentally chaotic and dynamic and inherently dangerous. Formal triage systems use diagnostic algorithms, colored markers, and four or more named categories. We hypothesized that formal triage systems are inadequately trained and practiced and too complex to successfully implement in true MASCAL events. This retrospective analysis evaluates the real-world application of triage systems in prehospital military MASCALs and other aspects of MASCAL management. Methods: We surveyed Special Operations Forces (SOF) medics known to us who have participated in military prehospital MASCALs and analyzed them. Aggregated data describing the scope of the incidents, the use of formal triage algorithms and colored markers, the number of categories, and the interventions on scene were analyzed using descriptive statistics, and lessons learned were consolidated. Results: From 1996 to 2022 we identified 29 MASCALs that were managed by military medics in the prehospital setting. There was a median of three providers (range 1-85) and 15 casualties (range 6-519) per event. Four or more formal triage categories were used in only one event. Colored markers and formal algorithms were not used. Life-saving interventions were performed in 27 of 29 (93%) missions and blood transfusions were performed in four (17%) MASCALs. The top lessons learned were: 1) security and accountability are cornerstones of MASCAL management; 2) casualty movement is a priority; 3) intuitive triage categories are the default; 4) life-saving interventions are performed as time and tactics permit. Conclusion: Formal triage systems requiring the use ofdiagnostic algorithms, colored tags, and four or five categories are seldom implemented in real-world military prehospital MASCAL management. The training of field triage should be simplified and pragmatic, as exemplified by these instances.
Keywords: mass casualty management; triage; MASCAL; survey; SOF medics
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
Marchesini M, Ippolito C, Ambrosini L, Bignami EG, Fasani M, Abbenante D. 21(2). 67 - 71. (Journal Article)
Abstract
Background: Studies have highlighted the incidence and prevalence of chronic pain, which is an epidemic problem in all career sectors, as well as estimated the economic loss that follows its pathology. Several studies have indicated a high incidence of chronic osteoarticular pain in military service members, particularly in flight personnel. To date, no studies have estimated the incidence of pain pathology in the Italian military population, despite the implications related to flight qualification. Methods: A survey was conducted on helicopter flight personnel undergoing periodic annual evaluation. Results: A statistically significantly higher incidence of pain pathology than that reported in the global civilian population was demonstrated. More than 80% of the interviewed population reported moderate-to-severe back pain (45% in the lumbar tract and 38% in the cervical tract). Further, it was found that most staff with chronic pain do not use drugs or other treatments for severe pain because of concerns that such treatment approaches may compromise flight qualifications. Discussion: The present study observed a high incidence of pain in Italian military flight personnel and examined the degree to which this problem is undertreated in these individuals. To address this problem, further in-depth and larger investigations that include therapeutic protocols to resolve such pain pathologies should be conducted. Such investigations could help to reduce pain experienced by flight personnel and enhance the productivity of the Italian military forces while considering the pharmacologic limitations related to the task. Conclusion: Chronic lumbar and neck pain is more common in military helicopter crews than in the civilian population. The true figure is frequently underestimated because of staff concerns regarding the potential influence of therapies on work activity.
Keywords: pain, low back; pain, cervical back; helicopter crew, military; helicopter crew, Italian
Wessels LE, Roper MT, Ignacio RC, Davis KL, Ambrosio AA. 21(3). 93 - 95. (Journal Article)
Abstract
Background: Virtual health (VH) may enhance mentorship to remote first responders. We evaluated the feasibility of synchronous bidirectional VH to mentor life-saving procedures performed by deployed novice providers. Methods: Video teleconferencing (VTC) was established between the USNS Mercy (T-AH 19) underway in the Pacific Ocean to Naval Medical Center San Diego using surgeon teleconsultation. The adult simulated clinical vignette included injuries following a shipboard explosion with subsequent fire. The pediatric simulated vignette included injuries that resulted from an improvised explosive device (IED) blast. Using VTC, augmented reality (AR) goggles, and airway simulation equipment, corpsmen (HMs) received visual cues to perform advanced life-saving procedures. Results: In adult scenarios, 100% of novice hospital HMs performed tasks on first attempt (n = 12). Mean time for tourniquet placement was 46 seconds (standard deviation [SD], 19 seconds); needle thoracostomy, 70 seconds (SD, 67 seconds); tube thoracostomy, 313 seconds (SD, 152 seconds); and cricothyroidotomy, 274 seconds (SD, 82 seconds). In pediatric scenarios, 100% of novice HMs performed tasks on first attempt (n = 5). Mean time for tube thoracostomy completion was 532 seconds (SD, 109 seconds). Conclusion: VH can enhance the training and delivery of trauma care during prolonged field care in resource-limited settings.
Keywords: Tactical Combat Casualty Care; thoracostomy, tube; cricothyroidotomy; augmented reality; tourniquet
Singh M, Kroman A, Singh J, Tariq H, Amin S, Morales-Pablon CA, Cahill KV, Harrison EE. 15(1). 7 - 10. (Case Reports)
Abstract
Objective: We sought to characterize the risk of a heart attack in a 48-year-old asymptomatic US Special Operations Command (SOCOM) Soldier without known coronary artery disease (CAD). Background: CAD continues to be a leading cause of morbidity and mortality among most age groups in the United States. Much research is dedicated to establishing new techniques to predict myocardial infarction (MI). Methods: Coronary computed tomography (CT) angiography, also known as CCTA, along with 7-protein serum biomarker risk assessment was performed for risk evaluation. Results: A 48-year-old SOCOM Soldier with a family history of heart disease had skeletal chest pain from war injuries and a 5-fold higher risk of heart attack over the next 5 years on the basis of protein markers. A nonobstructive left anterior descending coronary artery (LAD) plaque with a lipid-rich core and a thin fibrous cap (i.e., vulnerable plaque) was detected by CCTA. The patient was warned about his risk and prescribed four cardiac medications and scheduled for angioplasty even though he fell outside the guidelines by not having a severe obstructive blockage. Four days later, unfortunately, he had a heart attack before starting his medications and before angioplasty. Conclusion: CCTA with biomarker testing may have an important role in predicating acute coronary syndrome (ACS) in Special Operations Forces (SOF) Soldiers with at least one risk factor. Conventional stress testing and nuclear scanning would not detect non-flow-limiting vulnerable plaques in vulnerable patients. In order to collect more data, the PROTECT Registry has been started to evaluate asymptomatic Soldiers with at least one risk factor referred to the clinic by military physicians.
Keywords: cardiac risk; heart attack; CCTA; risk assessment
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
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
Reyes J, Kelly J, Badaki-Makun O, Anders J. 23(2). 40 - 43. (Journal Article)
Abstract
Introduction: Although the instances of Special Operations Forces (SOF) medical providers treating pediatric pelvic fractures are rare, such fractures are notable injuries in terror attacks and are at high risk for morbidity and mortality for the patient as well as stress for the provider. Presently, guidelines for pediatric-sized pelvic stabilization device application are limited to measured pelvic circumference. This study aims to inform more practical sizing guidelines. Methods: Subjects aged 1 year to 14 years were enrolled. Subject height, weight, pelvic circumference, and fit on the Broselow Pediatric Emergency Tape® (Armstrong Medical Industries), fit with the Pediatric PelvicBinder® (PelvicBinder), and fit with the small SAM Pelvic Sling® (SAM® Medical) were collected. The primary outcome was the proportion of subjects fitting each device. Results: Sixty-five subjects were recruited; median age was 5 years (interquartile range, 1-8 years); 40 (62%) subjects were male. Ninety-one percent of subjects fit within the scale of the Broselow Tape (height <143-cm). One hundred percent of subjects with a height <143-cm had an appropriate fit with the Pediatric PelvicBinder (95% confidence level [CI], 91.8-100%), while 91.7% of subjects with a height >143-cm fit the SAM Pelvic Sling (95%CI, 61.5-99.8%). Conclusions: Providers should attempt to fit the Pediatric PelvicBinder for children >1 year old with suspected unstable pelvic fracture who fall on the Broselow Tape (<143-cm). The small SAM Pelvic Sling should be used for those taller than 143-cm.
Keywords: pediatrics; pelvic fractures; pelvic stabilizer; terrorist attacks
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
Houser AP, Soto MA, Bell KS, Goldberg PG, Cronin KJ, Caldwell RC, Schilling BK, Bebarta VS, Ritter A, Small E, Eazor J, Getz T, Anderson A, Musi M, Miner T, Keenan S, Reno E, Giesbrect G, Comart C, Vallin T, Lemery J, Eisenhauer IF, Irons P, Treager CD, Spivey D, Gonzalez F, Stuart SM, Lopachin T, Gower L, Sheldon D, Friedrich EE, Lassiter B, Piehl M, Broome JM, Dransfield T, Marino M, Duchesne J. 24(3). 94 - 96. (Classical Conference)
Abstract
Kerr W, Hubbard B, Anderson B, Montgomery HR, Glassberg E, King DR, Hardin RD, Knight RM, Cunningham CW. 19(2). 128 - 133. (Journal Article)
Abstract
Effectively and rapidly controlling significant junctional hemorrhage is an important effort of Tactical Combat Casualty Care (TCCC) and can potentially contribute to greater survival on the battlefield. Although the US Food and Drug Administration (FDA) has approved labeling of four devices for use as junctional tourniquets, many Special Operations Forces (SOF) medics do not carry commercially marketed junctional tourniquets. As part of ongoing educational improvement during Special Operations Combat Medical Skills Sustainment Courses (SOCMSSC), the authors surveyed medics to determine why they do not carry commercial tourniquets and present principles and methods of improvised junctional tourniquet (IJT) application. The authors describe the construction and application of IJTs, including the use of available pressure delivery devices and emphasizing that successful application requires sufficient and repetitive training.
Keywords: tourniquets; tourniquets, improvised; hemorrhage, junctional; training; austere
Powell E, Betzold R, Kundi R, Anderson D, Haase D, Keville M, Galvagno S. 24(1). 32 - 37. (Journal Article)
Abstract
Background: Veno-venous extracorporeal membrane oxygenation (VV ECMO) is a low-frequency, high-intensity procedure used for severe lung illness or injury to facilitate rapid correction of hypoxemia and respiratory acidosis. This technology is more portable and extracorporeal support is more frequently performed outside of the hospital. Future conflicts may require prolonged causality care and more specialized critical care capabilities including VV ECMO to improve patient outcomes. We used an expert consensus survey based on a developed bifemoral VV ECMO cannulation checklist with an operational focus to establish a standard for training, validation testing, and sustainment. Methods: A 36-item procedural checklist was provided to 14 experts from multiple specialties. Using the modified Delphi method, the checklist was serially modified based on expert feedback. Results: Three rounds of the study were performed, resulting in a final 32-item checklist. Each item on the checklist received at least 70% expert agreement on its inclusion in the final checklist. Conclusion: A procedural performance checklist was created for bifemoral VV ECMO using the modified Delphi method. This is an objective tool to assist procedural training and validation for medical providers performing VV ECMO in austere environments.
Keywords: VVECMO; checklist; prolonged casualty care; ARDS
Anderson JL, Johannigman J. 21(3). 111 - 117. (Journal Article)
Abstract
Keywords: Lest We Forget; combat casualty care; blood; transfusion; fluid resuscitation
DesRosiers TT, Anderson JL, Adams B, Carver RA. 22(2). 48 - 54. (Journal Article)
Abstract
Pain is one of the most common complaints of battlefield casualties, and unique considerations apply in the tactical environment when managing the pain of wounded service members. The resource constraints commonly experienced in an operational setting, plus the likelihood of prolonged casualty care by medics or corpsmen on future battlefields, necessitates a review of analgesia and sedation in the prehospital setting. Four clinical scenarios highlight the spectrum of analgesia and sedation that may be necessary in this prehospital and/or austere environment.
Keywords: traumatic brain injury; pathophysiology; prehospital management; critical care
Anderson JL, Cole M, Pannell D. 22(2). 43 - 47. (Journal Article)
Abstract
Crush injuries present a challenging case for medical providers and require knowledge and skill to manage the subsequent damage to multiple organ systems. In an austere environment, in which resources are limited and evacuation time is extensive, a medic must be prepared to identify trends and predict outcomes based on the mechanism of injury and patient presentation. These injuries occur in a variety of environments from motor vehicle accidents (at home or abroad) to natural disasters and building collapses. Crush injury can lead to compartment syndrome, traumatic rhabdomyolysis, arrythmias, and metabolic acidosis, especially for patients with extended treatment and extrication times. While crush syndrome occurs due to the systemic effects of the injury, the onset can be as early as 1 hour postinjury. With a comprehensive understanding of the pathophysiology, diagnosis, management, and tactical considerations, a prehospital provider can optimize patient outcomes and be prepared with the tools they have on hand for the progression of crush injury into crush syndrome.
Keywords: crush injury; Special Operations Medicine; tactical medicine; compartment syndrome; rhabdomyolysis
Anderson JL, Kronstedt S, Bergens MA, Johannigman J. 23(1). 103 - 106. (Journal Article)
Abstract
Keywords: Lest We Forget; combat casualty care; war wound therapy; antibiotic therapy; wound care
Younce W, Anderson J, Kronstedt S, Johannigman J. 24(3). 75 - 78. (Journal Article)
Abstract
In the third installment of the "Lest We Forget" series, the authors discuss a critical advance-vascular repair, pioneered by Dr. Carl Hughes-in the care of the war-wounded during the Korean War. This article reviews the management of large vessel injuries in wartime, the challenges and advances in military medicine during the Korean War, and the application of these lessons to current practices.
Keywords: Lest We Forget; vascular repair; military medicine
Grier T, Anderson MK, Depenbrock P, Eiserman R, Nindl BC, Jones BH. 18(2). 42 - 48. (Journal Article)
Abstract
Background: We sought to assess the rehabilitation process, training, performance, and injury rates among those participating and not participating in the Tactical Human Optimization, Rapid Rehabilitation, and Reconditioning (THOR3) program and determine injury risk factors. Methods: A survey inquiring about personal characteristics, injuries, physical performance, and THOR3 participation during the previous 12 months was administered to Army Special Operations Forces (SOF) Soldiers. Based on responses to physical training, Soldiers were categorized into three groups: a traditional physical training (TPT) group, a cross-training (CT) group, and a THOR3 group. To identify potential injury risk factors, risk ratios and 95% confidence intervals (95% CIs) were calculated. Backward- stepping multivariable logistic regression models were used to assess key factors associated with injury risk. Results: The survey was completed by 328 male Soldiers. Most of the Soldiers (62%) who scheduled an appointment with the physical therapist were seen within 1 day. Self-reported injury rates for the TPT, CT, and THOR3 groups were 70%, 52%, and 48%, respectively. When controlling for personal characteristics, unit training, and fitness, the TPT group had a marginally higher risk of being injured than the THOR3 group (odds ratio [OR], 2.72; 95% CI, 0.86-8.59; p = .09). Soldiers who did not perform any unit resistance training (ORnone/90-160 min, 3.62; 95% CI, 1.05-12.53; p = .04) or the greatest amount of resistance training (OR>160 min/90-160 min, 3.44; 95% CI, 1.64-7.20; p < .01) were more likely to experience an injury than the moderate-resistance training group. Conclusion: THOR3 appears to offer human performance optimization/injury prevention advantages over other SOF human performance programs.
Keywords: THOR3; physical fitness; physical training; musculoskeletal; athletic performance; injury
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.
Butler FK, Holcomb JB, Shackelford SA, Montgomery HR, Anderson S, Cain JS, Champion HR, Cunningham CW, Dorlac WC, Drew B, Edwards K, Gandy JV, Glassberg E, Gurney JM, Harcke T, Jenkins DA, Johannigman J, Kheirabadi BS, Kotwal RS, Littlejohn LF, Martin MJ, Mazuchowski EL, Otten EJ, Polk T, Rhee P, Seery JM, Stockinger Z, Torrisi J, Yitzak A, Zafren K, Zietlow SP. 18(2). 19 - 35. (Journal Article)
Abstract
This change to the Tactical Combat Casualty Care (TCCC) Guidelines that updates the recommendations for management of suspected tension pneumothorax for combat casualties in the prehospital setting does the following things: (1) Continues the aggressive approach to suspecting and treating tension pneumothorax based on mechanism of injury and respiratory distress that TCCC has advocated for in the past, as opposed to waiting until shock develops as a result of the tension pneumothorax before treating. The new wording does, however, emphasize that shock and cardiac arrest may ensue if the tension pneumothorax is not treated promptly. (2) Adds additional emphasis to the importance of the current TCCC recommendation to perform needle decompression (NDC) on both sides of the chest on a combat casualty with torso trauma who suffers a traumatic cardiac arrest before reaching a medical treatment facility. (3) Adds a 10-gauge, 3.25-in needle/ catheter unit as an alternative to the previously recommended 14-gauge, 3.25-in needle/catheter unit as recommended devices for needle decompression. (4) Designates the location at which NDC should be performed as either the lateral site (fifth intercostal space [ICS] at the anterior axillary line [AAL]) or the anterior site (second ICS at the midclavicular line [MCL]). For the reasons enumerated in the body of the change report, participants on the 14 December 2017 TCCC Working Group teleconference favored including both potential sites for NDC without specifying a preferred site. (5) Adds two key elements to the description of the NDC procedure: insert the needle/ catheter unit at a perpendicular angle to the chest wall all the way to the hub, then hold the needle/catheter unit in place for 5 to 10 seconds before removing the needle in order to allow for full decompression of the pleural space to occur. (6) Defines what constitutes a successful NDC, using specific metrics such as: an observed hiss of air escaping from the chest during the NDC procedure; a decrease in respiratory distress; an increase in hemoglobin oxygen saturation; and/or an improvement in signs of shock that may be present. (7) Recommends that only two needle decompressions be attempted before continuing on to the "Circulation" portion of the TCCC Guidelines. After two NDCs have been performed, the combat medical provider should proceed to the fourth element in the "MARCH" algorithm and evaluate/treat the casualty for shock as outlined in the Circulation section of the TCCC Guidelines. Eastridge's landmark 2012 report documented that noncompressible hemorrhage caused many more combat fatalities than tension pneumothorax.1 Since the manifestations of hemorrhagic shock and shock from tension pneumothorax may be similar, the TCCC Guidelines now recommend proceeding to treatment for hemorrhagic shock (when present) after two NDCs have been performed. (8) Adds a paragraph to the end of the Circulation section of the TCCC Guidelines that calls for consideration of untreated tension pneumothorax as a potential cause for shock that has not responded to fluid resuscitation. This is an important aspect of treating shock in combat casualties that was not presently addressed in the TCCC Guidelines. (9) Adds finger thoracostomy (simple thoracostomy) and chest tubes as additional treatment options to treat suspected tension pneumothorax when further treatment is deemed necessary after two unsuccessful NDC attempts-if the combat medical provider has the skills, experience, and authorizations to perform these advanced interventions and the casualty is in shock. These two more invasive procedures are recommended only when the casualty is in refractory shock, not as the initial treatment.
Keywords: guidelines; tension pneumothorax; Tactical Combat Casualty Care
Walker TB, Lennemann LM, Anderson V, Lyons W, Zupan MF. 11(3). 37 - 44. (Journal Article)
Abstract
Objectives: The United States Air Force combat controller (CCT) training pipeline is extremely arduous and historically has a high attrition rate of 70 to 80%. The primary objective of this study was to evaluate the impact of incorporating a 711 Human Performance Wing (HPW) / Biobehavior, Bioassessment, and Biosurveillance Branch (RHPF)-developed physical fitness-training program into the combat controller (CCT) 5-level training physical fitness program. Methods: One-hundred-nine CCT trainees were tested and trained during their initial eight weeks at the 720th Special Tactics Training Squadron (STTS) at Hurlburt Field. Modifications to their physical training program were principally aimed at reducing overtraining and overuse injury, educating trainees and cadre on how to train smarter, and transitioning from traditional to "functional" PT. A battery of physiological measurements and a psychological test were administered prior to and immediately after trainees undertook an 8-week modified physical fitness training program designed to reduce overtraining and injury and improve performance. We performed multiple physical tests for cardiovascular endurance (VO2max and running economy), "anaerobic" capacity (Wingate power and loaded running tests), body composition (skinfolds), power (Wingate and vertical jump), and reaction time (Makoto eye-hand test). We used the Mental Toughness Questionnaire 48 (MTQ-48) for the psychological test. Results: We observed several significant improvements in physical and physiological performance over the eight weeks of training. Body composition improved by 16.2% (p<0.05). VO2max, time-to-exhaustion, and ventilatory threshold were all significantly higher after implementation of the new program than before it. We observed strong trends towards improvement in work accomplished during loaded running (ρ = 0.07) and in average power per body mass during lower body Wingate (ρ = 0.08). Other measures of lower body power did not change significantly over the training period, but did show mild trends towards improvement. Upper body average and peak power per kilogram of body mass both improved significantly by 5.8% and 8.1%, respectively. Reaction time was significantly better posttraining as demonstrated by a 7% improvement during the reactive test. Reactive accuracy also improved significantly with the post test accuracy percentage jumping from 61% to 76%. Furthermore, overuse injuries, a major source of attrition fell by a dramatic 67%. Conclusions: The modifications resulted in significant improvement in trainees' graduation rate. In the eight classes prior to implementation of these changes, average CCT graduating class size was nine trainees. For the eight classes following the changes, average CCT graduating class rose to 16.5 trainees, an increase of 83%. Due to its success, STTS leadership expanded the modifications from the eight weeks prior to CDS to include the entire second year of the pipeline.
Mahmood M, Riley K, Bennett D, Anderson W. 11(1). 37 - 42. (Previously Published)
Previously published in Military Medicine, 176, 8:852, 2011
Abstract
In this article, we provide an overview of key international guidelines governing the supply of pharmaceuticals during disasters and complex emergencies. We review the World Health Organization's guidelines on pharmaceutical supply chain management and highlight their relevance for military humanitarian assistance missions. Given the important role of pharmaceuticals in addressing population health needs during humanitarian emergencies, a good understanding of how pharmaceuticals are supplied at the local level in different countries can help military health personnel identify the most appropriate supply options. Familiarity with international guidelines involved in cross-border movement of pharmaceuticals can improve the ability of military personnel to communicate more effectively with other actors involved in humanitarian and development spheres. Enhancing the knowledge base available to military personnel in terms of existing supply models and funding procedures can improve the effectiveness of humanitarian military operations and invite policy changes necessary to establish more flexible acquisition and funding regulations.
Beadling C, Maza J, Nakano G, Mahmood M, Jawad S, Al-Ameri A, Zuerlein S, Anderson W. 12(3). 10 - 16. (Journal Article)
Abstract
This article presents findings from a survey conducted to examine the availability of foreign language and culture training to Civil Affairs health personnel and the relevance of that training to the tasks they perform. Civil Affairs forces recognize the value of cross-cultural communication competence because their missions involve a significant level of interaction with foreign governments' officials, military, and civilians. Members of the 95th Civil Affairs Brigade (Airborne) who had a health-related military occupational specialty code were invited to participate in the survey. More than 45% of those surveyed were foreign language qualified. Many also received predeployment language and culture training specific to the area of deployment. Significantly more respondents reported receiving cultural training and training on how to work effectively with interpreters than having received foreign language training. Respondents perceived interpreters as important assets and were generally satisfied with their performance. Findings from the survey highlight a need to identify standard requirements for predeployment language training that focuses on medical and health terminology and to determine the best delivery platform(s). Civil Affairs health personnel would benefit from additional cultural training that focuses on health and healthcare in the country or region of deployment. Investing in the development of distance learning capabilities as a platform for delivering health-specific language and culture training may help ease the time and resources constraints that limit the ability of Civil Affairs health personnel to access the training they need.
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.
Vallier DJ, Anderson WJ, Snelson JV, Yauger YJ, Felix JR, Alford KI, Bermoy WA. 22(4). 9 - 13. (Journal Article)
Abstract
US Army Forward Surgical Elements (FSEs) are highly mobile teams that provide damage control surgery (DCS) and damage control resuscitation (DCR) in austere locations that often lack standard hospital utilities (electricity, heat, food, and water). FSEs rely on portable battery-operated intravenous (IV) fluid warmers to remain light and mobile. However, their ability to warm blood in a massive resuscitation requires additional analysis. The purpose of this literature review is to examine the three most common battery-operated IV fluid warmers as determined by type and quantity listed on the Mission Table of Organization and Equipment (MTOE) of organic mobile medical units. These include the Buddy Lite, enFlow, and Thermal Angel, which are available to deployed US Army FSEs for blood resuscitation therapy. Based on limited available evidence, the enFlow produced higher outlet temperatures, effectively warmed greater volumes, reached the time to peak temperature faster, and produced greatest flow rates, with cool saline (5-10°C), compared to the Thermal Angel and Buddy Lite. However, recently the US Food and Drug Administration (FDA) issued a Class 1 recall on enFlow cartridges. Testing demonstrated aluminum elution from enFlow cartridges into IV solutions, thereby exposing patients to potentially unsafe aluminum levels. The authors recommend FSE units conduct a 100% enFlow cartridge inventory and seek an alternative IV fluid warming system prior to enFlow cartridge disposal. If an alternative does not exist, or the alternative warming system does not fit mission requirements, then medical personnel must carefully weigh the risks and benefits associated with the enFlow delivery system.
Keywords: Thermal Angel; enFlow; Buddy Lite; fluid warmer; intravenous fluids, IVF; cartridge
Delmonaco BL, Andrews J, May A. 08(3). 61 - 64. (Journal Article)
Abstract
In August 2007 a three-man Special Operations Forces (SOF) Team attempted a rapid ascent of Mt Rainier after a five-day intermittent hypoxic exposure (IHE) protocol in a Colorado Exercise Room. The following article discusses the process used by the team to select the five-day IHE protocol as well as the science upon which IHE protocols for altitude acclimatization is based. The experiences of the team as they attempted to summit Mt Rainier at greater than 14,000 feet are summarized with a focus on acute mountain sickness (AMS) and its possible prevention with IHE. The subject of rapid acclimatization to prevent AMS is important to the SOF community in order to quickly operate at high altitudes without succumbing to AMS or being forced to a lower altitude. Although medical literature is thinly populated with rigorous studies of IHE to prevent AMS, recent good studies, especially from Dr. Stephen Muza at the U.S. Army Research Institute of Environmental Medicine (USARIEM), validate some IHE protocols. This research is reviewed in the following article to help determine an appropriate IHE protocol for the SOF community.
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
Nam JJ, Wong AI, Cantong D, Cook JA, Andrews Z, Levy JH. 23(2). 118 - 121. (Journal Article)
Abstract
Coagulopathy can occur in trauma, and it can affect septic patients as a host tries to respond to infection. Sometimes, it can lead to disseminated intravascular coagulopathy (DIC) with a high potential for mortality. New research has delineated risk factors that include neutrophil extracellular traps and endothelial glycocalyx shedding. Managing DIC in septic patients focuses on first treating the underlying cause of sepsis. Further, the International Society on Thrombolysis and Haemostasis (ISTH) has DIC diagnostic criteria. "Sepsis-induced coagulopathy" (SIC) is a new category. Therapy of SIC focuses on treating the underlying infection and the ensuing coagulopathy. Most therapeutic approaches to SIC have focused on anticoagulant therapy. This review will discuss SIC and DIC and how they are relevant to prolonged casualty care (PCC).
