Sign up here for your FREE 3-day digital trial.
JSOM Header

Journal of Special Operations Medicine Author Index

The Journal of Special Operations medicine author index displays all of our articles grouped by author. Simply click on the author in whose work you are interested, and you will be taken to a list of tactical medicine articles written by that author. We hope that you find this list of peer-reviewed journal articles sorted by author to be a useful tool in your research.

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

A

B

C

D

E

F

G

H

I

J

K

L

M

N

O

P

Q

R

S

T

U

V

W

Y

Z

Author: Aberle SJ

Top

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

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

Abstract

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

Keywords: TEMS; emergency medical services; tactical; SWAT

Buy Now

Author: Abt JP

Top

Warrior Model For Human Performacne And Injury Prevention: Eagle Tactical Athlete Program (ETAP) Part I

Sell TC, Abt JP, Crawford K, Lovalekar M, Nagai T, Deluzio J, Smalley BW, McGrail MA, Rowe RS, Cardin S, Lephart SM. 10(3). 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.

Warrior Model For Human Performance And Injury Prevention: Eagle Tactical Athlete Program (ETAP) Part II

Abt JP, Sell TC, Crawford K, Lovalekar M, Nagai T, Deluzio J, Smalley BW, McGrail MA, Rowe RS, Cardin S, Lephart SM. 10(3). 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.

Author: Acharya SV

Top

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

Tien HC, Jung V, Rizoli SB, Acharya SV, MacDonald JC. 09(4). 65 - 68. (Previously Published)
Previously published in the Journal of the American College of Surgeons, Vol. 207, No. 2, August 2008. Republished in JSOM with permission of Elsevier.

Abstract

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

Author: Acierto D

Top

A Herpes Zoster Outbreak on the Sinai Peninsula

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

Abstract

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

Keywords: shingles; herpes zoster; operational medicine; Sinai

Buy Now

Author: Adams B

Top

Management of Burn Wounds Under Prolonged Field Care

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

Author: Adams BD

Top

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

Mabry RL, Cuniowski P, Frankfurt A, Adams BD. 11(2). 16 - 19. (Journal Article)

Abstract

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

Buy Now

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

Gerhardt RT, Berry J, Mabry RL, Flournoy L, Arnold RG, Hults C, Robinson JB, Thaxton RA, Cestero R, Heiner JD, Koller AR, Cox KM, Patterson JN, Dalton WR, McKeague AL, Gilbert G, Manemeit C, Adams BD. 14(1). 50 - 57. (Journal Article)

Abstract

Objective: We sought to determine whether Contingency Telemedical Support (CTS) improves the success rate and efficiency of primary care providers performing critical actions during simulated combat trauma resuscitation. Critical actions included advanced airway, chest decompression, extremity hemorrhage control, hypothermia prevention, antibiotics and analgesics, and hypotensive resuscitation, among others. Background: Recent studies report improved survival associated with skilled triage and treatment in the out-of-hospital/preoperative phase of combat casualty care. Historically, ground combat units are assigned primary care physicians and physician assistants as medical staff, due to resource limitations. Although they are recognized as optimal resuscitators, demand for military trauma surgeons and emergency physicians exceeds supply and is unlikely to improve in the near term. Methods: A prospective trial of telemedical mentoring during a casualty resuscitation encounter was studied using a high-fidelity patient simulator (HFPS). Subjects were randomized and formed into experimental (CTS) or control teams. CTS team leaders were equipped with a headset/microphone interface and telementored by a combat-experienced emergency physician or trauma surgeon. A standardized, scripted clinical scenario and HFPS were used with 14 critical actions. At completion, subjects were surveyed. Statistical approach included contingency table analysis, two-tailed t-test, and correlation coefficient. This study was reviewed and approved by our institutional review board (IRB). Results: Eighteen CTS teams and 16 control teams were studied. By intention-to-treat ITT analysis, 89% of CTS teams versus 56% of controls completed all life-threatening inventions (LSIs) (p < .01); 78% versus 19% completed all critical actions (p < .01); and 89% versus 56% established advanced airways within 8 minutes (p < .06). Average time to completion in minutes (95% confidence interval [CI] 95) was 12 minutes (10-14) for CTS versus 18 (16-20) for controls, with 75% of control teams not completing all critical actions. Conclusion: In this model, real-time telementoring of simulated trauma resuscitation was feasible and improved accuracy and efficiency of non-emergency-trained resuscitators. Clinical validation and replicated study of these findings for guiding remote damage control resuscitation are warranted.