Keywords: sepsis; disseminated intravascular coagulation; coagulopathy; antithrombin; prolonged casualty care; PCC; austere critical care
Androski CP, Bianchi W, Robinson DL, Zarow GJ, Moore CH, Deaton TG, Drew B, Gonzalez S, Knight RM. 20(4). 85 - 91. (Journal Article)
Abstract
Early tranexamic acid (TXA) administration for resuscitation of critically injured warfighters provides a mortality benefit. The 2019 Tactical Combat Casualty Care (TCCC) recommendations of a 1g drip over 10 minutes, followed by 1g drip over 8 hours, is intended to limit potential TXA side effects, including hypotension, seizures, and anaphylaxis. However, this slow and cumbersome TXA infusion protocol is difficult to execute in the tactical care environment. Additionally, the side effect cautions derive from studies of elderly or cardiothoracic surgery patients, not young healthy warfighters. Therefore, the 75th Ranger Regiment developed and implemented a 2g intravenous or intraosseous (IV/IO) TXA flush protocol. We report on the first six cases of this protocol in the history of the Regiment. After-action reports (AARs) revealed no incidences of post-TXA hypotension, seizures, or anaphylaxis. Combined, the results of this case series are encouraging and provide a foundation for larger studies to fully determine the safety of the novel 2g IV/IO TXA flush protocol toward preserving the lives of traumatically injured warfighters.
Keywords: tranexamic acid; TXA; TXA flush; TXA intraosseous; TXA protocol; Tactical Combat Casualty Care; TCCC
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
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
Anonymous A. 14(1). 113 - 115. (Classical Conference)
Abstract
Anonymous A. 14(2). 113 - 120. (Classical Conference)
Abstract
Anonymous A. 14(3). 124 - 132. (Classical Conference)
Abstract
Anonymous A. 15(2). 154 - 167. (Classical Conference)
Abstract
Anonymous A. 15(3). 129 - 147. (Classical Conference)
Abstract
Anonymous A. 15(4). 175 - 177. (Classical Conference)
Abstract
Anonymous A. 16(2). 138 - 147. (Classical Conference)
Abstract
Anonymous A. 16(3). 99 - 119. (Classical Conference)
Abstract
Anonymous A. 18(4). 159 - 161. (Classical Conference)
Abstract
Anonymous A. 19(4). 22 - 24. (Classical Conference)
Abstract
Keywords: case reports; bleeding; TCCC
Anonymous A. 19(4). 114 - 117. (Journal Article)
Abstract
Some of the current methods of instruction used within international armed forces courses are not always goal oriented and satisfactory for both the teaching staff and the student. The Swiss Armed Forces approach presented here has been historically effective in preparing and sustaining national conscription with large numbers of recruits and new cadres every year.
Keywords: comprehension; goals; learning; training; NATO Special Operations Combat Medic; NSOCM; Swiss Armed Forces
Anonymous A. 19(4). 130 - 131. (Classical Conference)
Abstract
Anonymous A. 19(4). 108 - 108. (Journal Article)
Abstract
Anonymous A. 21(4). 104 - 105. (Journal Article)
Abstract
The Centers for Disease Control and Prevention warned that two people are dead and two have recovered after being infected with the bacterial disease melioidosis - a disease that had never before been detected on contiguous US soil. The cases occurred between March and July 2021 in Georgia, Kansas, Texas, and Minnesota. Melioidosis, also called Whitmore's disease, is an infectious disease that can infect humans or animals. The disease is caused by the bacterium Burkholderia pseudomallei. It is predominately a disease of tropical climates, especially in Southeast Asia and northern Australia where it is widespread.
Keywords: bacteria; melioidosis; contaminated source; Whitmore's disease; Burkholderia pseudomallei
Anonymous A. 22(3). 109 - 117. (Classical Conference)
Abstract
Anonymous A. 22(4). 132 - 135. (Classical Conference)
Abstract
Anonymous A, Hetzler MR. 24(3). 90 - 93. (Journal Article)
Abstract
Special Forces increasingly operate in austere environments, which are known to have limited medical support and prolonged evacuation times. On the battlefield, pain remains the first complaint of casualties and can impact direct autonomic stability, recovery, and the development of posttraumatic stress disorder. Although medical education has been improving, medical providers still encounter difficulties, such as lack of human and material resources, while trying to achieve pain management. This article summarizes a survey sent to 35 Special Operations medical providers and suggests possible strategies to address challenges to pain management on the battlefield. Potential solutions have been gathered through medical texts, medical/NATO documents, and medical expertise. Nerves blocks have been identified as valuable tools for pain management in the current battlefield environment, where prolonged evacuation and limited freedom of movement are the norm. The survey showed that, although the vast majority of providers had already received lectures on regional anesthesia, 83% were not trained in it, and 54% had never been made aware of multimodal analgesia. This lack of familiarity highlights knowledge and training gaps in nerve block techniques. Diffusion blocks are a very low-risk, useful, and safe pain management technique, which requires less skill sustainment and resources than more complex techniques. The use of epinephrine as adjunct can be useful for decreasing local anesthetic toxicity and increasing long-term pain management. The need for both education on and training in the use of nerve blocks has been identified by the Special Operations health provider community.
Keywords: Special Operations Forces; regional anesthesia; multimodal analgesia; local anesthetics; nerve block; hybrid warfare; unconventional warfare; prolonged casualty care
Anonymous A. 16(2). 71 - 77. (Letter)
Abstract
Anonymous A. 18(3). 136 - 146. (Classical Conference)
Abstract
Anonymous A. 18(3). 79 - 85. (Classical Conference)
Abstract
Anonymous A, Anonymous A. 22(1). 144 - 145. (Classical Conference)
Abstract
Anonymous A, Anonymous A. 22(1). 144 - 145. (Classical Conference)
Abstract
Anonymous A. 22(1). 11 - 17. (Classical Conference)
Abstract
Anonymous A. 18(4). 115 - 122. (Classical Conference)
Abstract
Anonymous A. 19(3). 94 - 99. (Classical Conference)
Abstract
Anonymous A. 19(3). 18 - 21. (Classical Conference)
Abstract
Keywords: case reports; airway; TCCC
Anonymous A. 20(1). 123 - 123. (Journal Article)
Abstract
Anonymous A. 20(2). 43 - 74. (Journal Article)
Abstract
Anonymous A. 20(2). 25 - 42. (Journal Article)
Abstract
Anonymous A. 21(3). 100 - 106. (Classical Conference)
Abstract
Anonymous A. 21(4). 85 - 89. (Classical Conference)
Abstract
Keywords: mental health; military psychology; military personnel; emergency responders; stigma; partners; health services accessibility
Goforth C, Antico D. 16(3). 53 - 56. (Editorial)
Abstract
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
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
Michael R, Gaddy M, Antonino N, Payne R, DeSoucy ES, Rush JT. 22(3). 98 - 100. (Journal Article)
Abstract
Severe traumatic brain injury (sTBI) is a devastating injury with limited prehospital therapies available. The Joint Trauma System (JTS) Clinical Practice Guidelines recommend hypertonic saline (HTS) for casualties with sTBI and signs of impending or ongoing herniation (IOH), but its use by combat medics has never been reported in the literature. This report details the management of a pregnant patient with sTBI and signs of IOH, including the use of HTS, by US Air Force pararescumen in an austere prehospital setting. Treatment with HTS was followed by improvement in the patient's neurologic exam and successful evacuation to definitive care where her child was delivered alive. Additionally, we review the pathophysiology and signs of herniation, the mechanism of action of hyperosmotic therapies, and the rationale behind the use of HTS in the combat setting.
Keywords: impending ongoing herniation; IOH; hypertonic saline; hypertonic sodium chloride; military medicine; brain herniation; TBI; traumatic brain injury
Antosh IJ, McGrane OL, Capan EJ, Dominguez JD, Hofmann LJ. 19(1). 48 - 51. (Journal Article)
Abstract
There are no established ground medical-evacuation systems within Special Operations Command Africa (SOCAFRICA), given the austere and varied environments. Transporting the injured casualty requires ingenuity and modification of existing vehicles. The Expeditionary Resuscitative Surgical Team (ERST) assigned to SOCAFRICA used four unconventional means for ground evacuation. This is a retrospective review of the various modes of ground transportation used by the ERST-3 during deployment with SOCAFRICA. All handcarried litter and air evacuation platforms were excluded. Over 9 months, four different ground casualty platforms were used after they were modified: (1) Mine-Resistant Ambush-Protected All-Terrain Vehicle (MAT-V; Oshkosh Defense); (2) MRZR-4 ("Razor"; Polaris Industries); (3) nonstandard tactical vehicles, (NSTVs; Toyota HiLux); and (4) John Deere TH 6x4 ("Gator"). Use of all vehicle platforms was initially rehearsed and then they were used on missions for transport of casualties. Each of the four methods of ground evacuation includes a description of the talon litter setup, the necessary modifications, the litter capacity, the strengths and weaknesses, and any summary recommendations for that platform. Understanding and planning for ground casualty evacuation is necessary in the austere environment. Although each modified vehicle was used successfully to transfer the combat casualty with an ERST team member, consideration should be given to acquisition of the MAT-V medical-specific vehicle. Understanding the currently available modes of ground casualty evacuation transport promotes successful transfer of the battlefield casualty to the next echelon of care.
Keywords: patient transport; ground evacuation; Special Operations; austere; prolonged field care
Montagnon R, Cungi P, Aoun O, Morand G, Desmottes J, Pasquier P, Travers S, Aigle L, Dubecq C. 23(3). 39 - 43. (Journal Article)
Abstract
Background: Pain management is essential in military medicine, particularly in Tactical Combat Casualty Care (TCCC) during deployments in remote and austere settings. The few previously published studies on intranasal analgesia (INA) focused only on the efficacy and onset of action of the medications used (ketamine, sufentanil, and fentanyl). Side-effects were rarely reported. The aim of our study was to evaluate the use of intranasal analgesia by French military physicians. Methods: We carried out a multicentric survey between 15 January and 14 April 2020. The survey population included all French military physicians in primary-care centers (n = 727) or emergency departments (n = 55) regardless of being stationed in mainland France or French overseas departments and territories. Results: We collected 259 responses (33% responsiveness rate), of which 201 (77.6%) physicians reported being familiar with INA. However, regarding its use, of the 256 physicians with completed surveys, only 47 (18.3%) had already administered it. Emergency medicine physicians supporting highly operational units (e.g., Special Forces) were more familiar with this route of administration and used it more frequently. Ketamine was the most common medication used (n = 32; 57.1%). Finally, 234 (90%) respondents expressed an interest in further education on INA. Conclusion: Although a majority of French military physicians who replied to the survey were familiar with INA, few used it in practice. This route of administration seems to be a promising medication for remote and austere environments. Specific training should, therefore, be recommended to spread and standardize its use.
Keywords: Intranasal route; disaster medicine; emergency medicine; prehospital care; military medicine; analgesia; ketamine; Special Operations
Thompson P, Hudson AJ, Convertino VA, Bjerkvig C, Eliassen HS, Eastridge BJ, Irvine-Smith T, Braverman MA, Hellander S, Jenkins DH, Rappold JF, Gurney JM, Glassberg E, Cap AP, Aussett S, Apelseth TO, Williams S, Ward KR, Shackelford SA, Stroberg P, Vikeness BH, Pepe PE, Winckler CJ, Woolley T, Enbuske S, De Pasquale M, Boffard KD, Austlid I, Fosse TK, Asbjornsen H, Spinella PC, Strandenes G. 20(3). 97 - 102. (Editorial)
Abstract
Based on limited published evidence, physiological principles, clinical experience, and expertise, the author group has developed a consensus statement on the potential for iatrogenic harm with rapid sequence induction (RSI) intubation and positive-pressure ventilation (PPV) on patients in hemorrhagic shock. "In hemorrhagic shock, or any low flow (central hypovolemic) state, it should be noted that RSI and PPV are likely to cause iatrogenic harm by decreasing cardiac output." The use of RSI and PPV leads to an increased burden of shock due to a decreased cardiac output (CO)2 which is one of the primary determinants of oxygen delivery (DO2). The diminishing DO2 creates a state of systemic hypoxia, the severity of which will determine the magnitude of the shock (shock dose) and a growing deficit of oxygen, referred to as oxygen debt. Rapid accumulation of critical levels of oxygen debt results in coagulopathy and organ dysfunction and failure. Spontaneous respiration induced negative intrathoracic pressure (ITP) provides the pressure differential driving venous return. PPV subsequently increases ITP and thus right atrial pressure. The loss in pressure differential directly decreases CO and DO2 with a resultant increase in systemic hypoxia. If RSI and PPV are deemed necessary, prior or parallel resuscitation with blood products is required to mitigate post intervention reduction of DO2 and the potential for inducing cardiac arrest in the critically shocked patient.
Sarkisian S, Sletten ZJ, Clark RA, Soh EK, Appel DA, Bellin DA, Nayak KR, Kaviratne S, Strilka R, Schimke A, Nasir J, Mone D, Keenan S, Shackelford SA. 21(3). 11 - 20. (Journal Article)
Abstract
Deployed medical providers at all roles of care must be prepared to recognize and manage acute coronary syndrome (ACS). Under optimal conditions, treatment is initiated with medical therapy and may be followed by prompt coronary angiography and revascularization. Emergent percutaneous coronary intervention (PCI) is not available in most deployed locations, however, and the time for such intervention is often dependent on long-range evacuation. This CPG provides guidance on best management for ACS patients in the deployed and resource-constrained environment.
Bellaire CP, Shin J, Nietsch KS, Ditzel RM, Appel JM. 21(3). 98 - 99. (Editorial)
Abstract
Bellaire CP, Ditzel RM, Meade ZS, Love ZD, Appel JM. 22(3). 62 - 64. (Journal Article)
Abstract
This year is the 80th anniversary of the Women's Army Auxiliary Corps. The passage of this seminal legislation - sponsored by Edith Nourse Rogers - formalized the role of women in the US military and compensated them for their service and in the event of injury or illness. Rogers was a pioneer in her own right. A trailblazer for women and a staunch advocate for military veterans' healthcare, Rogers was forged by her wartime experiences. The authors describe Rogers' contributions as a congresswoman during World War II and during her 35 years of public service in the House of Representatives. Congresswoman Rogers was foundational to the modern US healthcare system.
Keywords: veterans; military personnel; military medicine; school admission criteria; schools, medical; education, medical; women
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
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
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
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
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
April MD, Lopes T, Schauer SG, Meneses M, Roszenweig H, Byram D, Timms-Williams Z, Shields TP, Cross AN, Hoffmann LJ. 17(4). 63 - 67. (Journal Article)
Abstract
Background: Training partner forces in battlefield first-responder medical skills is an important component of US military advise-and-assist operations. We designed and executed a training curriculum focused on high-yield-based medical skills to prevent death on the battlefield for non-English speaking members of the Turkish, Azerbaijani, and Albanian militaries deployed to Afghanistan. Methods: We designed a 2-hour training curriculum focusing on four basic medical skills: (1) assessment of scene safety; (2) limb tourniquet application; (3) wound bandaging; and (4) patient transportation via litter. Our combat medics delivered standardized training using both didactic and practicum components. Instructors made beforeand- after assessments of the proficiency of each participant for each skill in accordance with the Dreyfus model of skill acquisition. We also administered before-and-after, Likertscale- based surveys for training participants to report their self-assessed comfort level with each of the four skills. Results: We delivered training to 187 participants over five classes. All 28 participants in the final teaching class completed the study. Instructors categorized each participant's skill level as novice before training for all four skills. After the training curriculum, all participants achieved a skill level consistent with advanced beginner for all four skills. Participants reported significant improvements in self-reported comfort levels for all taught procedures (ρ < .001 by Wilcoxon signed-rank test for all four skills). The largest reported increase in median comfort level was for tourniquet application: median pretraining comfort level, 4 (interquartile range [IQR], 0-6.25) versus 9.5 (IQR, 9-10) posttraining. Conclusion: Our curriculum resulted in significant improvements in instructor-assessed proficiency and self-reported comfort level for all four basic medical skills. Although our outcome measures have important limitations, this curriculum may be useful framework for future medics and physicians designing battlefield first-responder training curricula for members of foreign militaries.
Keywords: education; wounds and injuries; emergency medical services; military personnel
Fleming ME, Heiner JD, Summers S, April MD, Chin EJ. 17(4). 72 - 75. (Journal Article)
Abstract
Background: Soft-tissue occult foreign bodies are a concerning cause of morbidity in the emergency department. The identification of wooden foreign bodies is a unique challenge because they are often not detectable by plain radiography. The purpose of this study was to determine the diagnostic accuracy of emergency physician-performed ultrasonography to detect wooden foreign bodies of varying sizes. We hypothesized that sonographic sensitivity would improve with increasing foreign body size. Methods: We conducted a blinded, prospective evaluation using a previously validated, chicken, soft-tissue model to simulate human tissue. We inserted wooden toothpicks of varying lengths (1mm, 2.5mm, 5mm, 7.5mm, 10mm) to a depth of 1cm in five tissue models. Five additional models were left without a foreign body to serve as controls. Fifty emergency physicians with prior ultrasonography training performed sonographic examinations of all 10 models and reported on the presence or absence of wooden foreign bodies. Results: Subjects performed 10 ultrasonography examinations each for a total of 500 examinations. For the detection of wooden foreign bodies, overall test characteristics for sonography included sensitivity 48.4% (95% confidence interval [CI], 42.1%-54.8%) and specificity 67.6% (95% CI, 61.3%- 73.2%). Sensitivity did not change as object size increased (ρ = s.709). Conclusion: Emergency physician bedside ultrasonography demonstrated poor diagnostic accuracy for the detection of wooden foreign bodies. Accuracy did not improve with increasing object size up to 10mm. Providers should consider alternative diagnostic modalities if there is persistent clinical concern for a retained, radiolucent, soft-tissue foreign body.
Keywords: ultrasound; foreign body; wooden object
Schauer SG, April MD, Fisher AD, Cunningham CW, Gurney JM. 18(2). 71 - 74. (Journal Article)
Abstract
Background: Hemorrhage is the leading cause of potentially preventable death on the battlefield. Although the resurgence of limb tourniquets revolutionized hemorrhage control in combat casualties in the recent conflicts, the mortality rate for patients with junctional hemorrhage is still high. Junctional tourniquets (JTQs) offer a mechanism to address the high mortality rate. The success of these devices in the combat setting is unclear given a dearth of existing data. Methods: From the Prehospital Trauma Registry (PHTR) and the Department of Defense Trauma Registry, we extracted cases of JTQ use in Afghanistan. Results: We identified 13 uses of a JTQ. We excluded one case in which an improvised pelvic binder was used. Of the remaining 12 cases of JTQ use, seven had documented success of hemorrhage control, three failed to control hemorrhage, and two were missing documentation regarding success or failure. Conclusion: We report 12 cases of prehospital use of JTQ in Afghanistan. The findings from this case series suggest these devices may have some utility in achieving hemorrhage control strictly at junctional sites (e.g., inguinal creases). However, they also highlight device limitations. This analysis demonstrates the need for continued improvements in technologies for junctional hemorrhage control, prehospital documentation, data fidelity and collection, as well as training and sustainment of the training for utilization of prehospital hemorrhage control techniques.
Keywords: junctional tourniquet; junctional hemorrhage; trauma; combat
Schauer SG, Fisher AD, April MD, Stolper KA, Cunningham CW, Carter R, Fernandez JD, Pfaff JA. 18(2). 53 - 56. (Journal Article)
Abstract
Background: Military operations place injured Servicemembers at high risk for open wounds. Austere environments and initial wound contamination increase the risk for infection. Wound infections continue to cause significant morbidity among injured Servicemembers. Limited evidence suggests that early antibiotic therapy for open wounds reduces infection rates. Methods: We obtained data from the Prehospital Trauma Registry (PHTR) from January 2013 through September 2014. This database includes data from Tactical Combat Casualty Care (TCCC) cards, Department of Defense 1380 forms, and after-action reports to provide near-real-time feedback to units on prehospital medical care. We evaluated whether patients with open wounds received antibiotics in accordance with TCCC guidelines. Low adherence was defined at less than 80%. Results: In this data set, overall, prefixed facility providers administered antibiotics to 54.0% of patients with an open combat wound. Of the antibiotics given, 11.1% were within TCCC guidelines. The relatively low administration and adherence rates persisted across subgroup analyses. Conclusion: Overall, relatively few patients with open combat wounds receive antibiotic administration as recommended by TCCC guidelines. In the group that received antibiotics, few received the specific antibiotics recommended by TCCC guidelines. The development of strategies to improve adherence to these TCCC recommendations is a research priority.
Keywords: prehospital; antibiotics; wound; prophylaxis; combat; emergency; tactical; casualty
Schauer SG, Naylor JF, April MD, Fisher AD, Cunningham CW, Fernandez JD, Shreve BP, Bebarta VS. 19(1). 52 - 55. (Journal Article)
Abstract
Background: Peripheral intravenous (IV) cannulation is often difficult to obtain in a patient with hemorrhagic shock, delaying the appropriate resuscitation of critically ill patients. Intraosseous (IO) access is an alternative method. To date, few data exist on use of this procedure by ground forces in Afghanistan. Here, we compare patient characteristics and concomitant interventions among patients undergoing IO access versus those undergoing IV access only. Methods: We obtained data from the Prehospital Trauma Registry (PHTR). When possible, patients were linked to the Department of Defense Trauma Registry for outcome data. To develop the cohorts, we searched for all patients with documented IO or IV access placement. Those with both IO and IV access documented were placed in the IO group. Results: Of the 705 available patients in the PHTR, we identified 55 patients (7.8% of the population) in the IO group and 432 (61.3%) in the IV group. Among patients with documentation of access location, the most common location was the tibia (64.3%; n = 18). Compared with patients with IV access, those who underwent IO access had higher urgent evacuation rates (90.9% versus 72.4%; p = .01) and air evacuation rates (58.2% versus 14.8%; p < .01). The IO cohort had significantly higher rates of interventions for hypothermia, chest seals, chest tubes, needle decompressions, and tourniquets, but a significantly lower rate of analgesic administration (ρ ≤ .05). Conclusion: Within the registry, IO placement was relatively low (<10%) and used in casualties who received several other life-saving interventions at a higher rate than casualties who had IV access. Incidentally, lower proportions of analgesia administration were detected in the IO group compared with the IV group, despite higher intervention rates.
Keywords: hemorrhagic shock; intraosseous access; intravenous access; prehospital; combat; hypotension; resuscitation; military
Schauer SG, Fisher AD, April MD, Carter R, Cunningham CW, Aden JK, Fernandez JD, DeLorenzo RA. 19(1). 70 - 74. (Journal Article)
Abstract
Background: Low rates of prehospital analgesia, as recommended by Tactical Combat Casualty Care (TCCC) guidelines, have been demonstrated in the Joint Theaters combat setting. The reasons for this remain unclear. This study expands on previous reports by evaluating a larger prehospital dataset for determinants of analgesia administration. Methods: This was part of an approved quality assurance project evaluating adherence to TCCC guidelines across multiple modalities. Data were from the Prehospital Trauma Registry, which existed from January 2013 through September 2014, and comprises data from TCCC cards, Department of Defense 1380 forms, and after-action reports to provide real-time feedback to units on prehospital medical care. Results: Of 705 total patient encounters, there were 501 documented administrations of analgesic medications given to 397 patients. Of these events, 242 (34.3%) were within TCCC guidelines. Special Operations Command had the highest rate of overall adherence, but rates were still low (68.5%). Medical officers had the highest rates of overall administration. The low rates of administration and adherence persisted across all subgroups. Conclusion: Rates of analgesia administration remained low overall and in subgroup analyses. Medical officers appeared to have higher rates of compliance with TCCC guidelines for analgesia administration, but overall adherence to TCCC guidelines was low. Future research will be aimed at finding methods to improve administration and adherence rates.
Keywords: analgesia; combat; compliance; military; pain; prehospital; Tactical Combat Casualty Care
Schauer SG, Naylor JF, Chow AL, Maddry JK, Cunningham CW, Blackburn MB, Nawn CD, April MD. 19(2). 91 - 94. (Journal Article)
Abstract
Background: Airway compromise is the second leading cause of preventable death on the battlefield. Unlike a cricothyrotomy, supraglottic airway (SGA) placement does not require an incision and is less technically challenging. We compare the survival of causalities undergoing cricothyrotomy versus SGA placement. Methods: We used a series of emergency department (ED) procedure codes to search within the Department of Defense Trauma Registry (DODTR) from January 2007 to August 2016. This is a subanalysis of that data set. Results: During the study period, 194 casualties had a documented cricothyrotomy and 22 had a documented SGA as the sole airway intervention. The two groups had similar proportions of explosive injuries (57.7% versus 63.6%, p = .328), similar composite injury severity scores (25 versus 27.5, p = .168), and similar AIS for the head, face, extremities, and external body regions. The cricothyrotomy group had lower AIS for the thorax (0 versus 3, p = .019), a trend toward lower AIS for the abdomen (0 versus 0, p = .077), more serious injuries to the head (67.5% versus 45.5%, p = .039), and similar rates of serious injuries to the face (4.6% versus 4.6%, p = .984). Glasgow Coma Scale (GCS) scores were similar on arrival to the ED (3 versus 3, p = .467) as were the proportion of patients surviving to discharge (45.4% versus 40.9%, p = .691). On repeated multivariable analyses, the odds ratios for survival were not significantly different between the two groups. Conclusions: We found no difference in short-term outcomes between combat casualties who received an SGA vs those who received a cricothyrotomy. Military prehospital personnel rarely used either advanced airway intervention during the recent conflicts in Afghanistan and Iraq.
Keywords: airway; supraglottic; extraglottic; prehospital; cricothyroidotomy
Schauer SG, April MD, Aden JK, Rowan M, Chung KK. 19(2). 77 - 80. (Journal Article)
Abstract
Background: The military is rapidly moving into a battlespace in which prolonged holding times in the field are probable. Ketamine provides hemodynamic support and has analgesic properties, but the safety of prolonged infusions is unclear. We compare in-hospital mortality between intubated burn intensive care unit (ICU) patients receiving prolonged ketamine infusion lasting =7 days or until death versus controls. Methods: We conducted a before/after cohort study of patients undergoing admission to a burn ICU with intubation within the first 24 hours as part of treatment for thermal burns. In January 2012, this ICU implemented a novel continuous ketamine infusions protocol. We performed a preintervention and postintervention cohort analysis. Results: We identified 2394 patients meeting our inclusion criteria-475 in the ketamine group and 1919 in the control group. Regarding burn total body surface area (TBSA) involvement, there were 1533 in the <10% group, 586 in the 11-30% group, and 281 in the >31% group. The median number of ventilator-free days within the first 30 days did not vary significantly between the ketamine group and the control group: 8.5 days (interquartile range [IQR] 1-16 days) versus 8 days (IQR 3-13 days, p = .442). Subjects receiving ketamine had higher mortality rates: 59.4% (n = 117) versus 40.6% (n = 80, p < .001), with an odds ratio for in-hospital mortality of 7.51 (95% CI 5.53-10.20, p < .001). When controlling for TBSA category, ventilator days and vasopressor administration, there was no association between ketamine and in-hospital mortality (0.66, 0.41-1.05, p = .08). Conclusions: When controlling for confounders, we found no difference in in-hospital mortality between the prolonged ketamine infusion recipients versus non-recipients.
Keywords: ketamine; prolonged; military; trauma; analgesia
Schauer SG, April MD, Tannenbaum LI, Maddry JK, Cunningham CW, Blackburn MB, Arana AA, Shackelford S. 19(2). 87 - 90. (Journal Article)
Abstract
Background: Airway obstruction is the second most common cause of potentially preventable death on the battlefield. We compared survival in the combat setting among patients undergoing prehospital versus emergency department (ED) intubation. Methods: Patients were identified from the Department of Defense Trauma Registry (DODTR) from January 2007 to August 2016. We defined the prehospital cohort as subjects undergoing intubation prior to arrival to a forward surgical team (FST) or combat support hospital (CSH), and the ED cohort as subjects undergoing intubation at an FST or CSH. We compared study variables between these cohorts; survival was our primary outcome. Results: There were 4341 intubations documented in the DODTR during the study period: 1117 (25.7%) patients were intubated prehospital and 3224 (74.3%) were intubated in the ED. Patients intubated prehospital had a lower median age (24 versus 25 years, p < .001), composed a higher proportion of host nation forces (36.1% versus 29.1%, p < .001), had a lower proportion of injuries from explosives (57.6% versus 61.0%, p = .030), and had higher median injury severity scores (20 versus 18, p = .045). A lower proportion of the prehospital cohort survived to hospital discharge (76.4% versus 84.3%, p < .001). The prehospital cohort had lower odds of survival to hospital discharge in both univariable (odds ratio [OR] 0.60, 95% confidence interval [CI] 0.51-0.71) and multivariable analyses controlling for confounders (OR 0.70, 95% CI 0.58-0.85). In a subgroup analysis of patients with a head injury, the lower odds of survival persisted in the multivariable analysis (OR 0.49, 95% CI 0.49-0.82). Conclusions: Patients intubated in the prehospital setting had a lower survival than those intubated in the ED. This finding persisted after controlling for measurable confounders.
Schauer SG, Naylor JF, Chow AL, Maddry JK, Cunningham CW, Blackburn MB, Nawn CD, April MD. 19(3). 86 - 89. (Journal Article)
Abstract
Background: Airway compromise is the second leading cause of preventable death on the battlefield. Unlike a cricothyrotomy, supraglottic airway (SGA) placement does not require an incision and is less technically challenging. We compare survival of causalities undergoing cricothyrotomy versus SGA placement. Methods: We used a series of emergency department (ED) procedure codes to search within the Department of Defense Trauma Registry (DoDTR) from January 2007 to August 2016. This is a subanalysis of that dataset. Results: During the study period, 194 casualties had a documented cricothyrotomy and 22 had a documented SGA as the sole airway intervention. The two groups had similar proportions of explosive injuries (57.7% versus 63.6%, p = .328), similar composite injury severity scores (25 versus 27.5, p = .168), and similar AIS for the head, face, extremities, and external body regions. The cricothyrotomy group had lower AIS for the thorax (0 versus 3, p = .019) a trend toward lower AIS for the abdomen (0 versus 0, p = .077), more serious injuries to the head (67.5% versus 45.5%, p = .039), and similar rates of serious injuries to the face (4.6% versus 4.6%, p = .984). Glasgow Coma Scale (GCS) scores were similar upon arrival to the ED (3 versus 3, p = .467) as were the proportion of patients surviving to discharge (45.4% versus 40.9%, p = .691). On repeated multivariable analyses, the odds ratios (ORs) for survival were not significantly different between the two groups. Conclusion: We found no difference in short-term outcomes between combat casualties who received an SGA vs cricothyrotomy. Military prehospital personnel rarely used either advanced airway intervention during the recent conflicts in Afghanistan and Iraq.
Keywords: airway; supraglottic; extraglottic; prehospital; cricothyroidotomy; injury; explosive
Schauer SG, Naylor JF, Uhaa N, April MD, De Lorenzo RA. 20(1). 61 - 64. (Journal Article)
Abstract
Introduction: Tactical Combat Casualty Care (TCCC) recommends life-saving interventions; however, these interventions can only be implemented if military prehospital providers carry the necessary equipment to the injured casualty. Combat medics primarily use aid bags to transport medical materiels forward on the battlefield. We seek to assess combat medic materiel preparedness to employ TCCC-recommended interventions by inventorying active duty, combat medic aid bags. Methods: We sought combat medics organic to combat arms units stationed at Joint Base Lewis McChord. Medics volunteered to complete a demographic worksheet and have the contents of their aid bag photographed and inventoried. We spoke with medic unit leadership prior to their participation and asked that the medics bring their aid bags in the way they would pack for a combat mission. We categorized medic aid bag contents in the following manner: (1) hemorrhage control; (2) airway management; (3) pneumothorax treatment, or (4) volume resuscitation. We compared the items found in the aid bags against the contemporary TCCC guidelines. Results: In January 2019, we prospectively inventoried 44 combat medic aid bags. Most of the medics were male (86%), in the grade of E4 (64%), and had no deployment experience (64%). More medics carried a commercial aid bag (55%) than used the standard issue M9 medical bag (45%). Overall, the most frequently carried medical device was an NPA (93%). Overall, 91% of medics carried at least one limb tourniquet, 2% carried a junctional tourniquet, 31% carried a supraglottic airway (SGA), 64% carried a cricothyrotomy setup/kit, 75% carried a chest seal, and 75% carried intravenous (IV) fluid. The most commonly stocked limb tourniquet was the C-A-T (88%), the airway kit was the H&H cricothyrotomy kit (38%), the chest injury set were prepackaged needle decompression kits (81%), and normal saline was the most frequently carried fluid (47%). Most medics carried a heating blanket (54%). Conclusions: Most medics carried materiels that address the common causes of preventable death on the battlefield. However, most materiels stowed in aid bags were not TCCC-preferred items. Moreover, there was a small subset of medics who were not prepared to handle the major causes of death on the battlefield based on the current state of their aid bag.
Keywords: combat; medic; aid bag; military
Schauer SG, Naylor JF, Beaumont DM, April MD, Tanaka K, Baldwin D, Maddry JK, Becker TE, De Lorenzo RA. 20(3). 62 - 66. (Journal Article)
Abstract
Introduction: Airway compromise is the second leading cause of potentially survivable death on the battlefield. Studies show that airway management is a challenge in prehospital combat care with high error and missed opportunity rates. Lacking is user information on the perceived reasons for the challenges. The US military uses several performance improvement and field feedback systems to solicit feedback regarding deployed experiences. We seek to review feedback and after-action reviews (AARs) from end-users with specific regard to airway challenges noted. Methods: We queried the Center for Army Lessons Learned (CALL), the Army Medical Department Lessons Learned (AMEDDLL), and the Joint Lessons Learned Information System (JLLIS).Our queries comprised a series of search terms with a focus on airway management. Three military emergency medicine expert reviewers performed the primary analysis for lessons learned specific to deployment and predeployment training lessons learned. Upon narrowing the scope of entries to those relevant to deployment and predeployment training, a panel of eight experts performed reviews. The varied nature of the sources lent itself to an unstructured qualitative approach with results tabulated into thematic categories. Results: Our initial search yielded 611 nonduplicate entries. The primary reviewers then analyzed these entries to determine relevance to the project-this resulted in 70 deployment- based lessons learned and four training-based lessons learned. The panel of eight experts then reviewed the 74 lessons learned. We categorized 37 AARs as equipment challenges/malfunctions, 28 as training/education challenges, and 9 as other. Several lessons learned specifically stated that units failed to prioritize medic training; multiple comments suggested that units should consider sending their medics to civilian training centers. Other comments highlighted equipment shortages and equipment malfunctions specific to certain mission types (e.g., pediatric casualties, extreme weather). Conclusions: In this review of military lessons learned systems, most of the feedback referenced equipment malfunctions and gaps in initial and maintenance training.This review of AARs provides guidance for targeted research efforts based the needs of the end-users.
Keywords: prehospital; combat; airway; review; lessons
Schauer SG, Naylor JF, Ahmed YM, Maddry JK, April MD. 20(3). 76 - 80. (Journal Article)
Abstract
Background: The United States (US) military utilizes combat wound medication packs (CWMP) to provide analgesia and wound prophylaxis in casualties who are still able to fight. We compared characteristics of combat casualties receiving CWMP to those not receiving CWMP. We also describe the proportions of casualties with injury patterns consistent with Tactical Combat Casualty Care (TCCC) guideline indications for CWMP use who received this intervention. Methods: This is a secondary analysis of Department of a Defense Trauma Registry (DODTR) dataset of US military personnel from January 2007 to August 2016. We searched for all subjects with documented use of at least one medication from the CWMP (acetaminophen, meloxicam, moxifloxacin). Results: Within our dataset, 11,665 casualties were US military Servicemembers. Overall, <1% (84) of our study population received the CWMP. The median age and mechanism of injuries were similar between CWMP nonrecipients versus recipients. Median composite injury scores were higher for nonrecipients than recipients (6 versus 4, P < .001). Proportions of casualties with injury patterns meeting TCCC guideline CWMP indications who received this intervention were low: gunshot wound, <1% (14 of 1805), tourniquet applied, <1% (11 of 1912), major amputation, <1% (5 of 803), and open fracture, <1% (10 of 2425). Based on serious injuries by body region, we had similar findings for the thorax (<1%; 3 of 1122), abdomen (<1%; 1 of 736), and extremities (<1%; 11 of 2699). Conclusions: Subjects receiving the CWMP were less severely injured compared to those who did not receive this intervention. The CWMP had very infrequent use among those casualties with injury patterns meeting indications specified in the TCCC Guidelines for use of this intervention.
Keywords: combat; pill; pack; military; pain; antibiotics
Fisher AD, Naylor JF, April MD, Thompson D, Kotwal RS, Schauer SG. 20(4). 53 - 59. (Journal Article)
Abstract
Background: Role 1 care represents all aspects of prehospital care on the battlefield. Recent conflicts and military operations conducted on behalf of the Global War on Terrorism have resulted in medical officers (MOs) being used nondoctrinally on combat missions. We are seeking to describe Role 1 trauma care provided by MOs and compare this care to that provided by medics. Methods: This is a secondary analysis of previously described data from the Prehospital Trauma Registry and the Department of Defense Trauma Registry from April 2003 through May 2019. Encounters were categorized by type of care provider (MO or medic). If both were documented, they were categorized as MO; those without either were excluded. Descriptive statistics were used. Results: A total of 826 casualty encounters met inclusion criteria. There were 418 encounters categorized as MO (57 with MO, 361 with MO and medic), and 408 encounters categorized as medic only. The composite injury severity score (median, interquartile range) was higher for casualties treated by the medic cohort (9, 3.5-17) than for the MO cohort (5, 2-9.5; P = .006). There was no difference in survival to discharge between the MO and medic groups (98.6% vs. 95.6%; P = .226). More life-saving interventions were performed by MOs compared to medics. MOs demonstrated a higher rate of vital sign documentation than medics. Conclusion: More than half of casualty encounters in this study listed an MO in the chain of care. The difference in proportion of interventions highlights differences in provider skills, training and equipment, or that interventions were dictated by differences in mechanisms of injury.
Keywords: prehospital; medic; healthcare provider; military medicine; war-related injuries
Schauer SG, April MD, Fairley R, Uhaa N, Hudson IL, Johnson MD, Keen DE, De Lorenzo RA. 20(4). 68 - 72. (Journal Article)
Abstract
Background: Airway obstruction is the second leading cause of potentially preventable death on the battlefield. Prior to 2017, the Committee on Tactical Combat Casualty Care (CoTCCC) recommended the surgical cricothyrotomy as the definitive airway of choice. More recently, the CoTCCC has recommended the iGel™ as the supraglottic airway (SGA) of choice. Data comparing these methods in medics are limited. We compared first-pass placement success among combat medics using a synthetic cadaver model. Methods: We conducted a randomized cross-over study of United States Army combat medics using a synthetic cadaver model. Participants performed a surgical cricothyrotomy using a method of their choosing versus placement of the SGA iGel in random order. The primary outcome was first-pass success. Secondary outcomes included time-to-placement, complications, placement failures, and self-reported participant preferences. Results: Of the 68 medics recruited, 63 had sufficient data for inclusion. Most were noncommissioned officers in rank (54%, E6-E7), with 51% reporting previous deployment experience. There was no significant difference in first-pass success (P = .847) or successful cannulation with regard to the two devices. Time-to-placement was faster with the iGel (21.8 seconds vs. 63.8 seconds). Of the 59 medics who finished the survey, we found that 35 (59%) preferred the iGel and 24 (41%) preferred the cricothyrotomy. Conclusions: In our study of active duty Army combat medics, we found no significant difference with regard to first-pass success or overall successful placement between the iGel and cricothyrotomy. Time-to-placement was significantly lower with the iGel. Participants reported preferring the iGel versus the cricothyrotomy on survey. Further research is needed, as limitations in our study highlighted many shortcomings in airway research involving combat medics.
Keywords: combat, medic; airway; cricothyroidotomy; supraglottic; extraglottic
Fisher AD, DesRosiers TT, Papalski W, Remley MA, Schauer SG, April MD, Blackman V, Brown J, Butler FK, Cunningham CW, Gurney J, Holcomb JB, Montgomery HR, Morgan MM, Motov SM, Shackelford SA, Springer T, Drew B. 22(2). 154 - 165. (Classical Conference)
Abstract
Analgesia in the military prehospital setting is one of the most essential elements of caring for casualties wounded in combat. The goals of casualty care is to expedite the delivery of life-saving interventions, preserve tactical conditions, and prevent morbidity and mortality. The Tactical Combat Casualty Care (TCCC) Triple Option Analgesia guideline provided a simplified approach to analgesia in the prehospital combat setting using the options of combat medication pack, oral transmucosal fentanyl, or ketamine. This review will address the following issues related to analgesia on the battlefield: 1. The development of additional pain management strategies. 2. Recommended changes to dosing strategies of medications such as ketamine. 3. Recognition of the tiers within TCCC and guidelines for higher-level providers to use a wider range of analgesia and sedation techniques. 4. An option for sedation in casualties that require procedures. This review also acknowledges the next step of care: Prolonged Casualty Care (PCC). Specific questions addressed in this update include: 1) What additional analgesic options are appropriate for combat casualties? 2) What is the optimal dose of ketamine? 3) What sedation regimen is appropriate for combat casualties?
Keywords: analgesia; prehospital; casualties; Tactical Combat Casualty Care (TCCC) Triple Option Analgesia guideline; fentanyl; ketamine
Schauer S, Naylor JF, Fisher AD, Becker TE, April MD. 22(4). 18 - 21. (Journal Article)
Abstract
Background: Airway obstruction is the second leading cause of preventable death on the battlefield. Most airway obstruction occurs secondary to traumatic disruptions of the airway anatomical structures. Facial trauma is frequently cited as rationale for maintaining cricothyrotomy in the medics' skill set over the supraglottic airways more commonly used in the civilian setting. Methods: We used a series of emergency department procedure codes to identify patients within the Department of Defense Trauma Registry (DoDTR) from January 2007 to August 2016. This is a sub-group analysis of casualties with documented serious facial trauma based on an abbreviated injury scale of 3 or greater for the facial body region. Results: Our predefined search codes captured 28,222 DoDTR casualties, of which we identified 136 (0.5%) casualties with serious facial trauma, of which 19 of the 136 had documentation of an airway intervention (13.9%). No casualties with serious facial trauma underwent nasopharyngeal airway (NPA) placement, 0.04% underwent cricothyrotomy (n = 10), 0.03% underwent intubation (n = 9), and a single subject underwent supraglottic airway (SGA) placement (<0.01%). We only identified four casualties (0.01% of total dataset) with an isolated injury to the face. Conclusions: Serious injury to the face rarely occurred among trauma casualties within the DoDTR. In this subgroup analysis of casualties with serious facial trauma, the incidence of airway interventions to include cricothyrotomy was exceedingly low. However, within this small subset the mortality rate is high and thus better methods for airway management need to be developed.
Keywords: prehospital; airway; facial; trauma; military
Schauer SG, Hudson IL, Fisher AD, Dion G, Long B, Blackburn MB, De Lorenzo RA, Shaw TA, April MD. 23(1). 23 - 29. (Journal Article)
Abstract
Background: Airway obstruction is the second leading cause of potentially survivable death on the battlefield. Assessing outcomes associated with airway interventions is important, and temporal trends can reflect the influence of training, technology, the system of care, and other factors. We assessed mortality among casualties undergoing prehospital airway intervention occurring over the course of combat operations during 2007-2019. Methods: This is a retrospective analysis of a previously described dataset from the Department of Defense Trauma Registry (DODTR). We included only casualties with documented placement of an endotracheal tube, cricothyrotomy, or supraglottic airway (SGA) in the prehospital setting. Results: Within the DODTR from January 2007 to December 2019, there were 25,849 adult encounters with documentation of any prehospital activity. Within that group, there were 251 documented cricothyrotomies, 1,147 documented intubations, and 35 documented supraglottic airways placed. Cricothyrotomy recipients had a median age of 25. Within this group, the largest proportion were non-North Atlantic Treaty Organization (NATO) military personnel (35%), were injured by explosives (54%), had a median injury severity score (ISS) of 24, and 60% survived to hospital discharge. Intubation recipients had a median age of 24. Within this group, the largest proportion were non-NATO military personnel (37%), were injured by explosives (57%), had a median ISS of 18, and 76% survived to hospital discharge. SGA recipients had a median age of 28. Within this group, the largest proportion were non-NATO military (37%), were injured by firearms (48%), had a median ISS of 25, and 54% survived to hospital discharge. A downward trend existed in the quantity of all procedures performed during the study period. In both unadjusted and adjusted regression models, we identified no year-to-year differences in survival after prehospital cricothyrotomy or SGA placement. In the unadjusted and adjusted models, we noted a decrease in mortality during the 2007-2008 (odds ratio [OR] for death 0.47, 95% CI 0.26-0.86) and an increase from 2012-2013 (OR 2.10, 95% CI 1.09-4.05) for prehospital intubation. Conclusion: Mortality among combat casualties undergoing prehospital or emergency department airway interventions showed no sustained change during the study period. These findings suggest that advances in airway resuscitation are necessary to achieve mortality improvements in potentially survivable airway injuries in the prehospital setting.
Keywords: prehospital; trend; airway; combat; outcome; survival; military
Bedolla C, Zilevicius D, Copeland G, Guerra M, Salazar S, April MD, Long B, Naylor JF, De Lorenzo RA, Schauer SG, Hood RL. 23(2). 19 - 32. (Journal Article)
Abstract
Introduction: Airway obstruction is the second leading cause of death on the battlefield. The harsh conditions of the military combat setting require that devices be able to withstand extreme circumstances. Military standards (MIL-STD) testing is necessary before devices are fielded. We sought to determine the ability of supraglottic airway (SGA) devices to withstand MIL-STD testing. Methods: We tested 10 SGA models according to nine MIL-STD-810H test methods. We selected these tests by polling five military and civilian emergency-medicine subject matter experts (SMEs), who weighed the relevance of each test. We performed tests on three devices for each model, with operational and visual examinations, to assign a score (1 to 10) for each device after each test. We calculated the final score of each SGA model by averaging the score of each device and multiplying that by the weight for each test, for a possible final score of 2.6 to 26.3. Results: The scores for the SGA models were LMA Classic Airway, 25.9; AuraGain Disposable Laryngeal Mask, 25.5; i-gel Supraglottic Airway, 25.2; Solus Laryngeal Mask Airway, 24.4; LMA Fastrach Airway, 24.4; AuraStraight Disposable Laryngeal Mask, 24.1; King LTS-D Disposable Laryngeal Tube, 22.1; LMA Supreme Airway, 21.0; air-Q Disposable Intubating Laryngeal Airway, 20.1; and Baska Mask Supraglottic Airway, 18.1. The limited (one to three) samples available for testing provide adequate preliminary information but restrict the range of failures that could be discovered. Conclusions: Lower scoring SGA models may not be optimal for military field use. Models scoring sufficiently close to the top performers (LMA Classic, AuraGain, i-gel, Solus, LMA Fastrach, AuraStraight) may be viable for use in the military setting. The findings of our testing should help guide device procurement appropriate for different battlefield conditions.
Keywords: supraglottic; extraglottic; military; standard; testing; combat; medic
Schauer SG, Damrow T, Martin SM, Hudson IL, De Lorenzo RA, Blackburn MB, Hofmann LJ, April MD. 23(2). 13 - 18. (Journal Article)
Abstract
Background: Airway obstruction is the second leading cause of potentially preventable death on the battlefield. The treatment for airway obstruction is intubation or advanced airway adjunct, which has a known risk of aspiration. We sought to describe the variables associated with aspiration pneumonia after prehospital airway intervention. Methods: This is a sub-analysis of previously described data from the Department of Defense Trauma Registry (DoDTR) from 2007 to 2020. We included casualties that had at least one prehospital airway intervention with documentation of subsequent aspiration pneumonia or pneumonia within three days of the intervention. We used a generalized linear model with Firth bias estimates to test for associations. Results: There were 1,509 casualties that underwent prehospital airway device placement. Of these, 41 (2.7%) met inclusion criteria into the aspiration pneumonia cohort. The demographics had no statistical difference between the groups. The non-aspiration cohort had fewer median ventilator days (2 versus 6, p < 0.001), intensive care unit days (2 versus 7, p < 0.001, and hospital days [3 versus 8, p < 0.001]). Survival was lower in the non-aspiration cohort (74.2% versus 90.2%, p = 0.017). The administration of succinylcholine was higher in the non-aspiration cohort (28.0% versus 12.2%, p = 0.031). In our multivariable model, only the administration of succinylcholine was significant and was associated with lower probability of aspiration pneumonia (odds ratio 0.56). Conclusion: Overall, the incidence of aspiration pneumonia was low in our cohort. The administration of succinylcholine was associated with a lower odds of developing aspiration pneumonia.
Keywords: airway; combat; aspiration; vomit; intubation; prehospital
Schauer S, Long B, Fisher AD, Stednick PJ, Bebarta VS, Ginde AA, April MD. 23(4). 110 - 111. (Editorial)
Abstract
Keywords: airway; military; video; laryngoscopy; trauma
Schauer S, Fisher AD, April MD. 24(1). 81 - 84. (Journal Article)
Abstract
Background: The U.S. Military needs fast-acting, non-opioid solutions for battlefield pain. The U.S. Military recently used morphine auto-injectors, which are now unavailable. Off-label ketamine and oral transmucosal fentanyl citrate use introduces challenges and is therefore uncommon among conventional forces. Sublingual suftentanil is the only recent pain medication acquired to fill this gap. Conversely, methoxyflurane delivered by a handheld inhaler is promising, fast-acting, and available to some partner forces. We describe methoxyflurane use reported in the Department of Defense Trauma Registry (DODTR). Methods: We requested all available DODTR encounters from 2007 to 2023 with a documented intervention or assessment within the first 72 hours of care. We analyzed casualties who received methoxyflurane in the prehospital setting using descriptive statistics. Results: There were 22 encounters with documented methoxyflurane administration. The median patient age was 23 (range 21-31) years. All were men. The largest proportion was partner force (50%), followed by U.S. Military (27%). Most (64%) sustained battle injuries. Explosives were the most common mechanism of injury (46%), followed by firearms (23%). The median injury severity score was 5 (range 1-17). The most frequent injuries were serious injuries to the extremities (27%), and 23% of patients (5) received a tourniquet. One-half of the casualties received concomitant pain medications. Only three casualties had multiple pain scores measured, with a median pain score change of -3 on a scale of 10. Conclusion: Methoxyflurane use in deployed combat shows both feasibility and usability for analgesia.
Keywords: military; combat; trauma; pain; analgesia; methoxy flurane; penthrox
Fisher AD, Jude JW, April MD, Lavender S, Augustson XS, Maitha J, Schauer S. 24(2). 17 - 21. (Journal Article)
Abstract
Background: Thoracic trauma occurs frequently in combat and is associated with high mortality. Tube thoracostomy (chest tube) is the treatment for pneumothorax resulting from thoracic trauma, but little data exist to characterize combat casualties undergoing this intervention. We sought to describe the incidence of these injuries and procedures to inform training and materiel development priorities. Methods: This is a secondary analysis of a Department of Defense Trauma Registry (DoDTR) data set from 2007 to 2020 describing prehospital care within all theaters in the registry. We described all casualties who received a tube thoracostomy within 24 hours of admission to a military treatment facility. Variables described included casualty demographics; abbreviated injury scale (AIS) score by body region, presented as binary serious (=3) or not serious (<3); and prehospital interventions. Results: The database identified 25,897 casualties, 2,178 (8.4%) of whom received a tube thoracostomy within 24 hours of admission. Of those casualties, the body regions with the highest proportions of common serious injury (AIS >3) were thorax 62% (1,351), extremities 29% (629), abdomen 22% (473), and head/neck 22% (473). Of those casualties, 13% (276) had prehospital needle thoracostomies performed, and 19% (416) had limb tourniquets placed. Most of the patients were male (97%), partner forces members or humanitarian casualties (70%), and survived to discharge (87%). Conclusions: Combat casualties with chest trauma often have multiple injuries complicating prehospital and hospital care. Explosions and gunshot wounds are common mechanisms of injury associated with the need for tube thoracostomy, and these interventions are often performed by enlisted medical personnel. Future efforts should be made to provide a correlation between chest interventions and pneumothorax management in prehospital thoracic trauma.
Keywords: prehospital care; combat; chest wound; tube thoracostomy; needle thoracostomy
Inman BL, Long BJ, April MD, Fisher AD, Rizzo JA, Schauer S. 24(2). 61 - 66. (Journal Article)
Abstract
Background: The development of acute traumatic coagulopathy is associated with increased mortality and morbidity in patients with battlefield traumatic injuries. Currently, the incidence of acute traumatic coagulopathy in the Role 1 setting is unclear. Methods: We queried the Prehospital Trauma Registry (PHTR) module of the Department of Defense Trauma Registry (DoDTR) for all encounters from inception through May 2019. The PHTR captures data on Role 1 prehospital care. Data from the PHTR was linked to the DoDTR to analyze laboratory data and patient outcomes using descriptive statistics. We defined coagulopathy as an international normalized ratio (INR) of ≥1.5 or platelet count ≤150×109/L. Results: A total of 595 patients met the inclusion criteria; 36% (212) met our definition for coagulopathy, with 31% (185) carrying low platelet numbers, 11% (68) showing an elevated INR, and 7% (41) with both. The baseline (no coagulopathy) cohort had a mean INR of 1.10 (95% CI 1.09-1.12) versus 1.38 (95% CI 1.33-1.43) in the coagulopathic cohort. The mean platelet count was 218 (95% CI 213-223) ×109/L in the baseline cohort versus 117 (95% CI 110-125) ×109/L in the coagulopathic cohort. Conclusions: Our findings indicate a high incidence of coagulopathy in trauma patients. Approximately one-third of wounded patients had laboratory evidence of coagulopathy upon presentation to a forward medical care facility. Advanced diagnostic facilities are therefore needed to facilitate early diagnosis of acute traumatic coagulopathy. Blood products with a long shelf life can aid in early correction.