Keywords: military medicine; war; emergency medical services; resuscitation; telemedicine; wounds and injuries

Buy Now

Author: Aden JK

Top

U.S. Military Experience With Junctional Wounds in War From 2001 to 2010

Kragh JF, Dubick MA, Aden JK, McKeague AL, Rasmussen TE, Baer DG, 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

Buy Now

Emergency Tourniquet Effectiveness in Four Positions on the Proximal Thigh

Kragh JF, Wallum TE, Aden JK, Dubick MA, Baer DG. 14(1). 26 - 29. (Journal Article)

Abstract

Objective: The purpose of the present study is to determine the performance of tourniquet use by the placement of the tourniquet's windlass on the extremity in four positions-medial, lateral, anterior, and posterior-to inform tourniquet instructors and develop best tourniquet practices. Methods: A HapMed™ Leg Tourniquet Trainer was used as a manikin to test the effectiveness of an emergency tourniquet, the Special Operations Forces Tactical Tourniquet. Two users made 10 tests, each in four positions. Results: Effectiveness rates of tourniquet use were 100% in all four positions. The two tourniquet users were both right-hand dominant and used their right hand to turn the windlass. One user turned the windlass clockwise, and the other turned it counterclockwise. The association between time to stop bleeding and tourniquet position was statistically significant but associations between time to stop bleeding and the user, user-by-position, and windlass turn number were not statistically significant. The association between tourniquet position and pressure under the tourniquet was statistically significant, and the association between user and pressure under the tourniquet was statistically significant, but the user-by-position and windlass turn number were not statistically significant. The associations between tourniquet position and blood loss volume, user and blood loss volume, and user-by-position and blood loss volume were statistically significant. Conclusions: The present study found that tourniquet effectiveness rates were uniformly 100% irrespective of whether the windlass position was medial, lateral, anterior, or posterior. These excellent clinical and statistical results indicate that users may continue to place the tourniquets as they prefer upon the proximal thigh.

Keywords: first aid; resuscitation; damage control; hematoma; trauma; shock

Buy Now

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

Kragh JF, Parsons DL, Kotwal RS, Kheirabadi BS, Aden JK, Gerhardt RT, Baer DG, Dubick MA. 14(3). 58 - 63. (Journal Article)

Abstract

Background: Junctional hemorrhage is a common cause of death on the battlefield, but there is no documented direct comparison for the use of junctional tourniquet models by US medics. The purpose of this testing is to assess military medic experience with the use of junctional tourniquets in simulated out-of-hospital trauma care. Methods: Nine medics (seven men and two women) used four different junctional tourniquets: Combat Ready Clamp™ (CRoC™; http://www.combatmedicalsystems .com), Abdominal Aortic and Junctional Tourniquet™ (AAJT™; http://www.compressionworks.net), Junctional Emergency Treatment Tool (JETT™; http://www.narescue .com), and SAM Junctional Tourniquet® (SJT®; http:// www.sammedical.com/products). These medics also acted as simulated casualties. Effectiveness percentages, as measured by stopped distal pulse by Doppler auscultation, and time to effectiveness were recorded in two tests per tourniquet (72 total tests). Tourniquet users ranked their preference of model by answering the question: "If you had to go to war today and you could only choose one, which tourniquet would you choose to bring?" Results: All tourniquets used were safe under the conditions of this study. Both the SJT and the CRoC had high effectiveness percentages; their rate difference was not statistically significant. The SJT and the CRoC had fast times to effectiveness; their time difference was not statistically significant. Users preferred the SJT and the CRoC; their ranked difference was not statistically significant. Conclusion: The SJT and the CRoC were equally effective and fast and were preferred by the participants.

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

Buy Now

Laboratory Testing of Emergency Tourniquets Exposed to Prolonged Heat

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

Abstract

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

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

Buy Now

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

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

Abstract

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

Altamirano MP, Kragh JF, Aden JK, Dubick MA. 15(2). 42 - 46. (Journal Article)

Abstract

Background: In emergencies when commercially designed tourniquets are unavailable, hemorrhage may need to be controlled with improvised tourniquets. In the aftermath of the Boston Marathon bombing, no improvised strap-and-windlass tourniquets were used to treat casualties; tourniquets without windlasses were used. The purpose of the present study is to determine the effectiveness of improvised tourniquets with and without a windlass to better understand the role of the windlass in tightening the tourniquet strap. Methods: An experiment was designed to test the effectiveness of improvised strap-and-windlass tourniquets fashioned out of a tee shirt on a manikin thigh. Two users conducted 40 tests each with and without the use of a windlass. Results: Without a windlass, improvised tourniquets failed to stop bleeding in 99% of tests (79 of 80 tests). With a windlass, improvised tourniquets failed to stop bleeding in 32% of tests (ρ < .0001). In tests with no windlass, attempts to stop the pulse completely failed (100%, 80 of 80 tests). With a windlass, however, attempts to stop the pulse failed 31% of the time (25 of 80 tests); the difference in proportions was significant (ρ < .0001). Conclusions: Improvised strap-and-windlass tourniquets were more effective than those with no windlass, as a windlass allowed the user to gain mechanical advantage. However, improvised strap-and-windlass torniquets failed to control hemorrhage in 32% of tests.

Keywords: first aid; hemorrhage; tourniquet; shock; damage control; tourniquet, makeshift; tourniquet, homemade; strap-and-windlass

Buy Now

Testing Tourniquet Use in a Manikin Model: Two Improvised Techniques

Lyles WE, Kragh JF, Aden JK, Dubick MA. 15(4). 21 - 26. (Journal Article)

Abstract

Background: Improvised tourniquets may be used to treat limb wound hemorrhage, but there is little evidence for best techniques of use. The purpose of the present study is to compare use of two techniques of improvised tourniquet application and use of a common commercial tourniquet that is nonimprovised. Methods: A laboratory experiment was conducted to assess three groups of strap-and-windlass tourniquet designs on a manikin to test for differences in performance. Groups included two types of improvised tourniquets (bandage and bandana) and a third group that served as a control, the commercial Combat Application Tourniquet. Two users performed 10 tests of each group. Results: The commercial CAT had 100% effectiveness, but both improvised tourniquets had poor effectiveness (40% and 10% for the bandage and bandana groups, respectively). The commercial CAT performed fastest; the two improvised tourniquet groups were slower than the commercial group (p < .0001, both) but were not statistically different from each other. All time-of-application results in the commercial group were less than the minimums of either improvised group. The commercial CAT had the highest mean pressures, and all such pressures were within safe and effective ranges. Low pressures generated by both improvised tourniquet groups were ineffective. All results of simulated blood loss with the commercial CAT group were less than the minimums of either improvised tourniquet group. Conclusion: In the present experiment, the commercial CAT performed better than either improvised tourniquet.

Keywords: first aid; hemorrhage; resuscitation; groin; inguinal; medical device; injuries; wounds; tourniquet

Buy Now

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

Kragh JF, Moore VK, Aden JK, Parsons DL, Dubick MA. 16(1). 14 - 17. (Journal Article)

Abstract

Background: The Combat Application Tourniquet® (C-A-T) is the standard-issue military tourniquet used in first aid in 2015, and the current model is called Generation 6. Soldiers in the field, however, have been asking for design changes in a possible Generation 7 to improve ease of use. This study compared the differential performance in use of the C-A-T in two designs: Generation 6 (C-A-T 6) versus a prototype Generation 7 (C-A-T 7). Methods: A laboratory experiment was designed to test the performance of two tourniquet designs in hemorrhage control, ease of use, and user preference. Ten users of the two C-A-T models placed them on a manikin thigh to stop simulated bleeding. Users included trauma researchers and instructors of US Army student medics. Ten users conducted 20 tests (10 each of both designs). Results: Most results were not statistically significant in their difference by C-A-T design. The mean difference in blood loss was statistically significant (ρ = .03) in that the C-A-T 7 performed better than the C-A-T 6, but only in the mixed statistical model analysis of variance, which accounted for user effects. The difference in ease-of-use score was statistically significant (ρ = .002); the C-A-T 7 was easier. All users preferred the C-A-T 7. Conclusion: In each measure, the C-A-T Generation 7 prototype performed similar or better than Generation 6, was easier to use, and was preferred.