Keywords: prehospital; trauma; coagulopathy; coagulation; military
Braden SF, Long BJ, Rizzo JA, April MD, Dengler BA, Schauer S. 24(2). 24 - 33. (Journal Article)
Abstract
Background: Traumatic brain injury (TBI) is often underreported or undetected in prehospital civilian and military settings. This study evaluated the incidence of TBI within the Prehospital Trauma Registry (PHTR) system. Methods: We reviewed PHTR and the linked Department of Defense Trauma Registry (DoDTR) records of casualties from January 2003 through May 2019 for diagnostic data and surgical reports. Results: A total of 709 casualties met inclusion criteria. The most common mechanism was blast, including 328 (51%) in the non-TBI and 45 (63%) in the TBI cohorts. The median injury severity scores in the non-TBI and TBI cohorts were 5 and 14, respectively. The survival scores in the non-TBI and TBI cohorts were 98% and 92%, respectively. Subdural hematomas, followed by subarachnoid hemorrhages were the most common classifiable brain injuries. Other nonspecific TBIs occurred in 85% of the TBI cohort casualties. Seventy-two cases (10%) were documented by the Role 1 clinician. Based on coding or operative data, 15 of the 72 (21%) were identified as TBIs. Of the 637 cases, which could not be decided based on coding or operative data, TBI was suspected in 42 (7%) cases based on Role 1 records. Conclusions: Over 1 in 10 casualties presenting to a Role 1 facility had a TBI requiring transfer to a higher level of care. Our findings suggest the need for improved diagnostic technologies and documentation systems at Role 1 facilities for accurate TBI diagnosis and reporting.
Keywords: prehospital; trauma; brain injury; concussion; head injury
Schauer SG, April MD, Tannenbaum LI, Maddry JK, Cunningham CW, Blackburn MB, Arana AA, Shackelford S. 19(2). 87 - 90. (Journal Article)
Abstract
Background: Airway obstruction is the second most common cause of potentially preventable death on the battlefield. We compared survival in the combat setting among patients undergoing prehospital versus emergency department (ED) intubation. Methods: Patients were identified from the Department of Defense Trauma Registry (DODTR) from January 2007 to August 2016. We defined the prehospital cohort as subjects undergoing intubation prior to arrival to a forward surgical team (FST) or combat support hospital (CSH), and the ED cohort as subjects undergoing intubation at an FST or CSH. We compared study variables between these cohorts; survival was our primary outcome. Results: There were 4341 intubations documented in the DODTR during the study period: 1117 (25.7%) patients were intubated prehospital and 3224 (74.3%) were intubated in the ED. Patients intubated prehospital had a lower median age (24 versus 25 years, p < .001), composed a higher proportion of host nation forces (36.1% versus 29.1%, p < .001), had a lower proportion of injuries from explosives (57.6% versus 61.0%, p = .030), and had higher median injury severity scores (20 versus 18, p = .045). A lower proportion of the prehospital cohort survived to hospital discharge (76.4% versus 84.3%, p < .001). The prehospital cohort had lower odds of survival to hospital discharge in both univariable (odds ratio [OR] 0.60, 95% confidence interval [CI] 0.51-0.71) and multivariable analyses controlling for confounders (OR 0.70, 95% CI 0.58-0.85). In a subgroup analysis of patients with a head injury, the lower odds of survival persisted in the multivariable analysis (OR 0.49, 95% CI 0.49-0.82). Conclusions: Patients intubated in the prehospital setting had a lower survival than those intubated in the ED. This finding persisted after controlling for measurable confounders.
Arcure J, Harrison EE. 09(3). 22 - 25. (Journal Article)
Abstract
Traumatic brain injury (TBI) is an assault to the brain that disrupts neurological activity. Known as the signature wound of combat during Operations Iraqi Freedom (OIF) and Enduing Freedom (OEF), it has become one of the most common injuries to American Soldiers. While affected Soldiers may remain stable after the primary injury, progressing secondary mechanisms can produce neurological degeneration. Hypothermic medicine is the treatment of injuries by cooling the core body temperature below normal physiological levels. Such treatment may be indicated to improve neurological outcomes after traumatic brain injuries by reducing the evolving secondary deterioration. To date, clinical trials have reached mixed conclusions. Trials have used unique temperature goals for treatment, different methods and times to reach such goals, and different durations at therapeutic temperature. Such variances in procedure and experimental populations have made it difficult to assess significance. In the article written by Markgraf et al. in 2001, research in animals showed the effect of hypothermic treatment within rats. Their results suggest that early initiation of hypothermic medicine after an induced traumatic brain injury (TBI) improved neurological outcomes when the body was cooled to 30°Celsius (C) within four hours. An ongoing study by Clifton et al., on adults diagnosed with TBI, is examining the neurological outcome of early hypothermic medicine by centrally cooling the body to 33°C and maintaining that temperature for 48 hours. While previous hypothermic devices were unable to cool rapidly, new technology allows achievement of the goal temperature within 20 minutes. Implementation of such new treatment may show an improvement in neurological outcomes for patients when treatment target temperature is reached within a four-hour window. We recommend that the use of hypothermic medicine should be re-evaluated for its indication in TBI due to the capabilities of a new extremely rapid cooling device.
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
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
Gray BO, St. George D, Cativo M, Tagore A, Ariyaprakai N, Palmer LE. 20(3). 103 - 108. (Journal Article)
Abstract
Severe acute respiratory syndrome coronavirus 2 (SARSCov- 2) is hypothesized to have originated from a spillover event from an animal reservoir. This has raised many questions, with an important one being whether the widely disseminated coronavirus disease 2019 (COVID-19) is transmissible to other animal species. SARS-CoV-2 is primarily transmitted person to person. K9-to-human transmission, although theoretically possible via fomites, is considered minimal, if at all, and there have been no reported cases of K9-to-human transmission. Human-to-K9 transmission, although rare, seems more likely; however, in only one case has a K9 been suspected to have displayed symptoms of COVID-19. Preparation, decontamination, hand hygiene, and distancing remain the key factors in reducing transmission of the virus. The information presented is applicable to personnel operating within the military conventional and Special Operation Forces as well as civilian Tactical Emergency Medical Services communities who may have the responsibility of supporting an operational K9.
Keywords: canine; transmission; disease; COVID-19; Coronavirus; pandemic; SARS-CoV-2
Jeschke EA, Armon J, Wyma-Bradley J, Baker JB, Dorsch J, Huffman SL. 24(3). 84 - 89. (Journal Article)
Abstract
Building on our strategic framework and operational model, we will discuss findings from our ethnographic study entitled, "The Impact of Catastrophic Injury Exposure on Resilience in Special Operations Surgical Teams (SOST)." Our goal is to establish that medical-martial creativity supports Special Operation Forces (SOF) medics' ability to fluidly modulate pressure amid real-time military medical decision-making in austere environments. We will use qualitative quotes to explore how SOST medics express medical-martial creativity in support of unconventional resilience. We continue to highlight tactical engagement by using bag sets as a metaphor for understanding the practical performance of this social determinant. To achieve our goals, we will: 1) define the social determinant of medical-martial creativity and provide a brief background on creativity; 2) thematize various ways in which medical-martial creativity is optimized or degraded; and 3) relate tactical engagement with medical-martial creativity to our metaphor of bag sets. We conclude by gesturing to how medical-martial creativity enables SOF medics' ingenuity, which allows them to freely maneuver complex real-time decision-making to support SOF mission success.
Keywords: unconventional resilience; social determinant; martial; creativity; practical performance; SOF medic
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
Armstrong EL, Bryan CJ, Stephenson JA, Bryan AO, Morrow CE. 14(2). 26 - 34. (Journal Article)
Abstract
Objectives: Combat exposure is associated with increased mental health symptom severity among military personnel, whereas unit support is associated with decreased severity. However, to date no studies have examined these relationships among U.S. Air Force pararescuemen (PJs), who have a unique and specialized career field that serves in both medical and combatant capacities. Design: Crosssectional self-report survey. Methods: Self-reported survey data regarding depression symptoms, posttraumatic stress disorder (PTSD) symptoms, perceived unit support, and exposure to traditional combat experiences (e.g., firefights) and medical consequences of combat (e.g., injuries and human remains) were collected from 194 PJs in seven rescue squadrons. Results: Levels of combat exposure were compared with previously published findings from combat units, and levels of medical exposure were compared with previously published findings among military medical professionals. Medical exposure intensity showed a stronger relationship with PTSD severity (ß = .365, p = .018) than with combat exposure intensity (ß = .136, ρ = .373), but neither combat nor medical exposure was associated with depression severity (ßs < .296, ρs > .164). Unit support was associated with less severe PTSD (ß = -.402, ρ < .001) and depression (ß = -.259, ρ = .062) symptoms and did not moderate the effects of combat or medical exposure. Conclusions: Medical stressors contribute more to PTSD among PJs than do traditional combat stressors. Unit support is associated with reduced PTSD and depression severity regardless of intensity of warzone exposure among PJs.
Keywords: unit support; military; trauma; combat exposure; pararescue; aftermath
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
Sepowitz JJ, Armstrong NJ, Pasiakos SM. 17(4). 109 - 113. (Journal Article)
Abstract
Methods: This study characterized the total daily energy expenditure (TDEE), energy intake (EI), body weight, and diet quality (using the Healthy Eating Index-2010 [HEI]) of 20 male US Marines participating in the 9-month US Marine Corps Forces Special Operations Command Individual Training Course (ITC). Results: TDEE was highest (ρ < .05) during Raider Spirit (RS; 6,376 ± 712kcal/d) compared with Survival, Evasion, Resistance, and Escape (SERE; 4,011 ± 475kcal/d) School, Close-Quarters Battle (CQB; 4,189 ± 476kcal/d), and Derna Bridge (DB; 3,754 ± 314kcal/d). Body mass was lost (ρ < .05) during SERE, RS, and DB because EI was less than TDEE (SERE, -3,665kcal/d ± 475kcal/d; RS, -3,966 ± 776kcal/d; and DB, -1,027 ± 740kcal/d; p < .05). However, body mass was restored before the start of each subsequent phase and was not different between the start (86.4 ± 9.8kg) and end of ITC (86.7 ± 9.0kg). HEI score declined during ITC (before, 65.6 ± 11.2 versus after, 60.9 ± 9.7; p < .05) because less greens or beans and more empty calories were consumed (ρ < .05). Dietary protein intake was lowest during RS (0.9 ± 0.4g/kg) compared with all other phases, and carbohydrate intake during RS (3.6 ± 1g/kg), CQB (3.6 ± 1.0g/kg), and DB (3.7 ± 1.0g/kg) was lower than during the academic phase of SERE (5.1 ± 1.0g/kg; p < .05). Conclusion: These data suggest that ITC students, on average, adequately restore body mass between intermittent periods of negative energy balance. Education regarding the importance of maintaining healthy eating patterns while in garrison, consuming more carbohydrate and protein, and better matching EI with TDEE during strenuous training exercises may be warranted.
Keywords: Special Operations Forces; protein; carbohydrate; fatigue, volitional; military dietary reference intakes; weight loss
Arne BC. 10(3). 123 - 125. (Journal Article)
Abstract
Arne BC. 10(3). 120 - 122. (Journal Article)
Abstract
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
Dye C, Keenan S, Carius BM, Loos PE, Remley MA, Mendes B, Arnold JL, May I, Powell D, Tobin JM, Riesberg JC, Shackelford SA. 20(3). 141 - 156. (Journal Article)
Abstract
This Role 1, prolonged field care (PFC) clinical practice guideline (CPG) is intended to be used after Tactical Combat Casualty Care (TCCC) Guidelines, when evacuation to higher level of care is not immediately possible. A provider must first and foremost be an expert in TCCC, the Department of Defense standard of care for first responders. The intent of this PFC CPG is to provide evidence and experience-based solutions to those who manage airways in an austere environment. An emphasis is placed on utilizing the tools and adjuncts most familiar to a Role 1 provider. The PFC capability of airway is addressed to reflect the reality of managing an airway in a Role 1 resource-constrained environment. A separate Joint Trauma System CPG will address mechanical ventilation. This PFC CPG also introduces an acronym to assist providers and their teams in preparing for advanced procedures, to include airway management.
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
Patterson J, Bryan RT, Turconi M, Leiner A, Plackett TP, Rhodes LL, Sciulli L, Donnelly S, Reynolds CW, Leanza J, Fisher AD, Kushnir T, Artemenko V, Ward KR, Holcomb JB, Schmitzberger FF. 24(1). 18 - 25. (Journal Article)
Abstract
The use of tourniquets for life-threatening limb hemorrhage is standard of care in military and civilian medicine. The United States (U.S.) Department of Defense (DoD) Committee on Tactical Combat Casualty Care (CoTCCC) guidelines, as part of the Joint Trauma System, support the application of tourniquets within a structured system reliant on highly trained medics and expeditious evacuation. Current practices by entities such as the DoD and North Atlantic Treaty Organization (NATO) are supported by evidence collected in counter-insurgency operations and other conflicts in which transport times to care rarely went beyond one hour, and casualty rates and tactical situations rarely exceeded capabilities. Tourniquets cause complications when misused or utilized for prolonged durations, and in near-peer or peer-peer conflicts, contested airspace and the impact of high-attrition warfare may increase time to definitive care and limit training resources. We present a series of cases from the war in Ukraine that suggest tourniquet practices are contributing to complications such as limb amputation, overall morbidity and mortality, and increased burden on the medical system. We discuss factors that contribute to this phenomenon and propose interventions for use in current and future similar contexts, with the ultimate goal of reducing morbidity and mortality.
Keywords: tourniquets; amputation; traumatic injury; war-related injuries
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.
White N, Asato C, Wenthe A, Wang X, Ringgold K, St. John A, Han CY, Bennett JC, Stern SA. 23(3). 50 - 57. (Journal Article)
Abstract
Background: Our objective was to optimize a novel damage control resuscitation (DCR) cocktail composed of hydroxyethyl starch, vasopressin, and fibrinogen concentrate for the polytraumatized casualty. We hypothesized that slow intravenous infusion of the DCR cocktail in a pig polytrauma model would decrease internal hemorrhage and improve survival compared with bolus administration. Methods: We induced polytrauma, including traumatic brain injury (TBI), femoral fracture, hemorrhagic shock, and free bleeding from aortic tear injury, in 18 farm pigs. The DCR cocktail consisted of 6% hydroxyethyl starch in Ringer's lactate solution (14mL/kg), vasopressin (0.8U/kg), and fibrinogen concentrate (100mg/kg) in a total fluid volume of 20mL/kg that was either divided in half and given as two boluses separated by 30 minutes as control or given as a continuous slow infusion over 60 minutes. Nine animals were studied per group and monitored for up to 3 hours. Outcomes included internal blood loss, survival, hemodynamics, lactate concentration, and organ blood flow obtained by colored microsphere injection. Results: Mean internal blood loss was significantly decreased by 11.1mL/kg with infusion compared with the bolus group (p = .038). Survival to 3 hours was 80% with infusion and 40% with bolus, which was not statistically different (Kaplan Meier log-rank test, p = .17). Overall blood pressure was increased (p < .001), and blood lactate concentration was decreased (p < .001) with infusion compared with bolus. There were no differences in organ blood flow (p > .09). Conclusion: Controlled infusion of a novel DCR cocktail decreased hemorrhage and improved resuscitation in this polytrauma model compared with bolus. The rate of infusion of intravenous fluids should be considered as an important aspect of DCR.
Keywords: hemorrhage; resuscitation; hemorrhagic shock, traumatic brain injury; Fibrinogen; vasopressin; combat casualty care
Thompson P, Hudson AJ, Convertino VA, Bjerkvig C, Eliassen HS, Eastridge BJ, Irvine-Smith T, Braverman MA, Hellander S, Jenkins DH, Rappold JF, Gurney JM, Glassberg E, Cap AP, Aussett S, Apelseth TO, Williams S, Ward KR, Shackelford SA, Stroberg P, Vikeness BH, Pepe PE, Winckler CJ, Woolley T, Enbuske S, De Pasquale M, Boffard KD, Austlid I, Fosse TK, Asbjornsen H, Spinella PC, Strandenes G. 20(3). 97 - 102. (Editorial)
Abstract
Based on limited published evidence, physiological principles, clinical experience, and expertise, the author group has developed a consensus statement on the potential for iatrogenic harm with rapid sequence induction (RSI) intubation and positive-pressure ventilation (PPV) on patients in hemorrhagic shock. "In hemorrhagic shock, or any low flow (central hypovolemic) state, it should be noted that RSI and PPV are likely to cause iatrogenic harm by decreasing cardiac output." The use of RSI and PPV leads to an increased burden of shock due to a decreased cardiac output (CO)2 which is one of the primary determinants of oxygen delivery (DO2). The diminishing DO2 creates a state of systemic hypoxia, the severity of which will determine the magnitude of the shock (shock dose) and a growing deficit of oxygen, referred to as oxygen debt. Rapid accumulation of critical levels of oxygen debt results in coagulopathy and organ dysfunction and failure. Spontaneous respiration induced negative intrathoracic pressure (ITP) provides the pressure differential driving venous return. PPV subsequently increases ITP and thus right atrial pressure. The loss in pressure differential directly decreases CO and DO2 with a resultant increase in systemic hypoxia. If RSI and PPV are deemed necessary, prior or parallel resuscitation with blood products is required to mitigate post intervention reduction of DO2 and the potential for inducing cardiac arrest in the critically shocked patient.
Bowman M, Ashbaucher J, Cohee B, Fisher MS, Jennette JB, Huse JD, Copeland C, Muir KB. 19(4). 85 - 87. (Journal Article)
Abstract
US Special Operations Forces work by, with, and through partner forces (PFs) to accomplish mutual objectives. Surgical teams support these forces directly and may assist in treating injuries sustained by PF, based on established medical rules of engagement. These surgical operations are often conducted in austere conditions, with limited access to blood products. Limited blood product availability decreases US medical capacity to resuscitate injured PFs and augment the local trauma system. We present an innovative solution used by an expeditionary resuscitative surgical team (ERST) and Special Operations civil affairs team to partner with host nation (HN) medical personnel to improve PF access to damage control resuscitation and surgery. Whole blood obtained through a local HN hospital was provided to the ERST to allow for increased capacity to resuscitate PF casualties and augment the local trauma system. The ERST subsequently used this blood to resuscitate two PF surgical casualties.
Keywords: walking blood bank; stored whole blood; austere surgical team; US military
Benjamin JM, Chippaux J, Jackson K, Ashe S, Tamou-Sambo B, Massougbodji A, Akpakpa OC, Abo BN. 19(2). 18 - 22. (Case Reports)
Abstract
A 20-year-old man presented to a rural hospital in Bembéréké, northern Benin, after a witnessed bite from a small, dark snake to his left foot that occurred 3 hours earlier. The description of the snake was consistent with several neurotoxic elapids known to inhabit the area in addition to various species from at least 10 different genera of non-front-fanged colubroid (NFFC) venomous snakes. The presentation was consistent with the early signs of a neurotoxic snakebite as well as a sympathetic nervous system stress response. Diagnosis was further complicated by the presence of a makeshift tourniquet, which either could have been the cause of local signs and symptoms or a mechanical barrier delaying venom distribution and systemic effects until removal. Systemic envenomation did not develop after the removal of the constricting band, but significant local paresthesias persisted for longer than 24 hours and resolved after the administration of a placebo injection of normal saline in place of antivenom therapy. This was an unusual case of snakebite with persistent neuropathy despite an apparent lack of envenomation and a number of snakebite- specific variables that complicated the initial assessment, diagnosis, and treatment of the patient. This case presentation provides clinicians with an opportunity to familiarize themselves with the differential diagnosis and approach to a patient bitten by an unidentified snake, and it illustrates the importance of symptom progression as a pathognomonic sign during the early stages of a truly serious snake envenomation. Treatment should be based on clinical presentation and evolution of symptoms rather than on snake identification alone.
Keywords: snakebite; envenomation; clinical diagnosis; non-front-fanged colubroid; antivenom; dry bite
Tong RL, Bohlke CW, Clemente Fuentes RW, Moncada M, Schloe AD, Ashley RL. 21(2). 29 - 33. (Journal Article)
Abstract
Background: Administration of fresh whole blood (FWB) is a life-saving treatment that prolongs life until definitive surgical intervention can be performed; however, collecting FWB is a time-consuming and resource-intensive process. Furthermore, it may be difficult to collect sufficient FWB to treat critically wounded patients or multiple-hemorrhaging casualties. This study describes the effect of airdrop on FWB and explores the possibility of using airdrop to deliver FWB to combat medics treating casualties in the prehospital setting when FDA-approved, cold-stored blood products are not readily available and timely casualty evacuation (CASEVAC) is not feasible. Methods: Four units of FWB were collected from volunteer donors and loaded into a blood cooler that was dropped from a fixed-wing aircraft under a standard airdrop training bundle (SATB) parachute. A control group of 4 units of FWB was stored in a blood cooler that was not dropped. Baseline and postintervention laboratory samples were measured in both airdropped and control units, including full blood counts, prothrombin time/partial thromboplastin time/international normalized ratio (PT/PTT/INR), pH, lactate, potassium, indirect bilirubin, glucose, fibrinogen, lactate dehydrogenase, and peripheral blood smears. Results: The blood cooler, cooling bags, and all 4 FWB units did not sustain any damage from the airdrop. There was no evidence of hemolysis. All airdropped blood met parameters for transfusion per the Whole Blood Transfusion Clinical Practice Guideline of the Joint Trauma System (JTS). Conclusions: Airdrop of FWB in a blood cooler with a SATB parachute may be a viable way of delivering blood products to combat medics treating hemorrhaging patients in the prehospital setting, although further research is needed to fully validate the safety of this method of FWB delivery.
Keywords: fresh whole blood transfusion; airdrop; airdrop blood; aerial resupply; Tactical Combat Casualty Care
Friedman J, Assar SM. 22(2). 97 - 102. (Journal Article)
Abstract
Mechanical ventilation is machine-delivered flow of gases to both oxygenate and ventilate a patient who is unable to maintain physiological gas exchange, and positive-pressure ventilation (PPV) is the primary means of delivering invasive mechanical ventilation. The authors review invasive mechanical ventilation to give the Special Operations Force (SOF) medic a comprehensive conceptual understanding of a core application of critical care medicine.
Keywords: Mechanical Ventilation; invasive ventilation; ventilator; portable ventilator
Lampman P, Kennington K, Assar SM. 22(2). 63 - 68. (Journal Article)
Abstract
Shock is a life-threatening condition carrying a high mortality rate when untreated. The consequences of shock are cellular and metabolic derangements, which are initially reversible. The authors present the case of a Servicemember who sustained mortar shrapnel wounds that resulted in shock.
Keywords: shock; homeostasis; critical care
Asuku ME, Milner SM, Gerold KB. 11(1). 28 - 30. (Journal Article)
Abstract
Rush S, Lauria MJ, DeSoucy ES, Koch EJ, Kamler JJ, Remley MA, Alway N, Brodie F, Foudrait A, Barendregt P, Atkins M, Miller K, Hines R, Champagne M, Paladino L, Shackelford SA, Miles EA, Obiajulu J, Dorlac WC, Gurney J, Robb D, Kue RC. 24(3). 62 - 66. (Case Reports)
Abstract
Introduction: Mass casualty events (MASCALs) in the combat environment, which involve large numbers of casualties that overwhelm immediately available resources, are fundamentally chaotic and dynamic and inherently dangerous. Formal triage systems use diagnostic algorithms, colored markers, and four or more named categories. We hypothesized that formal triage systems are inadequately trained and practiced and too complex to successfully implement in true MASCAL events. This retrospective analysis evaluates the real-world application of triage systems in prehospital military MASCALs and other aspects of MASCAL management. Methods: We surveyed Special Operations Forces (SOF) medics known to us who have participated in military prehospital MASCALs and analyzed them. Aggregated data describing the scope of the incidents, the use of formal triage algorithms and colored markers, the number of categories, and the interventions on scene were analyzed using descriptive statistics, and lessons learned were consolidated. Results: From 1996 to 2022 we identified 29 MASCALs that were managed by military medics in the prehospital setting. There was a median of three providers (range 1-85) and 15 casualties (range 6-519) per event. Four or more formal triage categories were used in only one event. Colored markers and formal algorithms were not used. Life-saving interventions were performed in 27 of 29 (93%) missions and blood transfusions were performed in four (17%) MASCALs. The top lessons learned were: 1) security and accountability are cornerstones of MASCAL management; 2) casualty movement is a priority; 3) intuitive triage categories are the default; 4) life-saving interventions are performed as time and tactics permit. Conclusion: Formal triage systems requiring the use ofdiagnostic algorithms, colored tags, and four or five categories are seldom implemented in real-world military prehospital MASCAL management. The training of field triage should be simplified and pragmatic, as exemplified by these instances.
Keywords: mass casualty management; triage; MASCAL; survey; SOF medics
Schermerhorn SM, Auchincloss PJ, Kraft K, Nelson KJ, Pamplin JC. 18(1). 142 - 144. (Journal Article)
Abstract
Objective: Review the management of a patient with acute patella fracture supported by telemedical consultation. Clinical Context: Regionally Aligned Forces (RAF) supporting US Army Africa/Southern European Task Force (USARAF/ SETAF) in Africa Command area of responsibility. Care was provided by a Role I facility on the compound. Organic Expertise: Three 68W combat medics; one Special Operations Combat Medic (SOCM). Closest Medical Support: Organic battalion physician assistant (PA) located in the United States; USARAF PA located in a European country; French Role II located in nearby West African country; telemedical consults via e-mail, phone, or videoteleconsultation. Earliest Evacuation: Estimated at 12 to 24 hours with appropriate clearances.
Keywords: critical care; telemedicine; military personnel; emergency treatment; patient transfer; prolonged field care
Auchincloss PJ, Nam JJ, Blyth D, Childs G, Kraft K, Robben PM, Pamplin JC. 19(2). 123 - 126. (Journal Article)
Abstract
Objective: Review the application of telemedicine support for managing a patient with possible sepsis, suspected malaria, and unusual musculoskeletal symptoms. Clinical Context: Regionally Aligned Forces (RAF) supporting US Army Africa/Southern European Task Force (USARAF/ SETAF) in the Africa Command area of responsibility. Care provided by a small Role I facility on the compound. Organic Medical Expertise: Five 68W combat medics (one is the patient); one SOCM trained 68W combat medic. No US provider present in country. Closest Medical Support: Organic battalion physician assistant (PA) located in the USA; USARAF PA located in Italy; French Role II located in bordering West African country; medical consultation sought via telephone, WhatsApp® (communication with French physician) or over unclassified, encrypted e-mail. Earliest Evacuation: Estimated at 12 to 24 hours with appropriate country clearances and approval to fly from three countries including French forces support approval.
Keywords: critical care; telemedicine; military medicine; emergency treatment; prolonged field care; combat casualty care; patient transfer
Menon AS, Norris RL, Racciopi J, Tilson H, Gardner J, Mcadoo G, Brown IP, Auerbach PS. 12(1). 31 - 36. (Journal Article)
Abstract
A team of emergency physicians and nurses from Stanford University responded to the devastating January 2010 earthquake in Haiti. Because of the extreme nature of the situation, combined with limited resources, the team provided not only acute medical and surgical care to critically injured and ill victims, but was required to uniquely expand its scope of practice. Using a narrative format and discussion, it is the purpose of this paper to highlight our experience in Haiti and use these to estimate some of the skills and capabilities that will be useful for physicians who respond to similar future disasters.
Parsons DL, Convertino VA, Idris A, Smith S, Lindstrom D, Parquette B, Aufderheide T. 09(2). 49 - 53. (Journal Article)
Abstract
Inspiration through -7cm H2O resistance results in an increase in venous blood flow back to the heart and a subsequent increase in cardiac output and blood pressure in hypotensive animals and patients. Breathing through the impedance threshold device with 7cm H2O resistance (ITD-7) also reduces intracranial pressure with each inspiration, thereby providing greater blood flow to the brain. A new device called an ITD-7 was developed to exploit these physiological mechanisms to buy time in hypotensive War Fighters when other therapies are not readily available. Animal and clinical data with the ITD-7 demonstrate the potential value and limitations of this new non-invasive approach to enhancing circulation
Fisher AD, Jude JW, April MD, Lavender S, Augustson XS, Maitha J, Schauer S. 24(2). 17 - 21. (Journal Article)
Abstract
Background: Thoracic trauma occurs frequently in combat and is associated with high mortality. Tube thoracostomy (chest tube) is the treatment for pneumothorax resulting from thoracic trauma, but little data exist to characterize combat casualties undergoing this intervention. We sought to describe the incidence of these injuries and procedures to inform training and materiel development priorities. Methods: This is a secondary analysis of a Department of Defense Trauma Registry (DoDTR) data set from 2007 to 2020 describing prehospital care within all theaters in the registry. We described all casualties who received a tube thoracostomy within 24 hours of admission to a military treatment facility. Variables described included casualty demographics; abbreviated injury scale (AIS) score by body region, presented as binary serious (=3) or not serious (<3); and prehospital interventions. Results: The database identified 25,897 casualties, 2,178 (8.4%) of whom received a tube thoracostomy within 24 hours of admission. Of those casualties, the body regions with the highest proportions of common serious injury (AIS >3) were thorax 62% (1,351), extremities 29% (629), abdomen 22% (473), and head/neck 22% (473). Of those casualties, 13% (276) had prehospital needle thoracostomies performed, and 19% (416) had limb tourniquets placed. Most of the patients were male (97%), partner forces members or humanitarian casualties (70%), and survived to discharge (87%). Conclusions: Combat casualties with chest trauma often have multiple injuries complicating prehospital and hospital care. Explosions and gunshot wounds are common mechanisms of injury associated with the need for tube thoracostomy, and these interventions are often performed by enlisted medical personnel. Future efforts should be made to provide a correlation between chest interventions and pneumothorax management in prehospital thoracic trauma.
Keywords: prehospital care; combat; chest wound; tube thoracostomy; needle thoracostomy
Thompson P, Hudson AJ, Convertino VA, Bjerkvig C, Eliassen HS, Eastridge BJ, Irvine-Smith T, Braverman MA, Hellander S, Jenkins DH, Rappold JF, Gurney JM, Glassberg E, Cap AP, Aussett S, Apelseth TO, Williams S, Ward KR, Shackelford SA, Stroberg P, Vikeness BH, Pepe PE, Winckler CJ, Woolley T, Enbuske S, De Pasquale M, Boffard KD, Austlid I, Fosse TK, Asbjornsen H, Spinella PC, Strandenes G. 20(3). 97 - 102. (Editorial)
Abstract
Based on limited published evidence, physiological principles, clinical experience, and expertise, the author group has developed a consensus statement on the potential for iatrogenic harm with rapid sequence induction (RSI) intubation and positive-pressure ventilation (PPV) on patients in hemorrhagic shock. "In hemorrhagic shock, or any low flow (central hypovolemic) state, it should be noted that RSI and PPV are likely to cause iatrogenic harm by decreasing cardiac output." The use of RSI and PPV leads to an increased burden of shock due to a decreased cardiac output (CO)2 which is one of the primary determinants of oxygen delivery (DO2). The diminishing DO2 creates a state of systemic hypoxia, the severity of which will determine the magnitude of the shock (shock dose) and a growing deficit of oxygen, referred to as oxygen debt. Rapid accumulation of critical levels of oxygen debt results in coagulopathy and organ dysfunction and failure. Spontaneous respiration induced negative intrathoracic pressure (ITP) provides the pressure differential driving venous return. PPV subsequently increases ITP and thus right atrial pressure. The loss in pressure differential directly decreases CO and DO2 with a resultant increase in systemic hypoxia. If RSI and PPV are deemed necessary, prior or parallel resuscitation with blood products is required to mitigate post intervention reduction of DO2 and the potential for inducing cardiac arrest in the critically shocked patient.
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
Thompson P, Hudson AJ, Convertino VA, Bjerkvig C, Eliassen HS, Eastridge BJ, Irvine-Smith T, Braverman MA, Hellander S, Jenkins DH, Rappold JF, Gurney JM, Glassberg E, Cap AP, Aussett S, Apelseth TO, Williams S, Ward KR, Shackelford SA, Stroberg P, Vikeness BH, Pepe PE, Winckler CJ, Woolley T, Enbuske S, De Pasquale M, Boffard KD, Austlid I, Fosse TK, Asbjornsen H, Spinella PC, Strandenes G. 20(3). 97 - 102. (Editorial)
Abstract
Based on limited published evidence, physiological principles, clinical experience, and expertise, the author group has developed a consensus statement on the potential for iatrogenic harm with rapid sequence induction (RSI) intubation and positive-pressure ventilation (PPV) on patients in hemorrhagic shock. "In hemorrhagic shock, or any low flow (central hypovolemic) state, it should be noted that RSI and PPV are likely to cause iatrogenic harm by decreasing cardiac output." The use of RSI and PPV leads to an increased burden of shock due to a decreased cardiac output (CO)2 which is one of the primary determinants of oxygen delivery (DO2). The diminishing DO2 creates a state of systemic hypoxia, the severity of which will determine the magnitude of the shock (shock dose) and a growing deficit of oxygen, referred to as oxygen debt. Rapid accumulation of critical levels of oxygen debt results in coagulopathy and organ dysfunction and failure. Spontaneous respiration induced negative intrathoracic pressure (ITP) provides the pressure differential driving venous return. PPV subsequently increases ITP and thus right atrial pressure. The loss in pressure differential directly decreases CO and DO2 with a resultant increase in systemic hypoxia. If RSI and PPV are deemed necessary, prior or parallel resuscitation with blood products is required to mitigate post intervention reduction of DO2 and the potential for inducing cardiac arrest in the critically shocked patient.
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
Auten JD, Mclean JB, Kemp JD, Roszko PJ, Fortner GA, Krepela AL, Walchak AC, Walker CM, Deaton TG, Fishback JE. 18(3). 50 - 56. (Journal Article)
Abstract
Background: Intraosseous (IO) access is used by military first responders administering fluids, blood, and medications. Current IO transfusion strategies include gravity, pressure bags, rapid transfusion devices, and manual push-pull through a three-way stopcock. In a swine model of hemorrhagic shock, we compared flow rates among four different IO blood transfusion strategies. Methods: Nine Yorkshire swine were placed under general anesthesia. We removed 20 to 25mL/kg of each animal's estimated blood volume using flow of gravity. IO access was obtained in the proximal humerus. We then autologously infused 10 to 15mL/kg of the animal's estimated blood volume through one of four randomly assigned treatment arms. Results: The average weight of the swine was 77.3kg (interquartile range, 72.7kg-88.8kg). Infusion rates were as follows: gravity, 5mL/min; Belmont rapid infuser, 31mL/min; single-site pressure bag, 78mL/min; double-site pressure bag, 103mL/min; and push-pull technique, 109mL/min. No pulmonary arterial fat emboli were noted. Conclusion: The optimal IO transfusion strategy for injured Servicemembers appears to be single-site transfusion with a 10mL to 20mL flush of normal saline, followed immediately by transfusion under a pressure bag. Further study, powered to detect differences in flow rate and clinical complications. is required.
Keywords: blood transfusion; operational medicine; intraosseous infusion; intraosseous transfusion; hemorrhagic shock
Drew B, Auten JD, Cap AP, Deaton TG, Donham B, Dorlac WC, DuBose JJ, Fisher AD, Ginn AJ, Hancock J, Holcomb JB, Knight J, Koerner AK, Littlejohn LF, Martin MJ, Morey JK, Morrison J, Schreiber MA, Spinella PC, Walrath B, Butler FK. 20(3). 36 - 43. (Journal Article)
Abstract
The literature continues to provide strong support for the early use of tranexamic acid (TXA) in severely injured trauma patients. Questions persist, however, regarding the optimal medical and tactical/logistical use, timing, and dose of this medication, both from the published TXA literature and from the TCCC user community. The use of TXA has been explored outside of trauma, new dosing strategies have been pursued, and expansion of retrospective use data has grown as well. These questions emphasize the need for a reexamination of TXA by the CoTCCC. The most significant updates to the TCCC Guidelines are (i) including significant traumatic brain injury (TBI) as an indication for TXA, (ii) changing the dosing protocol to a single 2g IV/IO administration, and (iii) recommending TXA administration via slow IV/IO push.
Keywords: TXA; tranexamic acid; hemorrhage; hemostatics; antifibrinolytics; hemorrhagic shock; traumatic brain injury; traumatic injuries
Deaton TG, Auten JD, Betzold R, Butler FK, Byrne T, Cap AP, Donham B, DuBose JJ, Fisher AD, Hancock J, Jourdain V, Knight RM, Littlejohn LF, Martin MJ, Toland K, Drew B. 21(4). 126 - 137. (Classical Conference)
Abstract
Hemorrhagic shock in combat trauma remains the greatest life threat to casualties with potentially survivable injuries. Advances in external hemorrhage control and the increasing use of damage control resuscitation have demonstrated significant success in decreasing mortality in combat casualties. Presently, an expanding body of literature suggests that fluid resuscitation strategies for casualties in hemorrhagic shock that include the prehospital use of cold-stored or fresh whole blood when available, or blood components when whole blood is not available, are superior to crystalloid and colloid fluids. On the basis of this recent evidence, the Committee on Tactical Combat Casualty Care (TCCC) has conducted a review of fluid resuscitation for the combat casualty who is in hemorrhagic shock and made the following new recommendations: (1) cold stored low-titer group O whole blood (CS-LTOWB) has been designated as the preferred resuscitation fluid, with fresh LTOWB identified as the first alternate if CS-LTOWB is not available; (2) crystalloids and Hextend are no longer recommended as fluid resuscitation options in hemorrhagic shock; (3) target systolic blood pressure (SBP) resuscitation goals have been redefined for casualties with and without traumatic brain injury (TBI) coexisting with their hemorrhagic shock; and (4) empiric prehospital calcium administration is now recommended whenever blood product resuscitation is required.
Schwarzkoph BW, Emerling AD, Iteen A, Deaton TG, Auten JD, Bianchi WD. 22(1). 104 - 107. (Case Reports)
Abstract
Management of hemorrhagic shock and airway stabilization are two pillars of trauma resuscitation which have a dependent, yet incompletely understood relationship. Patients presenting with traumatic hemorrhage may manifest shock physiology prior to intubation, conferring a higher risk of postintubation hypotension, pulseless arrest, and mortality. This case series describes of a group of seven US military members with combat-related trauma who experienced pulseless arrest after rapid sequence intubation in a role 2 or role 3 setting. All except one of the patients had hemodynamics suggesting hemorrhagic shock prior to intubation. This case series highlights the need for further research to define which trauma patients are at risk of postintubation pulseless arrest. It also focuses on the knowledge gap related to the role that delayed airway management and judicious blood product resuscitation may play in preventable death after injury.
Keywords: pulseless arrest; traumatic arrest; rapid sequence intubation; transfusion; TCCC
Chang R, Boyle BP, Udoh MO, Maestas JM, Gehrz JA, Ruano E, Banker L, Cap AP, Bitterman JW, Deaton TG, Auten JD. 24(1). 60 - 66. (Journal Article)
Abstract
Background: Tactical Combat Casualty Care (TCCC) guidelines recognize low-titer group O whole blood (LTOWB) as the resuscitative fluid of choice for combat wounded. Utilization of prescreened LTOWB in a walking blood bank (WBB) format has been well described by the Ranger O low-titer blood (ROLO) and the United States Marine Corps Valkyrie programs, but it has not been applied to the maritime setting. Methods: We describe three WBB experiences of an expeditionary resuscitative surgical system (ERSS) team, attached to three nontraditional maritime medical receiving platforms, over 6 months. Results: Significant variations were identified in the number of screened eligible donors, the number of LTOWB donors, and the timely arrival at WBB activation sites between the platforms. Overall, 95% and 84% of the screened eligible group O blood donors on the Arleigh Burke Class Destroyer (DDG) and Nimitz Class Aircraft Carrier (CVN), respectively, were determined to be LTOWB. However, only 37% of the eligible screened group O blood donors aboard the Harper's Ferry Class Dock Landing Ship (LSD) were found to be LTOWB. Of the eligible donors, 66% did not complete screening, with 52% citing a correctable reason for nonparticipation. Conclusion: LTOWB attained through WBBs may be the only practical resuscitative fluid on maritime platforms without inherent blood product storage capabilities to perform remote damage control resuscitation. Future efforts should focus on optimizing WBBs through capability development, education, and training efforts.
Keywords: Low titer O; whole blood transfusion; damage control resuscitation; distributed maritime operations; walking blood bank
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)
de Lesquen H, Paris R, Fournier M, Cotte J, Vacher A, Schlienger D, Avaro JP, de La Villeon B. 23(2). 88 - 93. (Journal Article)
Abstract
Introduction: To prepare military doctors to face mass casualty incidents (MCIs), the French Army Health Service contributed to the development of TRAUMASIMS, a serious game (SG) for training medical responders to MCIs. Methods: French military doctors participated in a three-phase training study. The initial war trauma training was a combination of didactic lectures (Phase 1), laboratory exercises (Phase 2), and situational training exercises (STX) (Phase 3). Phase 1 lectures reviewed French Forward Combat Casualty Care (FFCCC) practices based on the acronym MARCHE (Massive bleeding, Airway, Respiration, Circulation, Head, hypothermia, Evacuation) for the detection of care priorities and implementation of life-saving interventions, triage, and medical evacuation (MEDEVAC) requests. Phase 2 was a case-control study that consisted of a traditional text-based simulation of MCIs (control group) or SG training (study group). Phase 3 was clinical: military students had to simultaneously manage five combat casualties in a prehospital setting. MCI management was evaluated using a standard 20-item scale of FFCCC benchmarks, 9-line MEDEVAC request, and time to evacuate the casualty collection point (CCP). Emotional responses of study participants were secondarily analyzed. Results: Among the 81 postgraduate military students included, 38 took SG training, and 35 trained with a text-based simulation in Phase 2. Regarding the error rates made during STX (Phase 3), SG improved FFCCC compliance (11.9% vs. 23.4%; p < .001). Additionally, triage was more accurate in the SG group (93.4% vs. 88.0%; p = .09). SG training mainly benefited priority and routine casualties, allowing faster clearance of the CCP (p = .001). Stress evaluations did not demonstrate any effect of immersive simulation. Conclusion: A brief SG-based curriculum (2 hours) improved FFCCC performance and categorization of casualties in MCI STX.
Keywords: traumatology; damage control; triage; mass casualty; simulation; medical education
Avila CO, Sayson SC, Bennett B. 22(3). 19 - 21. (Journal Article)
Abstract
Introduction: Military medical research has affirmed that early administration of blood products and timely treatment save lives. The US Navy's Expeditionary Resuscitative Surgical System (ERSS) is a Role 2 Light Maneuver team that functions close to the point of injury, administering blood products and providing damage-control resuscitation and surgery. However, information is lacking on the logistical constraints regarding provisions for and the stability of blood products in austere environments. Methods: ERSS conducted a study on the United States Central Command (USCENTCOM) area of responsibility. Expired but properly stored units of stored whole blood (SWB) were subjected to five different storage conditions, including combinations of passive and active refrigeration. The SWB was monitored continuously, including for external ambient temperatures. The time for the SWB to rise above the threshold temperature was recorded. Results: The main outcome of the study was the time for the SWB to rise above the recommended storage temperature. Average ambient temperature during the experiment involving conditions 1 through 4 was 25.6°C (78.08°F). Average ambient temperature during the experiment involving condition 5 was 34.8°C (94.64°F). Blood temperature reached the 6°C (42.8°F) threshold within 90 minutes in conditions 1 and 2, which included control and chemically activated ice packs in the thermal insulated chamber (TIC). Condition 2 included prechilling the TIC in a standard refrigerator to 4°C (39.2°F), which kept the units of SWB below the threshold temperature for 490 minutes (approximately 8 hours). Condition 4 entailed prechilling the TIC in a standard freezer to 0.4°C (32.72°F), thus keeping the units of SWB below threshold for 2,160 minutes (i.e., 36 hours). Condition 5 consisted of prechilling the TIC to 3.9°C (39.02°F) in the combat blood refrigerator, which kept the SWB units below the threshold for 780 minutes (i.e., 13 hours), despite a higher average ambient temperature of almost +10°C (50°F). Conclusion: Combining active and passive refrigeration methods will increase the time before SWB rises above the threshold temperature. We demonstrate an adaptable approach of preserving blood product temperature despite refrigeration power failure in austere settings, thereby maintaining mission readiness to increase the survival of potential casualties.
Keywords: stored whole blood; forward deployed surgical team; austere environments; walking blood bank; fresh whole blood; Role 2 care; blood transfusion; Golden Hour Offset Surgical Team
Avilla J, Rerucha C, Hu C. 23(2). 99 - 101. (Journal Article)
Abstract
The presentation of Type 3c diabetes is atypical, accounting for 0.5-1% of all types of diabetes. Combining this with the healthy Special Operations community is even more profound. A 38-year-old active-duty male in Special Operations developed acute abdominal pain and vomiting while deployed. He was diagnosed with severe acute necrotizing pancreatitis secondary to Type 3c diabetes, and the management of his condition became increasingly difficult. This case highlights Type 3c diabetes and the complexity of formulating a comprehensive treatment plan for a tactical athlete.
Keywords: tactical; type 3c diabetes; abdominal pain; pancreatitis; athlete; Special Operations
Reyes J, Kelly J, Badaki-Makun O, Anders J. 23(2). 40 - 43. (Journal Article)
Abstract
Introduction: Although the instances of Special Operations Forces (SOF) medical providers treating pediatric pelvic fractures are rare, such fractures are notable injuries in terror attacks and are at high risk for morbidity and mortality for the patient as well as stress for the provider. Presently, guidelines for pediatric-sized pelvic stabilization device application are limited to measured pelvic circumference. This study aims to inform more practical sizing guidelines. Methods: Subjects aged 1 year to 14 years were enrolled. Subject height, weight, pelvic circumference, and fit on the Broselow Pediatric Emergency Tape® (Armstrong Medical Industries), fit with the Pediatric PelvicBinder® (PelvicBinder), and fit with the small SAM Pelvic Sling® (SAM® Medical) were collected. The primary outcome was the proportion of subjects fitting each device. Results: Sixty-five subjects were recruited; median age was 5 years (interquartile range, 1-8 years); 40 (62%) subjects were male. Ninety-one percent of subjects fit within the scale of the Broselow Tape (height <143-cm). One hundred percent of subjects with a height <143-cm had an appropriate fit with the Pediatric PelvicBinder (95% confidence level [CI], 91.8-100%), while 91.7% of subjects with a height >143-cm fit the SAM Pelvic Sling (95%CI, 61.5-99.8%). Conclusions: Providers should attempt to fit the Pediatric PelvicBinder for children >1 year old with suspected unstable pelvic fracture who fall on the Broselow Tape (<143-cm). The small SAM Pelvic Sling should be used for those taller than 143-cm.
Keywords: pediatrics; pelvic fractures; pelvic stabilizer; terrorist attacks
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
Forsten RD, Roberts RJ, Stewart C, Solomon BE, Baggett MR. 08(3). 74 - 87. (Journal Article)
Abstract
French L, McCrea M, Baggett MR. 08(1). 68 - 77. (Journal Article)
Abstract
Traumatic brain injury (TBI), in both times of peace and times of war is a significant public health issue for the military. Even at its most mild, TBI (concussion) can degrade fighting effectiveness, put individuals at increased risk for another injury, and in some cases cause persistent difficulties in cognition, and aspects of physical and emotional functioning. Key to the appropriate treatment of those with TBI is the identification of those that have suffered TBI. This article describes one such tool for the identification of TBI in a military setting, the Military Acute Concussion Evaluation (MACE) including its history, administration, and interpretation.
Bagley GF, Ciochirca C. 22(2). 104 - 109. (Journal Article)
Abstract
The authors examine two acute lung injuries (ALI) that can occur in the tactical setting - positive pressure pulmonary edema and inhalation injury - as well as acute respiratory distress syndrome (ARDS), all of which can quickly progress in a prolonged field care (PFC) environment. These conditions present complex problems to emergency department (ED) and intensive care unit (ICU) teams worldwide, requiring intimate knowledge of their distinct disease pathophysiology and advanced critical care equipment. These challenges are compounded in the world of the Special Operations Forces (SOF) medic who often operates as the sole provider in environments with both limited resources and prolonged evacuation times. It is the hope of the authors that by breaking down these complex critical care topics and providing concrete guidance and treatment recommendations that we can ultimately improve the care SOF medics provide overseas in an austere operational environment.
Keywords: lethal triad; critical care; prehospital; coagulopathy; trauma; resuscitation; lethal diamond
Alterie J, Dennis AJ, Baig A, Impens A, Ivkovic K, Joseph KT, Messer TA, Poulakidas S, Starr FL, Wiley DE, Bokhari F, Nagy KK. 18(3). 71 - 74. (Journal Article)
Abstract
Background: One of the greatest conundrums with tourniquet (TQ) education is the use of an appropriate surrogate of hemorrhage in the training setting to determine whether a TQ has been successfully used. At our facility, we currently use loss of audible Doppler signal or loss of palpable pulse to represent adequate occlusion of vasculature and thus successful TQ application. We set out to determine whether pain can be used to indicate successful TQ application in the training setting. Methods: Three tourniquet systems (a pneumatic tourniquet, Combat Application Tourniquet® [C-A-T], and Stretch Wrap and Tuck Tourniquet™ [SWAT-T]) were used to occlude the arterial vasculature of the left upper arm (LUA), right upper arm (RUA), left forearm (LFA), right forearm (RFA), right thigh (RTH), and right calf (RCA) of 41 volunteers. A 4MHz, handheld Doppler ultrasound was used to confirm loss of Doppler signal (LOS) at the radial or posterior tibial artery to denote successful TQ application. Once successful placement of the TQ was noted, subjects rated their pain from 0 to 10 on the visual analog scale. In addition, the circumference of each limb, the pressure with the pneumatic TQ, number of twists with the C-A-T, and length of TQ used for the SWAT-T to obtain LOS was recorded. Results: All 41 subjects had measurements at all anatomic sites with the pneumatic TQ, except one participant who was unable to complete the LUA. In total, pain was rated as 1 or less by 61% of subjects for LUA, 50% for LFA, 57.5% for RUA, 52.5% RFA, 15% for RTH, and 25% for RCA. Pain was rated 3 or 4 by 45% of subjects for RTH. For the C-A-T, data were collected from 40 participants. In total, pain was rated as 1 or less by 57.5% for the LUA, 70% for the LFA, 62.5% for the RUA, 75% for the RFA, 15% for the RTH, and 40% for the RCA. Pain was rated 3 or 4 by 42.5%. The SWAT-T group consisted of 37 participants for all anatomic locations. In total, pain was rated as 1 or less by 27% for LUA, 40.5% for the LFA, 27.0% for the RUA, 43.2 for the RFA, 18.9% for the RTH, and 16.2% for the RCA. Pain was rated 5 by 21.6% for RTH application, and 3 or 4 by 35%. Conclusion: The unexpected low pain values recorded when loss of signal was reached make the use of pain too sensitive as an indicator to confirm adequate occlusion of vasculature and, thus, successful TQ application.
Keywords: tourniquet; pain; vasculature occlusion
Barczak-Scarboro NE, Cole WR, DeFreese JD, Fredrickson BL, Kiefer AW, Bailar-Heath M, Burke RJ, DeLellis SM, Kane SF, Lynch JH, Means GE, Depenbrock PJ, Mihalik JP. 22(3). 129 - 135. (Journal Article)
Abstract
Purpose: The present study investigated Special Operations Forces (SOF) combat Servicemember mental health at different SOF career stages in association with resilience. Methods: Fifty-eight SOF combat Service Members either entering SOF (career start; n=38) or multiple years with their SOF organization (mid-career; n=20) self-reported mild traumatic brain injury (TBI) history, resilience, subjective well-being, depression, anxiety, and posttraumatic stress. Poisson regression analyses were employed to test SOF career stage differences in each mental health symptom using resilience, while accounting for other pertinent military factors. Results: There were significant interaction effects of SOF career stage and resilience on mental health symptoms. SOF career start combat Servicemembers endorsed lower depression and posttraumatic stress and higher subjective well-being with higher resilience, but these associations between resilience and mental health symptoms were not seen in SOF mid-career Servicemembers. Conclusions: Although preliminary, the adaptive association between resilience and mental health seemed to be blunted in combat Servicemembers having served multiple years in SOF. This information informs research to provide evaluation tools to support prophylactic performance and long-term health preservation in military populations.
Keywords: depression; anxiety; posttraumatic stress; subjective well-being; military; concussion
Barczak-Scarboro NE, Cole WR, DeFreese JD, Fredrickson BL, Kiefer AW, Bailar-Heath M, Burke RJ, DeLellis SM, Kane SF, Lynch JH, Means GE, Depenbrock PJ, Mihalik JP. 22(3). 22 - 28. (Journal Article)
Abstract
Purpose: Our aim in this study was to psychometrically test resilience assessments (Ego Resiliency Scale [ER89], Connor-Davidson Resilience Scale [CD-RISC 25], Responses to Stressful Experiences Scale [RSES short-form]) and describe resilience levels in a Special Operations Forces (SOF) combat sample. Methods: Fifty-eight SOF combat Servicemembers either entering SOF (career start; n = 38) or having served multiple years with their SOF organization (mid-career; n = 20) self-reported resilience, mild traumatic brain injury (mTBI) history, and total military service. Results: All resilience metrics demonstrated acceptable internal consistency, but ceiling effects were found for CD-RISC and RSES scores. ER89 scores were moderate on average. ER89 scores were higher in SOF career start than mid-career Servicemembers (ηρ2 = 0.07) when accounting for the interaction between SOF career stage and total military service (ηρ2 = 0.07). Discussion: SOF mid-career Servicemembers had similar ER89 resilience scores with more total military service. The SOF career start combat Servicemembers had higher ER89 measured resilience with less total military service only, potentially showing a protective effect of greater service before entering SOF. Conclusion: The ER89 may be a more optimal military resilience metric than the other metrics studied; longitudinal research on SOF combat Servicemember resilience is warranted.
Keywords: ego resiliency; US Army; US Air Force; psychometrics; readiness
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
Verlo AR, Bailey HH, Cook MR. 15(3). 114 - 119. (Journal Article)
Abstract
Military deployments will always result in exposure to health hazards other than those from combat operations. The occupational and environmental health and endemic disease health risks are greater to the Special Operations Forces (SOF) deployed to the challenging conditions in Africa than elsewhere in the world. SOF are deployed to locations that lack life support infrastructures that have become standard for most military deployments; instead, they rely on local resources to sustain operations. Particularly, SOF in Africa do not generally have access to advanced diagnostic or monitoring capabilities or to medical treatment in austere locations that lack environmental or public health regulation. The keys to managing potential adverse health effects lie in identifying and documenting the health hazards and exposures, characterizing the associated risks, and communicating the risks to commanders, deployed personnel, and operational planners.