Keywords: first aid; damage control; hemorrhage; shock; tourniquet; resuscitation

Buy Now

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

Gibson R, Housler GJ, Rush SC, Aden JK, Kragh JF, Dubick MA. 16(1). 29 - 35. (Journal Article)

Abstract

Background: Emergency tourniquet use has been associated with hemorrhage control and improved survival during the wars since 2001. The purpose of the present study is to compare the differential performance of two new tactical tourniquets with the standard-issue tourniquet to provide preliminary evidence to guide decisions on device development. Methods: A laboratory experiment was designed to test the effectiveness of tourniquets on a manikin thigh. Three models of tourniquets were assessed. The Rapid Application Tourniquet System (RATS) and the Tactical Mechanical Tourniquet (TMT) were compared with the standard-issue Combat Application Tourniquet® (C-A-T). Two users conducted 30 tests each. Results: Percentages for effectiveness (hemorrhage control, yes/no) and distal pulse cessation did not differ significantly by model. When compared with the RATS, the C-A-T performed better (ρ < .001) for time to hemorrhage control and fluid loss. The C-A-T and TMT had comparable responses for most measures, but the C-A-T applied more pressure (ρ = .04) than did the TMT for hemorrhage control. Conclusion: All three tactical tourniquets showed substantial capacity for hemorrhage control. However, the two new tourniquet models (RATS and TMT) did not offer any improvement over the C-A-T, which is currently issued to military services. Indeed, one of the new models, the RATS, was inferior to the C-A-T in terms of speed of application and simulated loss of blood. Opportunities were detected for refinements in design of the two new tourniquets that may offer future improvements in their performance.

Keywords: first aid; damage control; hemorrhage; shock; tourniquet; resuscitation

Buy Now

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

Chen J, Benov A, Nadler R, Landau G, Sorkin A, Aden JK, Kragh JF, Glassberg E. 16(1). 36 - 42. (Journal Article)

Abstract

Background: Junctional hemorrhage is a common cause of battlefield death but little is known about testing of junctional tourniquet models by medics. The purpose of the testing described herein is to assess military experience in junctional tourniquet use in simulated prehospital care. Methods: Fourteen medics were to use the following four junctional tourniquets: Combat Ready Clamp (CRoC), Abdominal Aortic Junctional Tourniquet (AAJT), Junctional Emergency Treatment Tool (JETT), and SAM Junctional Tourniquet (SJT). The five assessment categories were safety, effectiveness, time to effectiveness, and two categories of user preference: (1) by all models assessed, and (2) by only the model most preferred. Users ranked preference by answering, "If you had to go to war today and you could only choose one, which tourniquet would you choose to bring?" Results: All tourniquet uses were safe. By the time the first five testers were done, all three AAJT models had been broken. CRoC and AAJT had the highest percentage effectiveness as their difference was not statistically significant. SJT and JETT had fastest mean times to effectiveness as their difference was not significant. For preference, using each user's ranking of all models assessed, SJT and AAJT were most preferred as their difference was not significant. For each user's most preferred model, SJT, AAJT, and JETT were most preferred as their difference was not significant. Conclusion: In the five assessment categories, multiple tourniquet models performed similarly well; SJT and AAJT performed best in four categories, JETT was best in three, and CRoC was best in two. Differences between the top-ranked models in each category were not statistically significant.

Keywords: tourniquets; hemorrhage; resuscitation; groin; inguinal; medical device; injuries; wounds

Buy Now

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

Gibson R, Aden JK, Dubick MA, Kragh JF. 16(2). 21 - 27. (Journal Article)