Keywords: Africa; health risk assessment; food and water ; occupational and environmental health; site survey
Kotwal RS, Butler FK, Montgomery HR, Brunstetter T, Diaz GY, Kirkpatrick JW, Summers NL, Shackelford SA, Holcomb JB, Bailey JA. 13(2). 82 - 87. (Journal Article)
Abstract
Optimizing trauma care delivery is paramount to saving lives on the battlefield. During the past decade of conflict, trauma care performance improvement at combat support hospitals and forward surgical teams in Afghanistan and Iraq has increased through Joint Trauma System and DoD Trauma Registry data collection, analysis, and rapid evidence-based adjustments to clinical practice guidelines. Although casualties have benefitted greatly from a trauma system and registry that improves hospital care, still lacking is a comprehensive and integrated system for data collection and analysis to improve performance at the prehospital level of care. Tactical Combat Casualty Care (TCCC) based casualty cards, TCCC after action reports, and unit-based prehospital trauma registries need to be implemented globally and linked to the DoD Trauma Registry in a seamless manner that will optimize prehospital trauma care delivery.
Butler FK, DuBose JJ, Otten EJ, Bennett DR, Gerhardt RT, Kheirabadi BS, Gross K, Cap AP, Littlejohn LF, Edgar EP, Shackelford SA, Blackbourne LH, Kotwal RS, Holcomb JB, Bailey JA. 13(3). 81 - 86. (Journal Article)
Abstract
During the recent United States Central Command (USCENTCOM) and Joint Trauma System (JTS) assessment of prehospital trauma care in Afghanistan, the deployed director of the Joint Theater Trauma System (JTTS), CAPT Donald R. Bennett, questioned why TCCC recommends treating a nonlethal injury (open pneumothorax) with an intervention (a nonvented chest seal) that could produce a lethal condition (tension pneumothorax). New research from the U.S. Army Institute of Surgical Research (USAISR) has found that, in a model of open pneumothorax treated with a chest seal in which increments of air were added to the pleural space to simulate an air leak from an injured lung, use of a vented chest seal prevented the subsequent development of a tension pneumothorax, whereas use of a nonvented chest seal did not. The updated TCCC Guideline for the battlefield management of open pneumothorax is: "All open and/ or sucking chest wounds should be treated by immediately applying a vented chest seal to cover the defect. If a vented chest seal is not available, use a non-vented chest seal. Monitor the casualty for the potential development of a subsequent tension pneumothorax. If the casualty develops increasing hypoxia, respiratory distress, or hypotension and a tension pneumothorax is suspected, treat by burping or removing the dressing or by needle decompression." This recommendation was approved by the required two-thirds majority of the Committee on TCCC in June 2013.
Keywords: pneumothorax; chest seal; TCCC Guideline
Kotwal RS, Butler FK, Gross K, Kheirabadi BS, Billings S, Dubick MA, Rasmussen TE, Weber MA, Bailey JA. 13(4). 85 - 93. (Journal Article)
Abstract
The vast majority of combat casualties who die from their injuries do so prior to reaching a medical treatment facility. Although most of these deaths result from nonsurvivable injuries, efforts to mitigate combat deaths can still be directed toward primary prevention through modification of techniques, tactics, and procedures and secondary prevention through improvement and use of personal protective equipment. For deaths that result from potentially survivable injuries, mitigation efforts should be directed toward primary and secondary prevention as well as tertiary prevention through medical care with an emphasis toward prehospital care as dictated by the fact that the preponderance of casualties die in the prehospital environment. Since the majority of casualties with potentially survivable injuries died from hemorrhage, priority must be placed on interventions, procedures, and training that mitigate death from truncal, junctional, and extremity exsanguination. In response to this need, multiple novel and effective junctional tourniquets have recently been developed.
Keywords: junctional hemorrhage; Tactical Combat Casualty Care guidelines
Butler FK, Kotwal RS, Buckenmaier CC, Edgar EP, O'Connor KC, Montgomery HR, Shackelford SA, Gandy JV, Wedmore I, Timby JW, Gross K, Bailey JA. 14(1). 13 - 25. (Journal Article)
Abstract
Although the majority of potentially preventable fatalities among U.S. combat forces serving in Afghanistan and Iraq have died from hemorrhagic shock, the majority of U.S. medics carry morphine autoinjectors for prehospital battlefield analgesia. Morphine given intramuscularly has a delayed onset of action and, like all opioids, may worsen hemorrhagic shock. Additionally, on a recent assessment of prehospital care in Afghanistan, combat medical personnel noted that Tactical Combat Casualty Care (TCCC) battlefield analgesia recommendations need to be simplified-there are too many options and not enough clear guidance on which medication to use in specific situations. They also reported that ketamine is presently being used as a battlefield analgesic by some medics in theater with good results. This report proposes that battlefield analgesia be achieved using one or more of three options: (1) the meloxicam and Tylenol in the TCCC Combat Pill Pack for casualties with relatively minor pain who are still able to function as effective combatants; (2) oral transmucosal fentanyl citrate (OTFC) for casualties who have moderate to severe pain, but who are not in hemorrhagic shock or respiratory distress and are not at significant risk for developing either condition; or (3) ketamine for casualties who have moderate to severe pain but who are in hemorrhagic shock or respiratory distress or are at significant risk for developing either condition. Ketamine may also be used to increase analgesic effect for casualties who have previously been given opioids (morphine or fentanyl.)
Keywords: battlefield analgesia; fentanyl; ketamine; morphine
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
Shackelford SA, Butler FK, Kragh JF, Stevens RA, Seery JM, Parsons DL, Montgomery HR, Kotwal RS, Mabry RL, Bailey JA. 15(1). 17 - 31. (Journal Article)
Abstract
Keywords: tourniquet; Tactical Combat Casualty Care guidelines; external hemorrhage control; shock; resuscitation; emergency medical services
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.
Butler FK, Holcomb JB, Shackelford SA, Barbabella S, Bailey JA, Baker JB, Cap AP, Conklin CC, Cunningham CW, Davis MS, DeLellis SM, Dorlac WC, DuBose JJ, Eastridge BJ, Fisher AD, Glasser JJ, Gurney JM, Jenkins DA, Johannigman J, King DR, Kotwal RS, Littlejohn LF, Mabry RL, Martin MJ, Miles EA, Montgomery HR, Northern DM, O'Connor KC, Rasmussen TE, Riesberg JC, Spinella PC, Stockinger Z, Strandenes G, Via DK, Weber MA. 18(4). 37 - 55. (Journal Article)
Abstract
TCCC has previously recommended interventions that can effectively prevent 4 of the top 5 causes of prehospital preventable death in combat casualties-extremity hemorrhage, junctional hemorrhage, airway obstruction, and tension pneumothorax- and deaths from these causes have been markedly reduced in US combat casualties. Noncompressible torso hemorrhage (NCTH) is the last remaining major cause of preventable death on the battlefield and often causes death within 30 minutes of wounding. Increased use of whole blood, including the capability for massive transfusion, if indicated, has the potential to increase survival in casualties with either thoracic and/or abdominopelvic hemorrhage. Additionally, Zone 1 Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) can provide temporary control of bleeding in the abdomen and pelvis and improve hemodynamics in casualties who may be approaching traumatic cardiac arrest as a result of hemorrhagic shock. Together, these two interventions are designated Advanced Resuscitative Care (ARC) and may enable casualties with severe NCTH to survive long enough to reach the care of a surgeon. Although Special Operations units are now using whole blood far-forward, this capability is not routinely present in other US combat units at this point in time. REBOA is not envisioned as care that could be accomplished by a unit medic working out of his or her aid bag. This intervention should be undertaken only by designated teams of advanced combat medical personnel with special training and equipment.
Keywords: Advanced Resuscitative Care; Committee on Emergency Casualty Care; guidelines
Brown J, Soto MA, Lindsay KG, Harris M, Karagosian SA, Bailey K, Hutchins A. 24(2). 44 - 50. (Journal Article)
Abstract
Background: This study assessed omega-3 fatty acid (O3FA) status, previous brain injury risk exposures, and associations between O3FA status and risk exposures among active-duty military personnel. Methods: O3FA status was measured by a Holman omega-3 blood test. A survey was conducted to assess brain injury risk history and dietary O3FA factors. Results: More than 50% of the participants had high-risk status, based on an omega-3 index (O3I) <4%, while less than 2% of the participants recorded low-risk O3I (>8%). O3FA supplementation (p<.001, Cramer's V=0.342) and fish consumption (p<.001, Cramer's V=0.210) were positively correlated with O3FA status. Only 5 O3FA supplement users (n=97 [5.2%]) had a low-risk O3I status, while all nonusers (n=223) had moderateto high-risk O3I status. Conclusions: Supplementing with O3FA was associated with better O3I status in this population. However, only a few participants achieved optimal O3I status even when taking an O3FA supplement. Participants who ate fish and did not supplement were in the moderateor high-risk O3I groups.
Keywords: omega-3 fatty acids; brain health; brain injury; brain injury risk; traumatic brain injury; TBI; active-duty military; Special Operations; Special Operations Forces; SOF
Bailey RA, Simon EM, Kreiner A, Powers D, Baker L, Giles C, Sweet R, Rush SC. 21(1). 44 - 48. (Journal Article)
Abstract
Uncontrolled hemorrhage secondary to unstable pelvic fractures is a preventable cause of prehospital death in the military and civilian sectors. Because the mortality rate associated with unstable pelvic ring injuries exceeds 50%, the use of external compression devices for associated hemorrhage control is paramount. During mass casualty incidents and in austere settings, the need for multiple external compression devices may arise. In assessing the efficacy of these devices, the magnitude of applied force has been offered as a surrogate measure of pubic symphysis diastasis reduction and subsequent hemostasis. This study offers a sensor-circuit assessment of applied force for a convenience sample of pelvic compression devices. The SAM® (structural aluminum malleable) Pelvic Sling II (SAM Medical) and improvised compression devices, including a SAM Splint tightened by a Combat Application Tourniquet® (C-A-T; North American Rescue) and a SAM® Splint tightened by a cravat, as well as two joined cravats and a standard-issue military belt, were assessed in male and female subjects. As hypothesized, compressive forces applied to the pelvis did not vary significantly based on device operator, subject sex, and subject body fat percentage. The use of the military belt as an improvised method to obtain pelvic stabilization is not advised.
Keywords: pelvic ring fractures; pelvic injuries; commercial pelvic compression devices; improvised pelvic compression devices; mass casualty incidents
Jackson SE, Baity MR, Thomas PR, Walker M, Goodkind M, Swick D, Barba D, Jacobson D, Byrd E, Ivey AS. 21(4). 46 - 53. (Journal Article)
Abstract
Background: Despite being a well-supported strategy, Stress Inoculation Training (SIT) has not been fully incorporated in the advancement of human performance among most military personnel. The RAND Study recommendations for maximizing SIT's potential within high-risk/ high-intensity occupational groups were used in designing the Core Training protocol targeting psychological performance, SIT-NORCAL (Part 1). Purpose: The current project (Part 2) sought to further develop the protocol as a health and human performance hybrid through quality improvement analysis of the content, process, and measurement elements for use in the human performance context. Methods: Evidence-based/evidence-driven methodologies were used in collaborative design tailored to the unique needs of special warfare enablers specializing in Explosive Ordnance Disposal (n = 17). The resultant three-phase training was conducted with a novice group (n = 10) using standardized measurements of collaboration, human performance, and adaptive capabilities on identified training targets. Results: Process elements demonstrated high feasibility, resulting in high collaboration and trainee satisfaction. Significant improvements in psychological performance targets were observed pre- to post-training, and during an Adaptive Environmental Simulation designed by unit members. Two weeks post-training, unit members (n = 5) responded to an actual crash of an F-16 aircraft; measurements indicated maintenance of skill set from training to real-world events. Conclusion: Deployment of the elements in the SIT-NORCAL protocol demonstrated early feasibility and positive training impact on occupationally relevant skills that carried over into real-world events.
Jackson SE, Baity MR, Thomas PR, Barba D, Jacobson D, Goodkind M, Swick D, Ivey AS. 21(4). 37 - 45. (Journal Article)
Abstract
Background: Stress inoculation training (SIT) interventions have demonstrated promise within military contexts for human performance enhancement and psychological health applications. However, lack of manualized guidance on core content selection, delivery, and measurement processes has limited their use. Purpose: The purpose of this study was to develop and evaluate a comprehensive SIT intervention protocol to enhance the performance and health of military personnel engaged in special warfare and first-response activities. Methods: Multidisciplinary teams of subject matter experts (n = 19) were consulted in protocol generation. The performance improvement/human performance technology (HPT) model was used in the selection, refinement, and measurement of core skills. The protocol was trialed and refined (44 cohorts, n = =300; 2013-2020) to generate the results. Results: Four primary aims were achieved: (1) The generation of a flexible, evidence-based/evidence-driven psychological performance and health sustainment hybrid, SIT-NORCAL. (2) Manualized content and process guidance. (3) The creation of multimedia materials using evidence-based methodologies. (4) The design of initial measurement systems. Preliminary quality improvement analysis demonstrated positive results using standard-of-care and performance enhancement assessments. Conclusion: Hybridized human performance and psychological health sustainment protocols represent a paradigm shift in the delivery of psychological performance training with the potential to overcome barriers to success in traditional care. Further study is needed to determine the effectiveness and reach of SIT-NORCAL.
Keywords: stress inoculation; training; performance training
Delmonaco BL, Baker A, Clay J, Kilburn J. 16(1). 103 - 108. (Journal Article)
Abstract
An eight-person team of conventional US Air Force (USAF) medical providers deployed to support US Special Operations Forces (SOF) in North and West Africa for the first time in November 2014. The predeployment training, operations while deployed, and lessons learned from the challenges of performing surgery and medical evacuations in the remote desert environment of Chad and Niger on the continent of Africa are described. The vast area of operations and far-forward posture of these teams requires cooperation between partner African nations, the French military, and SOF to make these medical teams effective providers of surgical and critical care in Africa. The continuous deployment of conventional USAF medical providers since 2014 in support of US Special Operations Command Africa is challenging and will benefit from more medical teams and effective air assets to provide casualty evacuation across the vast area of operations.
Keywords: US Special Operations Command North and West Africa; far-forward surgery; conventional US Air Force; Mobile Field Surgical Team; Niamey, Niger; N'Dhamena, Chad; CASEVAC; Boko Haram; al-Qaeda I the Islamic Maghreb; French Military
Heiner JD, Baker BL, McArthur TJ. 10(2). 7 - 10. (Journal Article)
Abstract
Introduction: U.S. Army Special Forces Medics (18Ds) operate in austere environments where decisions regarding patient management may be limited by available resources. Portable ultrasound may allow for the detection of fractures in environments where other imaging modalities such as radiography are not readily available or practical. Objective: We used a simulation training model for the ultrasound diagnosis of long bone fractures to study the ability of 18Ds to detect the presence or absence of a fracture using a portable ultrasound. Methods: The fracture simulation model is composed of a bare turkey leg bone that is mechanically fractured and housed in a shallow plastic container within an opaque gelatin base solution. Five fracture patterns were created: transverse, segmental, oblique, comminuted, and no fracture. After a brief orientation session, twenty 18Ds evaluated the models in a blinded fashion with a SonoSite M-Turbo portable ultrasound device for the presence or absence of a fracture. Results: 18Ds demonstrated 100% sensitivity (95% CI: 94.2% to 100%) in fracture detection and an overall specificity of 90% (95% CI: 66.8-98.2%) due to two false positive assessments of the no fracture model. Conclusions: Using a portable ultrasound device, 18Ds were able to correctly detect the presence or absence of a simulated long bone fracture with a high degree of sensitivity and specificity. Future studies are needed to investigate the clinical impact of this diagnostic ability.
Baker BL, Powell D, Riesberg JC, Keenan S. 16(1). 112 - 117. (Journal Article)
Abstract
The Prolonged Field Care Working Group concurs that fresh whole blood (FWB) is the fluid of choice for patients in hemorrhagic shock, and the capability to transfuse FWB should be a basic skill set for Special Operations Forces (SOF) Medics. Prolonged field care (PFC) must also address resuscitative and maintenance fluid requirements in nonhemorrhagic conditions.
Keywords: prolonged field care; blood, fresh whole; shock, hemorrhagic; transfusion
Baker JB, Modlin RE, Ong RC, Remick KN. 17(4). 52 - 55. (Journal Article)
Abstract
The US Army Special Operations Command and Army Medical Command are at a critical junction in Army medical training. Army Special Operations Forces (ARSOF) will receive Forward Resuscitative Surgical Teams (FRSTs) in the near future and must establish a training model to enable successful support for ARSOF operations. The military has been directed by Congress through the 2017 National Defense Authorization Act to embed trauma combat casualty care teams in civilian trauma centers. ARSOF FRSTs should be embedded in the nation's leading civilian trauma centers to build and sustain true expertise in delivering trauma care on the battlefield. The SOF Truths provide valuable insights into the required conditions for success of this new training paradigm.
Keywords: forward resuscitative surgical team; trauma
Fisher AD, Washbum G, Powell D, Callaway DW, Miles EA, Brown J, Dituro P, Baker JB, Christensen JB, Cunningham CW, Gurney JM, Lopata J, Loos PE, Maitha J, Riesberg JC, Stockinger Z, Strandenes G, Spinella PC, Cap AP, Keenan S, Shackelford SA. 18(3). 109 - 119. (Journal Article)
Abstract
Butler FK, Holcomb JB, Shackelford SA, Barbabella S, Bailey JA, Baker JB, Cap AP, Conklin CC, Cunningham CW, Davis MS, DeLellis SM, Dorlac WC, DuBose JJ, Eastridge BJ, Fisher AD, Glasser JJ, Gurney JM, Jenkins DA, Johannigman J, King DR, Kotwal RS, Littlejohn LF, Mabry RL, Martin MJ, Miles EA, Montgomery HR, Northern DM, O'Connor KC, Rasmussen TE, Riesberg JC, Spinella PC, Stockinger Z, Strandenes G, Via DK, Weber MA. 18(4). 37 - 55. (Journal Article)
Abstract
TCCC has previously recommended interventions that can effectively prevent 4 of the top 5 causes of prehospital preventable death in combat casualties-extremity hemorrhage, junctional hemorrhage, airway obstruction, and tension pneumothorax- and deaths from these causes have been markedly reduced in US combat casualties. Noncompressible torso hemorrhage (NCTH) is the last remaining major cause of preventable death on the battlefield and often causes death within 30 minutes of wounding. Increased use of whole blood, including the capability for massive transfusion, if indicated, has the potential to increase survival in casualties with either thoracic and/or abdominopelvic hemorrhage. Additionally, Zone 1 Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) can provide temporary control of bleeding in the abdomen and pelvis and improve hemodynamics in casualties who may be approaching traumatic cardiac arrest as a result of hemorrhagic shock. Together, these two interventions are designated Advanced Resuscitative Care (ARC) and may enable casualties with severe NCTH to survive long enough to reach the care of a surgeon. Although Special Operations units are now using whole blood far-forward, this capability is not routinely present in other US combat units at this point in time. REBOA is not envisioned as care that could be accomplished by a unit medic working out of his or her aid bag. This intervention should be undertaken only by designated teams of advanced combat medical personnel with special training and equipment.
Keywords: Advanced Resuscitative Care; Committee on Emergency Casualty Care; guidelines
Jeschke EA, Baker JB, Wyma-Bradley J, Dorsch J, Huffman SL. 23(2). 102 - 106. (Journal Article)
Abstract
This article presents a justification for using an ethnographic approach to research resilience. Our hypothesis is that the conventional resilience construct is ineffective in achieving its stated goal of mitigating diagnosable stress pathologies because it is grounded in a set of assumptions that overlook human experience when examining human performance in combat. To achieve this goal, we (1) describe the evolution of the strategic framework within which the conventional resilience construct is defined; (2) highlight certain limiting assumptions entailed in this framework; (3) explain how bottom-up ethnographic research relates the medic's practical performance to military requirements and mission capabilities; and (4) articulate the unique elements of our study that widen the aperture of the conventional resilience construct. We conclude by gesturing to initial research findings.
Keywords: resilience; SOST; Special Operations Surgical Team; SOF special operations; catastrophic; injury; ethnographic; combat
Colesar MT, Baker JB. 23(3). 24 - 31. (Journal Article)
Abstract
In the most austere combat conditions, Yugoslav guerillas of World War II (WWII) demonstrated an innovative and effective hospitalization system that saved countless lives. Yugoslav Partisans faced extreme medical and logistical challenges that spurred innovation while waging a guerrilla war against the Nazis. Partisans used concealed hospitals ranging between 25 to 215 beds throughout the country with wards that were often subterranean. Concealment and secrecy prevented discovery of many wards, which prototypically contained two bunk levels and held 30 patients in a 3.5 × 10.5-meter space that included storage and ventilation. Backup storage and treatment facilities provided critical redundancy. Intra-theater evacuation relied on pack animals and litter bearers while partisans relied on Allied fixed wing aircraft for inter-theater evacuation.
Keywords: Yugoslavia; warfare; hospital design and construction; military personnel; military health; military medicine; war-related injuries; armed conflicts; World War II
Jeschke EA, Baker JB, Wyma-Bradley J, Dorsch J, Huffman SL. 23(3). 58 - 62. (Journal Article)
Abstract
This will be the second in a series of nine articles in which we discuss findings from our ethnographic study entitled "The Impact of Catastrophic Injury Exposure on Resilience in Special Operations Surgical Teams." Our goal in this article is to establish the practical importance of redefining resilience within a strategic framework. Our bottom-up approach to strategy development explores unconventional resilience as an integrated transformational process that promotes change-agency through the force of movement. Synthesis of empirical data derived from participant interviews and focus groups highlights conceptual attributes that make up the essential components of this framework. To achieve our goal, the authors (1) briefly remind readers how we have problematized conventional resilience; (2) explain how we analyzed qualitative quotes to extrapolate our definition of unconventional resilience; and (3) describe in detail our strategic framework. We conclude by gesturing to why this strategic framework is applicable to practical performance of all Special Operation Forces (SOF) medics.
Keywords: resilience; performance; strategic; SOF medic; transformational
Jeschke EA, Baker JB, Wyma-Bradley J, Dorsch J, Huffman SL. 23(4). 64 - 68. (Journal Article)
Abstract
This is the third of nine planned papers drawn from the findings of our ethnographic study entitled "The Impact of Catastrophic Injury Exposure on Resilience in Special Operations Surgical Teams." Building from our strategic framework, this paper will establish that resilience is better understood as cohesive adaptation within a Special Operation Forces (SOF) cultural ecosystem. Exploring unconventional resilience as the inter-relationship across the organization, team, and individual, we will use qualitative quotes to describe the ecosystem of dynamic freedom of maneuver in ambiguity. To achieve our goals, we will: 1) compare conventional and unconventional resilience to operationalize the components of our strategic framework; 2) use qualitative quotes to show how the ecosystem of unconventional resilience functions at each level supporting our operational model; and 3) describe how the operational model of unconventional resilience links to tactical performance through five social determinants. We conclude by gesturing to how transformational change-agency applies to practical performance of all SOF medics.
Keywords: resilience; performance; operational model; SOF medic; ecosystem
Jeschke EA, Wyma-Bradley J, Baker JB, Dorsch J, Huffman SL. 24(1). 90 - 94. (Journal Article)
Abstract
Building upon our strategic framework and operational model, we will discuss findings from our ethnographic study, entitled: "The Impact of Catastrophic Injury Exposure on Resilience in Special Operations Surgical Teams (SOSTs)," to explain the tactical nature and importance of social determinants within our new characterization of unconventional resilience. Our fourth paper in this series, will explain how bonding patterns establish the quality of intra- and interpersonal connections that create a tensive conduit for the pressure of performance within our operational model, allowing for dynamic freedom of maneuver to take place in ambiguity. We will use qualita- tive quotes to illustrate various ways SOST medics relate to themselves, other people, and the Special Operations Forces (SOF) culture. To achieve our goals, we will: 1) provide an in- troduction to social determinants as tactical engagement with unconventional resilience; 2) define the social determinant of bonding patterns as extrapolated from qualitative data as well as use qualitative data to thematize various types of bonding patterns; and 3) relate tactical engagement with bonding pat- terns to our metaphor of bag sets. We conclude by gesturing to the importance of bonding patterns in orienting SOF medics' proprioception and kinesthesia in the SOF performance space.
Keywords: unconventional resilience; social determinant; bonding patterns; practical performance; SOF medic
Jeschke EA, Wyma-Bradley J, Baker JB, Dorsch J, Huffman SL. 24(2). 103 - 108. (Journal Article)
Abstract
Building upon our operational model, we will discuss findings from our ethnographic study titled "The Impact of Catastrophic Injury Exposure on Resilience in Special Operations Surgical Teams" to establish that impression management allows Special Operation Forces (SOF) medics to navigate implicit social status symbols to either degrade or optimize performance. We will use qualitative quotes to explore how Special Operations Surgical Team (SOST) medics engage in impression management to establish individual, team, and/or organizational competency to deal with ambiguity. To achieve our goals, we will: 1) provide a background on impression management and perception of competency; 2) define the social determinant of impression management extrapolated from qualitative data as well as use qualitative data to thematize various types of impression management; and 3) relate tactical engagement with impression to our metaphor of bag sets. We conclude by gesturing to the importance of impression management in orienting SOF medics' proprioception and kinesthesia in the SOF performance space.
Keywords: unconventional resilience; social determinant; tactical; impression management; practical performance; SOF medic
Jeschke EA, Armon J, Wyma-Bradley J, Baker JB, Dorsch J, Huffman SL. 24(3). 84 - 89. (Journal Article)
Abstract
Building on our strategic framework and operational model, we will discuss findings from our ethnographic study entitled, "The Impact of Catastrophic Injury Exposure on Resilience in Special Operations Surgical Teams (SOST)." Our goal is to establish that medical-martial creativity supports Special Operation Forces (SOF) medics' ability to fluidly modulate pressure amid real-time military medical decision-making in austere environments. We will use qualitative quotes to explore how SOST medics express medical-martial creativity in support of unconventional resilience. We continue to highlight tactical engagement by using bag sets as a metaphor for understanding the practical performance of this social determinant. To achieve our goals, we will: 1) define the social determinant of medical-martial creativity and provide a brief background on creativity; 2) thematize various ways in which medical-martial creativity is optimized or degraded; and 3) relate tactical engagement with medical-martial creativity to our metaphor of bag sets. We conclude by gesturing to how medical-martial creativity enables SOF medics' ingenuity, which allows them to freely maneuver complex real-time decision-making to support SOF mission success.
Keywords: unconventional resilience; social determinant; martial; creativity; practical performance; SOF medic
Baker JL, Truesdale CA. 08(1). 120 - 121. (Journal Article)
Abstract
Baker JL, Truesdale CA, Schlanser JR. 09(2). 105 - 108. (Previously Published)
Previously published in The United States Army Medical Department Journal / The Unites States Army Veterinary
Corps January - March 2009.
Abstract
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.
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
Bailey RA, Simon EM, Kreiner A, Powers D, Baker L, Giles C, Sweet R, Rush SC. 21(1). 44 - 48. (Journal Article)
Abstract
Uncontrolled hemorrhage secondary to unstable pelvic fractures is a preventable cause of prehospital death in the military and civilian sectors. Because the mortality rate associated with unstable pelvic ring injuries exceeds 50%, the use of external compression devices for associated hemorrhage control is paramount. During mass casualty incidents and in austere settings, the need for multiple external compression devices may arise. In assessing the efficacy of these devices, the magnitude of applied force has been offered as a surrogate measure of pubic symphysis diastasis reduction and subsequent hemostasis. This study offers a sensor-circuit assessment of applied force for a convenience sample of pelvic compression devices. The SAM® (structural aluminum malleable) Pelvic Sling II (SAM Medical) and improvised compression devices, including a SAM Splint tightened by a Combat Application Tourniquet® (C-A-T; North American Rescue) and a SAM® Splint tightened by a cravat, as well as two joined cravats and a standard-issue military belt, were assessed in male and female subjects. As hypothesized, compressive forces applied to the pelvis did not vary significantly based on device operator, subject sex, and subject body fat percentage. The use of the military belt as an improvised method to obtain pelvic stabilization is not advised.
Keywords: pelvic ring fractures; pelvic injuries; commercial pelvic compression devices; improvised pelvic compression devices; mass casualty incidents
Baker RA, Worth K, Pourrajabi N, Martin J, Mitchell S, Baker S. 22(1). 71 - 75. (Journal Article)
Abstract
Background: An austere field amputation can be a life-saving procedure for an entrapped patient when standard equipment is not available or operable. The objective of this study was to use hand tools to perform cadaveric amputations in < 2 minutes. Methods: Timed guillotine amputation of the extremities on three cadavers was attempted using four available hand tools: a multitool, a rescue tool, a hunting knife, and a fixedblade knife. The primary outcome was successful amputation of the extremity in < 2 minutes. Results: Amputation success was different among the tools. The multitool amputated 78% of attempts; the hunting knife, 67%; the rescue knife, 56%; and the fixed-blade knife, 44%. The distal tibia/fibula and radius/ ulna were amputated successfully in 100% of attempts, whereas none of the tools could amputate the femur. The multitool received the best subjective ranking - 1.4 (p = .001) - by amputators, with the fixed-blade knife receiving the worst score. Conclusions: In the rare circumstance that an emergent field amputation requires a hand tool, the multitool is a capable instrument for a distal extremity amputation.
Keywords: amputation; knife; saw; prehospital; field; emergency
Baker RA, Worth K, Pourrajabi N, Martin J, Mitchell S, Baker S. 22(1). 71 - 75. (Journal Article)
Abstract
Background: An austere field amputation can be a life-saving procedure for an entrapped patient when standard equipment is not available or operable. The objective of this study was to use hand tools to perform cadaveric amputations in < 2 minutes. Methods: Timed guillotine amputation of the extremities on three cadavers was attempted using four available hand tools: a multitool, a rescue tool, a hunting knife, and a fixedblade knife. The primary outcome was successful amputation of the extremity in < 2 minutes. Results: Amputation success was different among the tools. The multitool amputated 78% of attempts; the hunting knife, 67%; the rescue knife, 56%; and the fixed-blade knife, 44%. The distal tibia/fibula and radius/ ulna were amputated successfully in 100% of attempts, whereas none of the tools could amputate the femur. The multitool received the best subjective ranking - 1.4 (p = .001) - by amputators, with the fixed-blade knife receiving the worst score. Conclusions: In the rare circumstance that an emergent field amputation requires a hand tool, the multitool is a capable instrument for a distal extremity amputation.
Keywords: amputation; knife; saw; prehospital; field; emergency
Goudard Y, Camus D, de Landevoisin ES, Dobost C, Domos P, Balandraud P. 19(1). 16 - 18. (Case Reports)
Abstract
Managing acute trauma cases in military and low-resource environments usually requires adapted medicosurgical protocols to achieve best medical results with limited technical capacity. We report a case of unstable pelvic fracture that needed ultrasonographic assessment for closed reduction before external stabilization. In our opinion, ultrasonographic control should be considered as a useful technique for unstable pelvic fracture reduction and an alternative to radiographic control.
Keywords: pelvic fracture; ultrasonography
Balasoupramanien K, Comat G, Renard A, Meusnier J, Montigon C, Pitel A, Bascou M, Dubourg R, Cazes N. 22(3). 65 - 69. (Journal Article)
Abstract
Introduction: In current French military operations, it is not uncommon for military nurses (MNs) alone to be required to support soldiers in isolated areas. At a time when advanced practice nurses in the civilian sector develop extended skills, we asked MNs about their willingness to be trained in pointof- care ultrasound (POCUS). Methods: We conducted a webbased survey from 1 November 2018 to 1 December 2018, including all MNs deployed in Operation Barkhane. The questionnaire, sent by e-mail, aimed to describe the willingness of MNs to be trained in POCUS. Their opinion on the usefulness of this training, the situations, and ultrasound (US) targets that seemed most useful to them were also studied. Results: Thirty of 34 questionnaires were completed. On average, MNs had 7.4 years of practice and had been deployed three times for military operations. Five MNs reported having had informal training in clinical US by the military physicians (MPs) they work with and had performed POCUS in real-life situations; 24 (96%) of the untrained MNs wanted to be trained. Twenty- nine (96%) of the MNs felt that there was added value in knowing how to perform POCUS, especially in operations and in isolated posts without an MP. Focused assessment with sonography for trauma and pleural and renal US were the targets considered most useful to them, in that order. Conclusion: MNs are interested in learning POCUS and say it would be beneficial for the patient. Available scientific data tend to validate their ability after a brief training course to perform reliable, targeted US examinations in the field.
Keywords: ultrasonography; military medicine; military nurse
Montagnon R, Rouffilange L, Wagnon G, Balasoupramanien K, Texier G, Aigle L. 24(3). 44 - 48. (Journal Article)
Abstract
Introduction: A systematic radiological examination is needed for military airborne troops in order to detect subclinical medical contraindications for airborne training. Many potential recruits are excluded because of scoliosis, kyphosis, or spondylolisthesis. This study aimed to determine whether complementary radiological assessment excludes too many recruits and whether medical standards might be lowered without increasing medical risk to appointees. Methods: This retrospective, epidemiological, cross-sectional single-center study spanned 5 years at the French paratroopers' initial training center. We analyzed all medical files and full-spine X-ray results of all enlisted troops during this period. Secondary evaluation by an orthopedic surgeon enabled 23 enlisted personnel, deemed medically unacceptable because of X-ray findings, to be given waivers for airborne training. A follow-up review of their 23 files was conducted to determine whether static-line parachute jumps were hazardous to those who were initially declared medically unacceptable. Results: Of the 3,993 full-spine X-rays, 67.5% (2,695) were described as having normal alignment and structure; 21.8% (871) had lateral spinal deviation; and 10.7% (427) had scoliosis. Sixty-six recruits (1.6%) were deemed unfit because of findings that did not meet the standard on the fullspine X-ray: 53 enlisted personnel had scoliosis greater than 15°, and 13 had spondylolisthesis (grade II or III). Of the 23 patients granted waivers, 82.3% with scoliosis (14) and all patients with kyphosis had not declared any back pain after 5 years. Conclusion: The findings, supported by a literature review of foreign military data, suggest that spondylolisthesis above grade I and low back pain are more significant than scoliosis and kyphosis for establishing airborne standards.
Keywords: military medicine; airborne; scoliosis; kyphosis; spondylolisthesis
Thomas A, Pagenhardt J, Balcik B. 20(1). 37 - 39. (Case Reports)
Abstract
Atrial flutter and atrial fibrillation are among the most commonly encountered cardiac arrhythmias; however, there is a dearth of clinical trials or case studies regarding its occurrence in the setting of stimulants such as caffeine and nicotine in otherwise healthy young patients. Described here is a case of a 29-year-old physically fit white man without significant past medical history who presented in stable condition complaining only of palpitations. He was found to have atrial flutter without rapid ventricular response on cardiac monitoring, most likely due to concomitant presence of high levels of nicotine and caffeine via chewing tobacco and energy drinks. He was treated conservatively with vagal maneuvers and intravenous fluids with complete resolution of symptoms and electrocardiographic abnormalities within 14 hours. This demonstrates an alternate conservative treatment strategy in appropriately risk stratified patients who present in an austere field setting with limited resources.
Keywords: atrial flutter; caffeine; nicotine; vagal maneuver; athlete
Tadlock M, Maves R, Flieger DM, Baldino TJ, Adams D, Riesberg JC, Kitchen LK, Brower JJ, Tripp MS. 24(2). 94 - 102. (Journal Article)
Abstract
During distributed maritime operations, individual components of the naval force are more geographically dispersed. As the U.S. Navy further develops this concept, smaller vessels may be operating at a significant time and distance away from more advanced medical capabilities. Therefore, during both current and future contested Distributed Maritime Operations, Role 1 maritime caregivers such as Independent Duty Corpsman will have to manage patients for prolonged periods of time. This manuscript presents an innovative approach to teaching complex operational medicine concepts (including Prolonged Casualty Care [PCC]) to austere Role 1 maritime caregivers using a hypothetical scenario involving a patient with sepsis and septic shock. The scenario incorporates the Joint Trauma System PCC Clinical Practice Guidelines (CPG) and other standard references. The scenario includes a stem clinical vignette, expected clinical changes for the affected patient at specific time points (e.g., time 0, 1, 2, and 48h), and expected interventions based on the PCC CPG and available shipboard equipment. Epidemiology of sepsis in the deployed environment is also reviewed. This process also identifies opportunities to improve training, clinical skills sustainment, and standard shipboard medical supplies.
Keywords: prolonged casualty care; Tactical Combat Casualty Care; maritime operations; critical care; sepsis; septic shock; appendicitis
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
Schauer SG, Naylor JF, Beaumont DM, April MD, Tanaka K, Baldwin D, Maddry JK, Becker TE, De Lorenzo RA. 20(3). 62 - 66. (Journal Article)
Abstract
Introduction: Airway compromise is the second leading cause of potentially survivable death on the battlefield. Studies show that airway management is a challenge in prehospital combat care with high error and missed opportunity rates. Lacking is user information on the perceived reasons for the challenges. The US military uses several performance improvement and field feedback systems to solicit feedback regarding deployed experiences. We seek to review feedback and after-action reviews (AARs) from end-users with specific regard to airway challenges noted. Methods: We queried the Center for Army Lessons Learned (CALL), the Army Medical Department Lessons Learned (AMEDDLL), and the Joint Lessons Learned Information System (JLLIS).Our queries comprised a series of search terms with a focus on airway management. Three military emergency medicine expert reviewers performed the primary analysis for lessons learned specific to deployment and predeployment training lessons learned. Upon narrowing the scope of entries to those relevant to deployment and predeployment training, a panel of eight experts performed reviews. The varied nature of the sources lent itself to an unstructured qualitative approach with results tabulated into thematic categories. Results: Our initial search yielded 611 nonduplicate entries. The primary reviewers then analyzed these entries to determine relevance to the project-this resulted in 70 deployment- based lessons learned and four training-based lessons learned. The panel of eight experts then reviewed the 74 lessons learned. We categorized 37 AARs as equipment challenges/malfunctions, 28 as training/education challenges, and 9 as other. Several lessons learned specifically stated that units failed to prioritize medic training; multiple comments suggested that units should consider sending their medics to civilian training centers. Other comments highlighted equipment shortages and equipment malfunctions specific to certain mission types (e.g., pediatric casualties, extreme weather). Conclusions: In this review of military lessons learned systems, most of the feedback referenced equipment malfunctions and gaps in initial and maintenance training.This review of AARs provides guidance for targeted research efforts based the needs of the end-users.
Keywords: prehospital; combat; airway; review; lessons
Savell SC, Baldwin DS, Blessing A, Medelllin KL, Savell CB, Maddry JK. 21(2). 35 - 42. (Journal Article)
Abstract
Background: Point of care ultrasound (POCUS) offers multiple capabilities in a relatively small, lightweight device to military clinicians of all types and levels in multiple environments. Its application in diagnostics, procedural guidance, and patient monitoring has not been fully explored by the Military Health System (MHS). The purpose of this narrative review of the literature was to examine the overall use of POCUS in military settings, as well as the level of ultrasound training provided. Methods: Studies related to use of POCUS by military clinicians with reported sensitivity/specificity, accuracy of exam, and/or clinical decision impact met inclusion criteria. After initial topical review and removal of duplicates, two authors selected 17 papers for consideration for inclusion. Four of the authors reviewed the 17 papers and determined the final inclusion of 14 studies. Results: We identified seven prospective studies, of which three randomized subjects to groups. Five reports described use of POCUS in patients, two used healthy volunteers, two were in simulation training environments, four used animal models to simulate specific conditions, and one used a cadaver model. Clinician subjects ranged from one to 34. Conventional medics were subjects in six studies. Four studies included special operations medics. One study included nonmedical food service inspectors. The use of ultrasound in theater by deployed consultant radiologists is described in three reports. Conclusions: Military clinicians demonstrated the ability to perform focused exams, including FAST exams and fracture detection with acceptable sensitivity and specificity. POCUS in the hands of trained military clinicians has the potential to improve diagnostic accuracy and ultimately care of the war fighter.
Keywords: ultrasound; military; point of care ultrasound; POCUS
Baldwin TM. 09(3). 33 - 43. (Journal Article)
Abstract
Tinnitus is the phantom perception of sound in the absence of overt acoustic stimulation. Its impact on the military population is alarming. Annually, tinnitus is the most prevalent disability among new cases added to the Veterans Affairs numbers. Also, it is currently the most common disability from the War on Terror. Conventional medical treatments for tinnitus are well documented, but prove to be unsatisfying. Hyperbaric oxygen (HBO2) therapy may improve tinnitus, but the significance of the level of improvement is not clear. There is a case for large randomized trials of high methodological rigor in order to define the true extent of the benefit with the administration of HBO2 therapy for tinnitus.
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
Smith S, Liu M, Ball I, Meunier B, Hilsden R. 23(1). 31 - 37. (Journal Article)
Abstract
Medical leadership must decide how prehospital airways will be managed in a combat environment, and airway skills can be complicated and difficult to learn. Evidence informed airway strategies are essential. A search was conducted in Medline and EMBASE databases for prehospital combat airway use. The primary data of interest was what type of airway was used. Other data reviewed included: who performed the intervention and the success rate of the intervention. The search strategy produced 2,624 results, of which 18 were included in the final analysis. Endotracheal intubation, cricothyroidotomy, supraglottic airways, and nasopharyngeal airways have all been used in the prehospital combat environment. This review summarizes the entirety of the available combat literature such that commanders may make an evidence-based informed decision with respect to their airway management policies.
Keywords: endotracheal intubation; airway; cricothyroidotomy; supraglottic airways; and nasopharyngeal airways
Smith S, White J, McGuire T, Meunier B, Ball I, Hilsden R. 23(3). 32 - 38. (Journal Article)
Abstract
Medical leadership must decide how to obtain vascular access in a combat environment. Adequate combat trauma resuscitation requires efficient vascular access. A search of the Medline and EMBASE databases was conducted to find articles on combat vascular access. The primary dataset of interest was the type of vascular access obtained. Other data reviewed included who performed the intervention and the success rate of the intervention. The search strategy produced 1,339 results, of which 24 were included in the final analysis. Intravenous (IV), intraosseous (IO), and central venous access have all been used in the prehospital combat environment. This review summarizes the available combat literature to help commanders make an evidence-based decision about their prehospital vascular access strategy.
Keywords: intravenous access; vascular access; interosseus access; central venous catheters
Smith S, Hilsden R, Patton P, Vogt K, Beckett A, Ball IM. 24(1). 85 - 87. (Journal Article)
Abstract
Rib fractures in combat casualties are an under-appreciated injury, and their treatment may become more common as more patients survive because of modern body armor and point-ofinjury care. The combat environment has challenges such as equipment availability and sterility. A simple and thoughtful rib fracture treatment algorithm may be useful to reduce the morbidity and mortality of rib fractures in the combat environment. Intravenous lidocaine infusions for patients with traumatic rib fractures may have important combat applications. We propose an algorithm for the management of combat casualties with traumatic rib fractures.
Keywords: military medicine; rib fractures; lidocaine; combat medicine; pain management
Hetzler MR, Ball JA. 08(3). 47 - 53. (Journal Article)
Abstract
Ball JA, Hetzler MR. 08(4). 30 - 35. (Journal Article)
Abstract
Ball JA, Keenan S. 15(3). 76 - 77. (Journal Article)
Abstract
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.
Blenkinsop G, Mossadegh S, Ballard M, Parker PJ. 15(3). 60 - 65. (Journal Article)
Abstract
Significant lessons to inform best practice in trauma care should be learned from the last decade of conflict in Afghanistan and Iraq. This study used radiological data collated in the UK Military Hospital in Camp Bastion, Afghanistan, to investigate the most appropriate device length for needle chest decompression of tension pneumothorax (TP). We reviewed the optimal length of device and site needed for needle decompression of a tension pneumothorax in a UK military population and found no significant difference between sites for needle chest decompression (NCD). As a result, we do not recommend use of devices longer than 60mm for UK service personnel.
Keywords: decompression, chest; thoracostomy, needle; UK military
Beaven A, Ballard M, Sellon E, Briard R, Parker PJ. 18(3). 75 - 78. (Journal Article)
Abstract
Background: Exsanguination from limb injury is an important battlefield consideration that is mitigated with the use of emergency tourniquets. The Combat Application Tourniquet (C-A-T®) is the current British military standard tourniquet. Methods: We tested the self-application of a newer tourniquet system, the Tactical Mechanical Tourniquet (TMT), against self-application of the C-A-T. A total of 24 healthy British military volunteers self-applied the C-A-T and the TMT to their mid thigh in a randomized, sequential manner. Popliteal artery flow was monitored with a portable ultrasound machine, and time until arterial occlusion was measured. Pain scores were also recorded. Results The volunteers allowed testing on their lower limbs (n = 48 legs). The C-A-T was applied successfully to 22 volunteers (92%), and the TMT was successfully applied to 17 (71%). Median time to reach complete arterial occlusion was 37.5 (interquartile range [IQR], 27-52) seconds with the C-A-T, and 35 (IQR, 29-42) seconds with the TMT. The 2.5-second difference in median times was not significant (ρ = .589). The 1-in-10 difference in median pain score was also not significant (ρ = .656). The success or failure of self-application between the two tourniquet models as assessed by contingency table was not significant (p= .137). Conclusion: The TMT is effective when self-applied at the mid thigh. It does not offer an efficacy advantage over the C-A-T.
Ballard SR, Enzenauer RW, O'Donnell T, Fleming JC, Risk G, Waite AN. 09(3). 26 - 32. (Journal Article)
Abstract
Retrobulbar hemorrhage is an uncommon, but potentially devastating complication associated with facial trauma. It can rapidly fill the orbit and cause an "orbital compartment syndrome" that subsequently cuts off perfusion to vital ocular structures, leading to permanent visual loss. Treatment must be initiated within a limited time in order to prevent these effects; however, specialty consultation is not always available in remote field environments. This article addresses the mechanism, diagnosis, and treatment of retrobulbar hemorrhage via lateral canthotomy and cantholysis, and recommends that 18D medical sergeants be properly trained to evaluate and perform this sight-saving procedure in emergent settings where upper echelons of care are not immediately available.
Rankin CJ, Fetherston T, Ballentine CD, Adams B, Long B, Carius BM. 22(2). 69 - 74. (Journal Article)
Abstract
The ongoing evolution of prehospital medical care continues to advance beyond immediate triage care. Prehospital care is even more important to consider in theaters with extended evacuation times and limited local medical assets. Although blood loss is often associated with settings of acute traumatic hemorrhage in military medicine, the possibility for other hematologic compromise necessitating urgent action requires medics operating in these environments to have a fundamental knowledge of the pathophysiology, manifestations, and stabilization measures of anemia to aid their patients prior to, or in lieu of, evacuation. Continued development of and access to point-of-care testing in increasingly forward-deployed settings further enable medics to perform these tasks. Here, we provide a brief review of hemoglobin function and composition, and presentation and management considerations of anemia, to assist medics in their treatment efforts. We also address specific concerns for battlefield and atraumatic presentations.
Keywords: hemoglobin; anemia; prehospital care; blood loss, hemorrhage; military; laboratory; malaria; hemolysis; bleeding; transfusion
Chang R, Boyle BP, Udoh MO, Maestas JM, Gehrz JA, Ruano E, Banker L, Cap AP, Bitterman JW, Deaton TG, Auten JD. 24(1). 60 - 66. (Journal Article)
Abstract
Background: Tactical Combat Casualty Care (TCCC) guidelines recognize low-titer group O whole blood (LTOWB) as the resuscitative fluid of choice for combat wounded. Utilization of prescreened LTOWB in a walking blood bank (WBB) format has been well described by the Ranger O low-titer blood (ROLO) and the United States Marine Corps Valkyrie programs, but it has not been applied to the maritime setting. Methods: We describe three WBB experiences of an expeditionary resuscitative surgical system (ERSS) team, attached to three nontraditional maritime medical receiving platforms, over 6 months. Results: Significant variations were identified in the number of screened eligible donors, the number of LTOWB donors, and the timely arrival at WBB activation sites between the platforms. Overall, 95% and 84% of the screened eligible group O blood donors on the Arleigh Burke Class Destroyer (DDG) and Nimitz Class Aircraft Carrier (CVN), respectively, were determined to be LTOWB. However, only 37% of the eligible screened group O blood donors aboard the Harper's Ferry Class Dock Landing Ship (LSD) were found to be LTOWB. Of the eligible donors, 66% did not complete screening, with 52% citing a correctable reason for nonparticipation. Conclusion: LTOWB attained through WBBs may be the only practical resuscitative fluid on maritime platforms without inherent blood product storage capabilities to perform remote damage control resuscitation. Future efforts should focus on optimizing WBBs through capability development, education, and training efforts.
Keywords: Low titer O; whole blood transfusion; damage control resuscitation; distributed maritime operations; walking blood bank
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
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
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
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
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
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
Banting J, Meriano T. 16(3). 57 - 61. (Journal Article)
Abstract
Concepts and Objectives: The series objective is to review various clinical conditions/ presentations, including the latest evidence on management, and to dispel common myths. In the process, core knowledge and management principles are enhanced. A clinical case will be presented. Cases will be drawn from real life but phrased in a context that is applicable to the Special Operations Forces (SOF) or tactical emergency medical support (TEMS) environment. Details will be presented in such a way that the reader can follow along and identify how they would manage the case clinically depending on their experience and environment situation. Commentary will be provided by currently serving military medical technicians. The medics and author will draw on their SOF experience to communicate relevant clinical concepts pertinent to different operational environments including SOF and TEMS. Commentary and input from active special operations medical technicians will be part of the feature.
Keywords: cervical spinal injury; Canadian C-spine rule, NEXUS Criteria; cervical collar
Banting J, Meriano T. 17(1). 76 - 76. (Journal Article)
Abstract
Keywords: biostatics, statistics; tests; specificity; sensitivity
Banting J, Meriano T. 17(2). 108 - 111. (Journal Article)
Abstract
Banting J, Meriano T. 17(4). 93 - 96. (Journal Article)
Abstract
Valenzuela J, Harrison C, Barajas J, Johnston EE. 20(4). 136 - 138. (Journal Article)
Abstract
During the Spring 2020 COVID surge, a team primarily composed of SOF medics coalesces in New York City, rapidly establishes a field hospital within a large academic teaching hospital, then transitions to step-down and ICU care as institutional needs evolve. Empowered to work as RNs, by emergency decree, the SOF medics, remarkable performance supports the need to define a novel role within the civilian healthcare system for these valuable, highly experienced, and underused providers.
Keywords: COVID-19; SOF medics; COVID surge; Special Operations; field hospital; RVT
Jackson SE, Baity MR, Thomas PR, Walker M, Goodkind M, Swick D, Barba D, Jacobson D, Byrd E, Ivey AS. 21(4). 46 - 53. (Journal Article)
Abstract
Background: Despite being a well-supported strategy, Stress Inoculation Training (SIT) has not been fully incorporated in the advancement of human performance among most military personnel. The RAND Study recommendations for maximizing SIT's potential within high-risk/ high-intensity occupational groups were used in designing the Core Training protocol targeting psychological performance, SIT-NORCAL (Part 1). Purpose: The current project (Part 2) sought to further develop the protocol as a health and human performance hybrid through quality improvement analysis of the content, process, and measurement elements for use in the human performance context. Methods: Evidence-based/evidence-driven methodologies were used in collaborative design tailored to the unique needs of special warfare enablers specializing in Explosive Ordnance Disposal (n = 17). The resultant three-phase training was conducted with a novice group (n = 10) using standardized measurements of collaboration, human performance, and adaptive capabilities on identified training targets. Results: Process elements demonstrated high feasibility, resulting in high collaboration and trainee satisfaction. Significant improvements in psychological performance targets were observed pre- to post-training, and during an Adaptive Environmental Simulation designed by unit members. Two weeks post-training, unit members (n = 5) responded to an actual crash of an F-16 aircraft; measurements indicated maintenance of skill set from training to real-world events. Conclusion: Deployment of the elements in the SIT-NORCAL protocol demonstrated early feasibility and positive training impact on occupationally relevant skills that carried over into real-world events.
Jackson SE, Baity MR, Thomas PR, Barba D, Jacobson D, Goodkind M, Swick D, Ivey AS. 21(4). 37 - 45. (Journal Article)
Abstract
Background: Stress inoculation training (SIT) interventions have demonstrated promise within military contexts for human performance enhancement and psychological health applications. However, lack of manualized guidance on core content selection, delivery, and measurement processes has limited their use. Purpose: The purpose of this study was to develop and evaluate a comprehensive SIT intervention protocol to enhance the performance and health of military personnel engaged in special warfare and first-response activities. Methods: Multidisciplinary teams of subject matter experts (n = 19) were consulted in protocol generation. The performance improvement/human performance technology (HPT) model was used in the selection, refinement, and measurement of core skills. The protocol was trialed and refined (44 cohorts, n = =300; 2013-2020) to generate the results. Results: Four primary aims were achieved: (1) The generation of a flexible, evidence-based/evidence-driven psychological performance and health sustainment hybrid, SIT-NORCAL. (2) Manualized content and process guidance. (3) The creation of multimedia materials using evidence-based methodologies. (4) The design of initial measurement systems. Preliminary quality improvement analysis demonstrated positive results using standard-of-care and performance enhancement assessments. Conclusion: Hybridized human performance and psychological health sustainment protocols represent a paradigm shift in the delivery of psychological performance training with the potential to overcome barriers to success in traditional care. Further study is needed to determine the effectiveness and reach of SIT-NORCAL.
Keywords: stress inoculation; training; performance training
Butler FK, Holcomb JB, Shackelford SA, Barbabella S, Bailey JA, Baker JB, Cap AP, Conklin CC, Cunningham CW, Davis MS, DeLellis SM, Dorlac WC, DuBose JJ, Eastridge BJ, Fisher AD, Glasser JJ, Gurney JM, Jenkins DA, Johannigman J, King DR, Kotwal RS, Littlejohn LF, Mabry RL, Martin MJ, Miles EA, Montgomery HR, Northern DM, O'Connor KC, Rasmussen TE, Riesberg JC, Spinella PC, Stockinger Z, Strandenes G, Via DK, Weber MA. 18(4). 37 - 55. (Journal Article)
Abstract
TCCC has previously recommended interventions that can effectively prevent 4 of the top 5 causes of prehospital preventable death in combat casualties-extremity hemorrhage, junctional hemorrhage, airway obstruction, and tension pneumothorax- and deaths from these causes have been markedly reduced in US combat casualties. Noncompressible torso hemorrhage (NCTH) is the last remaining major cause of preventable death on the battlefield and often causes death within 30 minutes of wounding. Increased use of whole blood, including the capability for massive transfusion, if indicated, has the potential to increase survival in casualties with either thoracic and/or abdominopelvic hemorrhage. Additionally, Zone 1 Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) can provide temporary control of bleeding in the abdomen and pelvis and improve hemodynamics in casualties who may be approaching traumatic cardiac arrest as a result of hemorrhagic shock. Together, these two interventions are designated Advanced Resuscitative Care (ARC) and may enable casualties with severe NCTH to survive long enough to reach the care of a surgeon. Although Special Operations units are now using whole blood far-forward, this capability is not routinely present in other US combat units at this point in time. REBOA is not envisioned as care that could be accomplished by a unit medic working out of his or her aid bag. This intervention should be undertaken only by designated teams of advanced combat medical personnel with special training and equipment.