Abstract

Background: Emergency tourniquet use has been associated with hemorrhage control and improved survival during the wars since 2001, but little is known of the differential performance of pneumatic tourniquet models. The purpose of this study was to compare the performance of three models of pneumatic tourniquets in a laboratory setting to aid a possible decision to field test suitable models for medic preference. Methods: A laboratory experiment was designed to test the effectiveness of tourniquets on a manikin thigh. Three models (one Emergency and Military Tourniquet [EMT] and two Tactical Pneumatic Tourniquets differing in width: 2 in. and 3 in. [TPT3]) were compared with the standard-issue Combat Application Tourniquet of a strap-and-windlass design. Two users conducted 40 tests each on a right-thigh manikin (HapMed Leg Tourniquet Trainer) with a simulated above-knee amputation injury. Measurements included effectiveness in hemorrhage control, pulse stoppage distal to the tourniquet, time to stop bleeding, blood loss, and pressure. Results: All four models were 100% effective in both hemorrhage control and pulse stoppage distal to the tourniquet. The TPT3 had the slowest mean time to stop bleeding and the highest mean blood loss. The EMT had the least mean pressure. An interuser difference was found only for mean pressure. Conclusions: All models of tourniquet performed equally well for both the critical outcome of effectiveness and the important outcome of pulse stoppage, whereas results for secondary outcomes (time, pressure, and blood loss) differed by model. The EMT had best performance for every type of measurement.

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

Buy Now

Preliminary Measures of Instructor Learning in Teaching Junctional Tourniquet Users

Kragh JF, Aden JK, Shackelford S, Dubick MA. 16(2). 13 - 15. (Journal Article)

Abstract

Background: The objective of the present study was to assess the effect of instructor learning on student performance in use of junctional tourniquets. Methods: From a convenience sample of data available after another study, we used a manikin for assessment of control of bleeding from a right groin gunshot wound. Blood loss was measured by the instructor while training users. The data set represented a group of 30 persons taught one at a time. The first measure was a plot of mean blood loss volumes for the sequential users. The second measure was a plot of the cumulative sum (CUSUM) of mean blood loss (BL) volumes for users. Results: Mean blood loss trended down as the instructor gained experience with each newly instructed user. User performance continually improved as the instructor gained more experience with teaching. No plateau effect was observed within the 30 users. The CUSUM plot illustrated a turning point or cusp at the seventh user. The prior portion of the plot (users 1-7) had the greatest improvement; performance did not improve as much thereafter. The improvement after the seventh user was the only change detected in the instructor's trend of performance. Conclusions: The instructor's teaching experience appeared to directly affect user performance; in a model of junctional hemorrhage, the volume of blood loss from the manikin during junctional tourniquet placement was a useful metric of instructor learning. The CUSUM technique detected a small but meaningful change in trend where the instructor learning curve was greatest while working with the first seven users.

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

Buy Now

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

Kragh JF, Aden JK, Dubick MA. 16(3). 21 - 29. (Journal Article)

Abstract

Background: Pneumatic field tourniquets have been recommended for Military medics to stop bleeding from limb wounds, but no comparison of commercially available pneumatic models of tourniquet has been reported. The purpose of this study is to provide laboratory data on the differential performance of models of pneumatic tourniquets to inform decision-making of potential field assessment by military users. Methods: Models included the Emergency and Military Tourniquet (EMT), Tactical Pneumatic Tourniquet 2-inch (TPT2), and Tactical Pneumatic Tourniquet 3-inch (TPT3). One user tested the three tourniquet models 30 times each on a manikin to collect data on effectiveness (yes-no bleeding control), pulse cessation, time to stop bleeding, total time of application, after time (after bleeding was stopped), pressure applied, blood loss volume, composite outcome (whether all individual outcomes were good or not), and pump count of the bulb used to inflate the tourniquet. Results: Neither tourniquet effectiveness nor pulse cessation (ρ = 1; likelihood ratio, 0 for both) differed among tourniquet models: all three models had 100% (30 of 30 tests) for both outcomes. The EMT had the best or tied for best performance in time to stop bleeding, total time, after time, pressure blood loss, composite outcome, and pump count. Conclusion: Each of the three models of pneumatic field tourniquet was 100% effective in stopping simulated bleeding. Among the three models, the EMT showed the best or tied for best performance in time to stop bleeding, blood loss, and composite outcomes. All models are suitable for future field assessment among military users.

Keywords: first aid; damage control; hemorrhage; shock; tourniquet; resuscitation

Buy Now

Learning Curves of Emergency Tourniquet Use Exploring for Utility in Training

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

Abstract

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

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

Buy Now

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

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

Abstract

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

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

Buy Now

Author: Adkins DE

Top

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

Adkins DE, Mahon RT, Bennett S. 07(3). 28 - 32. (Journal Article)

Abstract

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

Author: Agawa S

Top

Progress Of Tactical Emergency Medical Support In Japan

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

Abstract

Buy Now

Author: Agee W

Top

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

Washington MA, Kajiura L, Leong MK, Agee W, Barnhill JC. 15(1). 100 - 104. (Journal Article)

Abstract

Staphylococcus sciuri is an emerging gram-positive bacterial pathogen that is infrequently isolated from cases of human disease. This organism is capable of rapid conversion from a state of methicillin sensitivity to a state of methicillin resistance and has been shown to express a set of highly effective virulence factors. The antibioticresistance breakpoints of S. sciuri differ significantly from the more common Staphylococcus species. Therefore, the rapid identification of S. sciuri in clinical material is a prerequisite for the proper determination of the antibiotic- resistance profile and the rapid initiation of antimicrobial therapy. Here, we present a brief literature review of S. sciuri and an entomological case study in which we describe the colonization of an American cockroach with this agent. In addition, we discuss potential implications for the distribution and evolution of antibiotic- resistant members of the genus Staphylococcus.

Keywords: bacteriology; entomology; operating environment; preventive medicine

Buy Now

Author: Agudelo JJ

Top

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

Agudelo JJ. 15(2). 136 - 138. (Journal Article)

Abstract

Throughout history, Soldiers in wartime have been especially vulnerable to infectious diseases, which have devastated and decimated entire armies, causing suspension and, in some cases, complete cancellation of military operations. Dr William Foege, a renowned Harvard epidemiologist, and his colleagues claim that throughout history, infectious diseases have killed more Soldiers than have weapons. Reality shows that it does not matter if your Soldiers had the best training available with the best equipment and top of the world intelligence: if your personnel get sick, they become more of a liability than an asset for a combat operation. This article presents some of the key findings that continue to affect our Special Operations Forces (SOF) and how the use of specifically designed new products can help in controlling short- and long-term consequences of infectious diseases.

Keywords: preventive medicine; diseases, infectious

Buy Now

Author: Ahmed A

Top

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

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

Abstract

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

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

Buy Now

Author: Akers TW

Top

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

Hillis GR, Yi CJ, Amrani DL, Akers TW, Schwartz RB, Wedmore I, McManus JG. 14(4). 41 - 47. (Journal Article)

Abstract

Background: Uncontrolled hemorrhage remains one of the most challenging problems facing emergency medical professionals and a leading cause of traumatic death in both battlefield and civilian environments. Survival is determined by the ability to rapidly control hemorrhage. Several commercially available topical adjunct agents have been shown to be effective in controlling hemorrhage, and one, Combat Gauze™ (CG), is used regularly on the battlefield and for civilian applications. However, recent literature reviews have concluded that no ideal topical agent exists for all injuries and scenarios. The authors compared a novel nonimpregnated dressing composed of cellulose and silica, NuStat® (NS), to CG in a lethal hemorrhagic groin injury. These dressings were selected for their commercial availability and design intended for control of massive hemorrhage. Methods: A complex penetrating femoral artery groin injury was made using a 5.5mm vascular punch followed by 45 seconds of uncontrolled hemorrhage in 15 swine. The hemostatic dressings were randomized using a random sequence generator and then assigned to the animals. Three minutes of manual pressure was applied with each agent after the free bleed. Hextend™ bolus (500mL) was subsequently rapidly infused using a standard pressure bag along with the addition of maintenance fluids to maintain blood pressure. Hemodynamic parameters were recorded every 10 minutes and additionally at critical time points defined in the protocol. Primary end points included immediate hemostasis upon release of manual pressure (T0), hemostasis at 60 minutes, and rebleeding during the 60-minute observation period. Results: NS was statistically superior to CG in a 5.5mm traumatic hemorrhage model at T0 for immediate hemostasis (ρ = .0475), duration of application time (ρ = .0093), use of resuscitative fluids (ρ = .0042) and additional blood loss after application (ρ = .0385). NS and CG were statistically equivalent for hemostasis at 60 minutes, rebleeding during the study, and the additional secondary metrics, although the trend indicated that in a larger sample size, NS could prove statistical superiority in selected categories. Conclusions: In this porcine model of uncontrolled hemorrhage, NS improved immediate hemorrhage control, stability, and use of fluid in a 60-minute severe porcine hemorrhage model. In this study, NS demonstrated equivalence to CG at achieving long-term hemostasis and the prevention of rebleed after application. NS was shown to be an efficacious choice for hemorrhage control in combat and civilian emergency medical service environments.