Keywords: Advanced Resuscitative Care; Committee on Emergency Casualty Care; guidelines
Barbee GA, Booms Z. 14(3). 1 - 6. (Journal Article)
Abstract
The authors report five cases of pelvic hematoma without associated pelvic fracture after military static-line parachute operations, a significantly underreported injury. The case reports and discussion include initial emergency department presentation, stabilization requirements, and imaging, disposition, and management recommendations. Data were collected retrospectively through review of medical records from a single institution over the course of a single calendar year, 2012-2013. Pelvic hematoma should be strongly considered in the patient with lower abdominal, hip, or pelvic pain after blunt injury from parachute landing fall even in the absence of associated fracture. The cases discussed display this underreported injury and highlight the frequent necessity for admission to a high-acuity care center for close monitoring.
Keywords: hematoma; retroperitoneal hemorrhage; trauma; vertical shear injury; military static-line parachute jump
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.
Donham B, Barbee GA, Deaton TG, Kerr W, Wier RP, Fisher AD. 19(3). 24 - 25. (Journal Article)
Abstract
Fresh whole blood (FWB) is increasingly being recognized as the ideal resuscitative fluid for hemorrhagic shock. Because of this, military units are working to establish the capability to give FWB from a walking blood bank donor in environments that are unsupported by conventional blood bank services. Therefore, many military units are performing autologous blood transfusion training. In this training, a volunteer has a unit of blood collected and then transfused back into the same donor. The authors report their experience performing an estimated 3408 autologous transfusions in training and report no instances of hemolytic transfusion reactions or other major complications. With appropriate control measures in place, autologous FWB training is low-risk training.
Keywords: military personnel; blood transfusion; autologous; simulation training
Remley MA, Mosley D, Keenan S, Deaton TG, Montgomery HR, Kotwal RS, Barbee GA, Littlejohn LF, Wilson J, Hall C, Loos PE, Holcomb JB, Gurney J. 24(2). 111 - 113. (Classical Conference)
Abstract
Mccown M, Alleman A, Sayler KA, Chandrashekar R, Thatcher B, Tyrrell P, Stillman B, Beall M, Barbet AF. 14(4). 81 - 85. (Journal Article)
Abstract
Background: Based on the high tick-borne pathogen results from a 2011 surveillance study in three Colombian cities, an in-depth point prevalence survey was conducted to determine the seroprevalence of tick-borne pathogens at a specific point in time in 70 working dogs, 101 shelter dogs, and 47 client-owned dogs in Barranquilla, Colombia. Results: Of the 218 serum samples, 163 (74%) were positive for Ehrlichia canis and 116 (53%) for Anaplasma platys. Exposure to tick-borne pathogens was highest in shelter and working dogs where more than 90% of the samples were seropositive or positive on polymerase chain reaction for one or more organisms as compared to 51% in client-owned animals. Conclusion: Surveillance for exposure to tickborne pathogens provides vital information necessary to protect and conserve the health of local humans and animals, deployed military service members, and working dogs in various parts of the world. This study and resultant data demonstrate the value of following a broadbased surveillance study with a more specific, focused analysis in an area of concern. This area's high levels of exposure warrant emphasis by medical planners and advisors on precautionary measures for military dogs, Special Operations Forces personnel, and the local public.
Keywords: tick-borne pathogens; point prevalence; surveillance; US Military SOF; military working dogs; Colombia
Getz C, Stuart SM, Barbour BM, Verga JM, Roszko PJ, Friedrich EE. 22(4). 50 - 54. (Journal Article)
Abstract
Background: Surgical cricothyrotomy (SC) is a difficult procedure with high failure rates in the battlefield environment. The difficulty of this procedure is compounded in a low-light tactical environment in which white light cannot be used. This study compared the use of red-green (RG) light and red (R) light in the performance of SC in a low-light environment. Materials and Methods: Tactical Combat Casualty Care-certified navy corpsmen (n = 33) were provided 15 minutes of standardized instruction followed by hands-on practice with the Tactical CricKit and the H&H bougie-assisted Emergency Cricothyrotomy Kit. Participants acclimated to a dark environment for 30 minutes before performing SC on a mannequin with both devices using both R and RG light in a randomized order. Application time, success, participant preference, and participant confidence were analyzed. Results: There were similarly high levels of successful placement (>87.5%) in all four cohorts. Light choice did not appear to affect placement time with either of the two kits. On Likert-scale surveys, participants reported that RG decreased difficulty (p < .0001) and increased confidence (p < .0001) in performing the procedure. Conclusion: RG light increased confidence and decreased perceived difficulty when performing SC, though no differences in placement time or success were observed.
Keywords: light source; TCCC; red light; bougie-assisted; green light; white light; cricothyrotomy
Barczak-Scarboro NE, Cole WR, DeFreese JD, Fredrickson BL, Kiefer AW, Bailar-Heath M, Burke RJ, DeLellis SM, Kane SF, Lynch JH, Means GE, Depenbrock PJ, Mihalik JP. 22(3). 129 - 135. (Journal Article)
Abstract
Purpose: The present study investigated Special Operations Forces (SOF) combat Servicemember mental health at different SOF career stages in association with resilience. Methods: Fifty-eight SOF combat Service Members either entering SOF (career start; n=38) or multiple years with their SOF organization (mid-career; n=20) self-reported mild traumatic brain injury (TBI) history, resilience, subjective well-being, depression, anxiety, and posttraumatic stress. Poisson regression analyses were employed to test SOF career stage differences in each mental health symptom using resilience, while accounting for other pertinent military factors. Results: There were significant interaction effects of SOF career stage and resilience on mental health symptoms. SOF career start combat Servicemembers endorsed lower depression and posttraumatic stress and higher subjective well-being with higher resilience, but these associations between resilience and mental health symptoms were not seen in SOF mid-career Servicemembers. Conclusions: Although preliminary, the adaptive association between resilience and mental health seemed to be blunted in combat Servicemembers having served multiple years in SOF. This information informs research to provide evaluation tools to support prophylactic performance and long-term health preservation in military populations.
Keywords: depression; anxiety; posttraumatic stress; subjective well-being; military; concussion
Barczak-Scarboro NE, Cole WR, DeFreese JD, Fredrickson BL, Kiefer AW, Bailar-Heath M, Burke RJ, DeLellis SM, Kane SF, Lynch JH, Means GE, Depenbrock PJ, Mihalik JP. 22(3). 22 - 28. (Journal Article)
Abstract
Purpose: Our aim in this study was to psychometrically test resilience assessments (Ego Resiliency Scale [ER89], Connor-Davidson Resilience Scale [CD-RISC 25], Responses to Stressful Experiences Scale [RSES short-form]) and describe resilience levels in a Special Operations Forces (SOF) combat sample. Methods: Fifty-eight SOF combat Servicemembers either entering SOF (career start; n = 38) or having served multiple years with their SOF organization (mid-career; n = 20) self-reported resilience, mild traumatic brain injury (mTBI) history, and total military service. Results: All resilience metrics demonstrated acceptable internal consistency, but ceiling effects were found for CD-RISC and RSES scores. ER89 scores were moderate on average. ER89 scores were higher in SOF career start than mid-career Servicemembers (ηρ2 = 0.07) when accounting for the interaction between SOF career stage and total military service (ηρ2 = 0.07). Discussion: SOF mid-career Servicemembers had similar ER89 resilience scores with more total military service. The SOF career start combat Servicemembers had higher ER89 measured resilience with less total military service only, potentially showing a protective effect of greater service before entering SOF. Conclusion: The ER89 may be a more optimal military resilience metric than the other metrics studied; longitudinal research on SOF combat Servicemember resilience is warranted.
Keywords: ego resiliency; US Army; US Air Force; psychometrics; readiness
McCarthy R, Park GH, Barczak-Scarboro NE, Barrientos S, Chamberlin R, Hansom A, Messina LA. 23(3). 85 - 90. (Journal Article)
Abstract
The Total Force Fitness (TFF) framework was envisioned as a holistic framework of interrelated domains, whereby impact in one domain could have cascading implications for the others. For this reason, definitional clarity surrounding how to achieve fitness in the various domains is crucial. Social fitness definitions tend to focus on individual efforts and overlook the powerful impact of the social group and the social environment on the individual. In this article, various definitions of social fitness are analyzed in an effort to broaden the current understanding of the social domain. Some of the knowledge gaps in understanding social fitness and the resulting challenges are addressed before reviewing a few existing social fitness interventions. Finally, this study offers recommendations for improvement, along with future directions for the increased integration of the social domain into the TFF framework.
Keywords: social environment; social fitness; social domain; total force fitness; performance optimization
Taylor M, Barczak-Scarboro NE, Hernandez L. 23(3). 44 - 49. (Journal Article)
Abstract
Purpose: This report describes the development and validation of the U.S. Navy Explosive Ordnance Disposal (EOD) Combat Mindset Scale-Training (CMS-T), a population-specific measure of psychological strategy use in EOD training environments. Methods: Scale items were developed by a working group composed of active-duty technicians from EOD Training and Evaluation Unit 1, Naval Health Research Center scientists, and a psychometrician. The working group developed 30 candidate items, which were administered to EOD accessions (new recruits), advanced students, and technicians (N = 164). Factor structure was explored with principal axis factoring and Varimax rotation with Kaiser normalization. Internal consistencies were established via Cronbach alpha, and convergent validity was evaluated with correlational and ANOVA models. Results: Five internally stable subscales were derived from 19 essential items, explaining 65% of total variance. The subscales were named relaxation, attentional-emotional control (AEC), goal setting-visualization (GSV), internal dialogue (ID), and automaticity. The most frequently used strategies were GSV and ID. Expected relationships emerged between strategies, most notably AEC and mental health. The scale also differentiated between subgroups. Conclusion: The EOD CMS-T demonstrates a stable factor structure, internal reliability, and convergent validity. This study yields a valid, practical, and easily administered instrument to support EOD training and evaluation.
Keywords: stress; military; psychological strategies; explosive ordnance disposal; Special Operations
Rush S, Lauria MJ, DeSoucy ES, Koch EJ, Kamler JJ, Remley MA, Alway N, Brodie F, Barendregt P, Miller K, Hines R, Champagne M, Paladino L, Shackelford SA, Miles EA, Dorlac WC, Gurney J, Robb D, Kue RC. 24(3). 24 - 29. (Journal Article)
Abstract
Herein, we present a simplified approach to prehospital mass casualty event (MASCAL) management called "Move, Treat, and Transport." Prior publications demonstrate a disconnect between MASCAL response training and actions taken during real-world incidents. Overly complex algorithms, infrequent training on their use, and chaotic events all contribute to the low utilization of formal triage systems in the real world. A review of published studies on prehospital MASCAL management and a recent series of military prehospital MASCAL responses highlight the need for an intuitive MASCAL management system that accounts for expected resource limitations and tactical constraints. "Move, Treat, and Transport" is a simple and pragmatic approach that emphasizes speed and efficiency of response; considers time, tactics, and scale of the event; and focuses on interventions and evacuation to definitive care if needed.
Keywords: MASCAL; mass casualty incident; prehospital care; triage; emergency preparedness
Rush S, Lauria MJ, DeSoucy ES, Koch EJ, Kamler JJ, Remley MA, Alway N, Brodie F, Foudrait A, Barendregt P, Atkins M, Miller K, Hines R, Champagne M, Paladino L, Shackelford SA, Miles EA, Obiajulu J, Dorlac WC, Gurney J, Robb D, Kue RC. 24(3). 62 - 66. (Case Reports)
Abstract
Introduction: Mass casualty events (MASCALs) in the combat environment, which involve large numbers of casualties that overwhelm immediately available resources, are fundamentally chaotic and dynamic and inherently dangerous. Formal triage systems use diagnostic algorithms, colored markers, and four or more named categories. We hypothesized that formal triage systems are inadequately trained and practiced and too complex to successfully implement in true MASCAL events. This retrospective analysis evaluates the real-world application of triage systems in prehospital military MASCALs and other aspects of MASCAL management. Methods: We surveyed Special Operations Forces (SOF) medics known to us who have participated in military prehospital MASCALs and analyzed them. Aggregated data describing the scope of the incidents, the use of formal triage algorithms and colored markers, the number of categories, and the interventions on scene were analyzed using descriptive statistics, and lessons learned were consolidated. Results: From 1996 to 2022 we identified 29 MASCALs that were managed by military medics in the prehospital setting. There was a median of three providers (range 1-85) and 15 casualties (range 6-519) per event. Four or more formal triage categories were used in only one event. Colored markers and formal algorithms were not used. Life-saving interventions were performed in 27 of 29 (93%) missions and blood transfusions were performed in four (17%) MASCALs. The top lessons learned were: 1) security and accountability are cornerstones of MASCAL management; 2) casualty movement is a priority; 3) intuitive triage categories are the default; 4) life-saving interventions are performed as time and tactics permit. Conclusion: Formal triage systems requiring the use ofdiagnostic algorithms, colored tags, and four or five categories are seldom implemented in real-world military prehospital MASCAL management. The training of field triage should be simplified and pragmatic, as exemplified by these instances.
Keywords: mass casualty management; triage; MASCAL; survey; SOF medics
Fatima H, Kuppalli S, Baribeau V, Wong VT, Chaudhary O, Sharkey A, Bordlee JW, Leibowitz A, Murugappan K, Pannu A, Rubenstein LA, Walsh DP, Kunze LJ, Stiles JK, Weinstein J, Mahmood F, Matyal R, Lodico DN, Mitchell J. 21(4). 54 - 61. (Journal Article)
Abstract
Background: Advances in ultrasound technology with enhanced portability and high-quality imaging has led to a surge in its use on the battlefield by nonphysician providers. However, there is a consistent need for comprehensive and standardized ultrasound training to improve ultrasound knowledge, manual skills, and workflow understanding of nonphysician providers. Materials and Methods: Our team designed a multimodal ultrasound course to improve ultrasound knowledge, manual skills, and workflow understanding of nine Special Operations combat medics and Special Operations tactical medics. The course was based on a flipped classroom model with a total time of 43 hours, consisting of an online component followed by live lectures and hands-on workshops. The effectiveness of the course was determined using a knowledge exam, expert ratings of manual skills using a global rating scale, and an objective structured clinical skills examination (OSCE). Results: The average knowledge exam score of the medics increased from pre-course (56% ± 6.8%) to post-course (80% ± 5.0%, p < .001). Based on expert ratings, their manual skills improved from baseline to day 4 of the course for image finding (p = .007), image optimization (p = .008), image acquisition speed (p = .008), final image quality (p = .008), and global assessment (p = .008). Their average score at every OSCE station was > 91%. Conclusion: A comprehensive multimodal training program can be used to improve military medics' ultrasound knowledge, manual skills, and workflow understanding for various applications of ultrasound. Further research is required to develop a reliable, sustainable course.
Keywords: ultraound; medics; competency; curriculum
Baribeau V, Murugappan K, Sharkey A, Lodico DN, Walsh DP, Lin DC, Wong VT, Weinstein J, Matyal R, Mahmood F, Mitchell JD. 23(1). 67 - 73. (Journal Article)
Abstract
Background: Point-of-care ultrasound (POCUS) is commonly employed to image the heart, lungs, and abdomen. Rapid ultrasound for shock and hypotension (RUSH) exams are a critical component of POCUS employed in austere environments by Special Operations Forces (SOF) and tactical medics for triage and diagnosis. Despite its utility, training for POCUS remains largely unstandardized with respect to feedback and markers of proficiency. We hypothesized that motion analysis could objectively identify improvement in medics' performance of RUSH exams. Furthermore, we predicted that motion metrics would correlate with qualitative ratings administered by attending anesthesiologists. Methods: A team of civilian and military attending anesthesiologists trained 24 medics in POCUS during a 5-day course. Each medic performed eight RUSH exams using an ultrasound probe equipped with an electromagnetic motion sensor to track total distance travelled (path length), movements performed (translational motions), degrees rotated (rotational sum), and time. Instructors (experts) observed and rated the exams on the following items: image finding, image fine-tuning, speed, final image accuracy, and global assessment. Motion metrics were used to provide feedback to medics throughout the course. Generalized estimating equations were used to analyze the trends of motion metrics across all trials. Correlations amongst motion metrics and expert ratings were assessed with Pearson correlation coefficients. Results: Participants exhibited a negative trend in all motion metrics (p < 0.001). Pearson correlation coefficients revealed moderate inverse correlations amongst motion metrics and expert ratings. Conclusion: Motion analysis was able to quantify and describe the performance of medics training in POCUS and correlated with expert ratings.
Keywords: medic; motion analysis; point-of-care ultrasound; POCUS; rapid ultrasound for shock and hypotension
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
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
Reynolds ME, Hoover C, Riesberg JC, Mazzoli RA, Colyer M, Barnes S, Calvano CJ, Karesh JW, Murray CK, Butler FK, Keenan S, Shackelford S. 17(4). 115 - 126. (Journal Article)
Abstract
Keywords: ocular injuries; vision-threatening conditions; prolonged field care; clinical practice guidelines
Fuentes RW, Shawler EK, Smith WD, Tong RL, Barnes WJ, Moncada M, Bohlke CW, Mitchell AL. 22(3). 9 - 14. (Journal Article)
Abstract
Background: Transfusion of whole blood (WB) is a lifesaving treatment that prolongs life until definitive surgical intervention can be performed; however, collecting WB is a time-consuming and resource-intensive process. Furthermore, it may be difficult to collect sufficient WB at the point of injury to treat critically wounded patients or multiple hemorrhaging casualties. This study is a follow-up to the proof-of-concept study on the effect of airdrop on WB. In addition, this study confirms the statistical significance for the plausibility of using airdrop to deliver WB to combat medics treating casualties in the pre-hospital setting when Food and Drug Administration (FDA)-approved cold-stored blood products are not available. Methods: Forty-eight units of WB were collected and loaded into a blood cooler that was dropped from a fixed-wing aircraft under a Standard Airdrop Training Bundle (SATB) parachute or 68-in pilot chute. Twenty-four of these units were dropped from a C-145 aircraft, and 24 were dropped from a C-130 aircraft. A control group of 15 units of WB was storedin a blood cooler that was not dropped. Baseline and post-intervention laboratory tests were measured in both airdroppedand control units, including complete blood count; prothrombin time/partial thromboplastin time (PT/PTT); pH, lactate, potassium, bilirubin, glucose, fibrinogen, and lactate dehydrogenase (LDH) levels; and peripheral blood smears. Results: The blood cooler, cooling packs, and all 48 WB units did not sustain any major damage from the airdrop. There was no evidence of hemolysis. Except for the one slightly damaged bag that was not sampled, all airdropped blood met parameters for transfusion per the Joint Trauma System Whole Blood Transfusion Clinical Practice Guideline and the Association for the Advancement of Blood and Biotherapies (AABB) Circular of Information for the Use of Human Blood and Blood Components. Conclusions: Airdrop of fresh or stored WB in a blood cooler with a chute is a viable way of delivering blood products to combat medics treating hemorrhaging patients in the pre-hospital setting. This study also demonstrated the portability of this technique for multiple aircraft. The techniques evaluated in this study have the potential for utilizationin other austere settings such as wilderness medicine or humanitarian disasters where an acute need for WB delivery by airdrop is the only option.
Keywords: whole blood transfusion; airdrop; airdrop blood; aerial resupply; Tactical Combat Casualty Care
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
Washington M, Kajiura L, Leong MK, Agee W, Barnhill JC. 15(1). 100 - 104. (Journal Article)
Abstract
Staphylococcus sciuri is an emerging gram-positive bacterial pathogen that is infrequently isolated from cases of human disease. This organism is capable of rapid conversion from a state of methicillin sensitivity to a state of methicillin resistance and has been shown to express a set of highly effective virulence factors. The antibioticresistance breakpoints of S. sciuri differ significantly from the more common Staphylococcus species. Therefore, the rapid identification of S. sciuri in clinical material is a prerequisite for the proper determination of the antibiotic- resistance profile and the rapid initiation of antimicrobial therapy. Here, we present a brief literature review of S. sciuri and an entomological case study in which we describe the colonization of an American cockroach with this agent. In addition, we discuss potential implications for the distribution and evolution of antibiotic- resistant members of the genus Staphylococcus.
Keywords: bacteriology; entomology; operating environment; preventive medicine
Washington M, Barnhill JC, Duff MA, Griffin J. 15(4). 113 - 116. (Journal Article)
Abstract
Acute and chronic wound infections can both be encountered in the deployed setting. These wounds are often contaminated by bacteria and fungi derived from the external environment. In this article, we present the case of a wound infection simultaneously colonized by Enterobacter cloacae (a bacterial pathogen) and Trichosporon asahii (an unusual fungal pathogen). We describe the examination and treatment of the patient and review the distinguishing characteristics of each organism
Keywords: infection; bacteria; fungi; Enterobacter cloacae; Trichosporon asahii
Griffin J, Barnhill JC, Washington MA. 19(1). 14 - 15. (Case Reports)
Abstract
The genus Acinetobacter has long been associated with war wounds. Indeed, A baumannii was responsible for so many infected wounds during Operation Iraqi Freedom that it was given the nickname "Iraqibacter." Therefore, it is important to monitor the occurrence and spread of Acinetobacter species in military populations and to identify new or unusual sources of infection. A junii is an infrequently reported human pathogen. Here, we report a case of a slow-healing wound infection with A junii in a woman on the island of Oahu. This case highlights the pathogenic potential of this organism and the need for proper wound care when dealing with slow-healing wounds of unknown etiology. It also underscores the need for identifying species of Acinetobacter that are not A baumannii to better understand the epidemiology of slow-healing wound infections.
Keywords: Acinetobacter junii; emerging infection; Hawaii; Oahu; wound
Peters AM, Yu I, Menguito M, Morrow S, Barnhill JC, Washington MA. 21(2). 85 - 88. (Journal Article)
Abstract
Background: Female Servicemembers are increasingly being incorporated into the combat arms and Special Operations communities. Female urinary diversion devices (FUDDs) have been used to facilitate urination in the austere environments that are encountered by Servicemembers. Importantly, the potential for the bacterial contamination of these devices has not been evaluated. The goals of this study were to determine whether microorganisms adhere to the surfaces of FUDDs in the field environment and to demonstrate the presence of potential pathogens on the used devices. Materials and Methods: A total of 15 devices that were used in a comprehensive 18-24-hour military field exercise were tested for the presence of microorganisms. Briefly, each device was swabbed, and the swabs were used to inoculate blood agar plates to encourage bacterial growth. The resulting bacterial colonies were identified, and the surface topography of the devices was investigated with electron microscopy. Results: Although microscopy revealed few surface features capable of facilitating bacterial attachment, several species were recovered. Significantly, a biofilm-forming strain of Proteus mirabilis (P. mirabilis) was detected on two of the devices. P. mirabilis is a mobile urinary pathogen that can potentially migrate from the surface of the device into the urinary tract of the user. Conclusion: Commercial FUDDs can support bacterial growth and harbor potential pathogens. Care should be taken to ensure that Servicemembers are aware of the importance of the proper care and cleaning of these devices in the field environment. To this end, standard operating procedures should be developed and distributed.
Keywords: female Servicemembers; female urinary diversion devices; urination; austere environment; Proteus mirabilis
Melanson V, Hershfield J, Deegan MK, Cho H, Perinon D, Bateman SL, Barnhill JC. 23(3). 63 - 69. (Journal Article)
Abstract
Massive hemorrhaging remains the most common cause of preventable battlefield deaths. Blood used for trauma care requires a robust donation network, capacity for long-term storage, and extensive and accurate testing. Bioengineering technologies could offer a remedy to these constraints in the form of blood substitutes-fluids that could be transfused into patients to provide oxygen, carry away waste, and aid in coagulation-that would be used in prolonged casualty care and in far-forward settings, overcoming the obstacles of distance and time. The different molecular properties of red blood cells (RBCs), blood substitutes, and platelet replacements contribute to their respective utilities, and each type is currently represented in ongoing clinical trials. Hemoglobin oxygen carriers (HBOCs) are the most advanced RBC replacements, many of which are currently being evaluated in clinical trials in the United States and other countries. Despite recent advancements, challenges remaining in the development of blood alternatives include stability, oxygen capacity, and compatibility. The continued research and investment in new technologies has the potential to significantly benefit the treatment of life-threatening emergency injuries, both on the battlefield and in the civilian sector. In this review, we discuss military blood-management practices and military-specific uses of individual blood components, as well as describe and analyze several artificial blood products that could be options for future battlefield use.
Keywords: artificial blood; blood substitutes; red blood cell substitutes; platelet replacements; biomanufacturing
Welch M, Barratt J, Peters A, Wright C. 21(4). 63 - 65. (Journal Article)
Abstract
Background: We sought to test whether Celox topical hemostatic dressing (Medtrade Products) would maintain hemostasis in extended use. Methods: An anesthetized swine underwent bilateral arteriotomies and treatment with topical hemostatic dressings in line with the Kheirabadi method. The dressings were covered with standard field dressings, and these were visually inspected for bleeding every 2 hours until 8 hours, when the swine was euthanized. Results: There was no evidence of rebleeding at any point up to and including 8 hours. The Celox dressings maintained hemostasis in extended use. Conclusion: Celox topical hemostatic dressing is effective for extended use and maintains hemostasis. It should be considered for use in situations in which evacuation and definitive care may be delayed.
Keywords: hemostatic; trauma; prehospital; hemorrhage; military
Saxon L, Faulk RT, Barrett T, McLelland S, Boberg J. 22(4). 78 - 82. (Journal Article)
Abstract
The role of US Special Operations Forces (SOF) globally has expanded greatly in the past 20 years, leaving SOF serving multiple deployments with little time or ability to recover in between. Currently, assessments of the health and human performance capabilities of these individuals are episodic, precluding an accurate assessment of physical and mental load over time, and leading to high rates of acute and chronic injury to the mind and body. The collection of personal health-related continuous datasets has recently been made feasible with the advancement of digital technologies. These comprehensive data allow for improved assessment, and consequently better results, partly due to the warfighters' real-time access to their data. Such information allows Soldiers to engage in their own health optimization. This article describes a research platform that allows for collection of data via a custom-made secure mobile application that extends the type, scope, and frequency of data collection beyond what is feasible during an in-person encounter. By digitizing existing assessments and by incorporating additional physical, neurocognitive, psychological, and lifestyle assessments, the platform provides individuals with the ability to better understand their mental and physical load, as well as reserve. The results of this interactive exchange may help to preserve the health of users as well as the stability and readiness of units.
Keywords: mobile applications; military personnel; digital technology; data visualization; wearable electronic devices; health behavior; computer security