Keywords: EMS; hemostatic dressing; hemorrhage, uncontrolled; hemorrhage, severe; traumatic injuries; NuStat; NS; CG; silica; bamboo; cellulose; Combat Gauze™; kaolin

Buy Now

Author: Alam HB

Top

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

Mejaddam AY, van der Wilden GM, Chang Y, Cropano CM, Sideris AC, Hwbejire JO, Velmahos GC, Alam HB, de Moya MA, King DR. 13(1). 29 - 33. (Journal Article)

Abstract

Introduction: The usefulness of heart rate variability (HRV) and heart rate complexity (HRC) analysis as a potential triage tool has been limited by the inability to perform real-time analysis on a portable, handheld monitoring platform. Through a multidisciplinary effort of academia and industry, we report on the development of a rugged, handheld and noninvasive device that provides HRV and HRC analysis in real-time in critically ill patients. Methods: After extensive re-engineering, real-time HRV and HRC analyses were incorporated into an existing, rugged, handheld monitoring platform. Following IRB approval, the prototype device was used to monitor 20 critically ill patients and 20 healthy controls to demonstrate real-world discriminatory potential. Patients were compared to healthy controls using a Student's t test as well as repeated measures analysis. Receiver operator characteristic (ROC) curves were generated for HRV and HRC. Results: Critically ill patients had a mean APACHE-2 score of 15, and over 50% were mechanically ventilated and requiring vasopressor support. HRV and HRC were both lower in the critically ill patients compared to healthy controls (ρ < 0.0001) and remained so after repeated measures analysis. The area under the ROC for HRV and HRC was 0.95 and 0.93, respectively. Conclusions: This is the first demonstration of real-time, handheld HRV and HRC analysis. This prototype device successfully discriminates critically ill patients from healthy controls. This may open up possibilities for real-world use as a trauma triage tool, particularly on the battlefield.

Keywords: heart rate complexity; heart rate variability; entropy; triage; combat

Buy Now

Author: Al-Ameri A

Top

Global Health Language and Culture Competency

Beadling C, Maza J, Nakano G, Mahmood M, Jawad S, Al-Ameri A, Zuerlein S, Anderson W. 12(1). 10 - 16. (Journal Article)

Abstract

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

Buy Now

Global Health Language and Culture Competency

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.

Buy Now

Author: Alcorta RL

Top

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

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

Abstract

Buy Now

Author: Alderman SM

Top

Medical Seminars: A New Paradigm For SOF Counterinsurgency Medical Programs

Alderman SM, Christensen J, Crawford I. 10(4). 16 - 22. (Journal Article)

Abstract

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

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

Alderman SM, Arvidsson CJ, Boedecker 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.

Buy Now

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

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.

Buy Now

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

Will JS, Alderman SM, Sawyer RC. 16(2). 36 - 43. (Journal Article)

Abstract

Special Operations Forces medical providers are often deployed far beyond traditional military supply chains, forcing them to rely on alternative methods for field sterilization of medical equipment. This literature review proposes several alternative methods for both sterilization and disinfection of medical instruments after use and cleaning of skin and wounds before procedures. This article reviews recommendations from sources like the United Nations, the World Health Organization, the Special Operations Forces Medical Handbook, and the Centers for Disease Control and Prevention.

Keywords: prolonged field care; field sanitation; instrument sterilization; expedtionary medicine

Buy Now

Author: Alleman A

Top

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

McCown ME, Alleman A, Sayler KA, Chandrashekar R, Thatcher B, Tyrrell P, Stillman B, Beall M, Barbet AF. 14(4). 81 - 85. (Journal Article)

Abstract

Background: Based on the high tick-borne pathogen results from a 2011 surveillance study in three Colombian cities, an in-depth point prevalence survey was conducted to determine the seroprevalence of tick-borne pathogens at a specific point in time in 70 working dogs, 101 shelter dogs, and 47 client-owned dogs in Barranquilla, Colombia. Results: Of the 218 serum samples, 163 (74%) were positive for Ehrlichia canis and 116 (53%) for Anaplasma platys. Exposure to tick-borne pathogens was highest in shelter and working dogs where more than 90% of the samples were seropositive or positive on polymerase chain reaction for one or more organisms as compared to 51% in client-owned animals. Conclusion: Surveillance for exposure to tickborne pathogens provides vital information necessary to protect and conserve the health of local humans and animals, deployed military service members, and working dogs in various parts of the world. This study and resultant data demonstrate the value of following a broadbased surveillance study with a more specific, focused analysis in an area of concern. This area's high levels of exposure warrant emphasis by medical planners and advisors on precautionary measures for military dogs, Special Operations Forces personnel, and the local public.

Keywords: tick-borne pathogens; point prevalence; surveillance; US Military SOF; military working dogs; Colombia

Buy Now

Author: Alson RL

Top

Medical Provider Ballistic Protection at Active Shooter Events

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

Abstract

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

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

Buy Now

Author: Altamirano MP

Top

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

Altamirano MP, Kragh JF, Aden JK, Dubick MA. 15(2). 42 - 46. (Journal Article)

Abstract

Background: In emergencies when commercially designed tourniquets are unavailable, hemorrhage may need to be controlled with improvised tourniquets. In the aftermath of the Boston Marathon bombing, no improvised strap-and-windlass tourniquets were used to treat casualties; tourniquets without windlasses were used. The purpose of the present study is to determine the effectiveness of improvised tourniquets with and without a windlass to better understand the role of the windlass in tightening the tourniquet strap. Methods: An experiment was designed to test the effectiveness of improvised strap-and-windlass tourniquets fashioned out of a tee shirt on a manikin thigh. Two users conducted 40 tests each with and without the use of a windlass. Results: Without a windlass, improvised tourniquets failed to stop bleeding in 99% of tests (79 of 80 tests). With a windlass, improvised tourniquets failed to stop bleeding in 32% of tests (ρ < .0001). In tests with no windlass, attempts to stop the pulse completely failed (100%, 80 of 80 tests). With a windlass, however, attempts to stop the pulse failed 31% of the time (25 of 80 tests); the difference in proportions was significant (ρ < .0001). Conclusions: Improvised strap-and-windlass tourniquets were more effective than those with no windlass, as a windlass allowed the user to gain mechanical advantage. However, improvised strap-and-windlass torniquets failed to control hemorrhage in 32% of tests.

Keywords: first aid; hemorrhage; tourniquet; shock; damage control; tourniquet, makeshift; tourniquet, homemade; strap-and-windlass

Buy Now

Author: Alves D

Top

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

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

Abstract

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

Keywords: tactical emergency medical support; tactical medicine

Buy Now

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

Gerold KB, Gibbons ME, Fisette RE, Alves D. 15(1). 62 - 69. (Journal Article)

Abstract

Excited delirium syndrome (ExDS) is a term used to describe patients experiencing a clinical condition characterized by bizarre and aggressive behavior, often in association with the use of chronic sympathomimetic drug abuse. The agitated and disruptive behavior of persons with ExDS often results in a call to police resulting in an arrest for disorderly conduct. The suspect's inability to comply with police commands during the arrest frequently results in a struggle and the use of physical or chemical control measures, including the use of conductive energy weapons (CEWs). Deaths from this hypermetabolic syndrome are infrequent but potentially preventable with early identification, a coordinated aggressive police intervention, and prompt medical care. Preliminary experiences suggest that ExDS is a medical emergency treated most effectively using a coordinated response between police officers and emergency medical providers. Once the person suspected of experiencing ExDS is in custody, medical providers should rapidly sedate noncompliant patients with medications such as ketamine or an antipsychotic drug such as haloperidol in combination with a benzodiazepine drug such as midazolam or diazepam. Once sedated, patients should undergo a screening medical assessment and undergo initial treatment for conditions such as hyperthermia and dehydration. All patients exhibiting signs of ExDS should be transported rapidly to a medical treatment facility for further evaluation and treatment. This article reviews the epidemiology, clinical presentation, diagnosis, and treatment options for ExDS.

Keywords: excited delirium; excited delirium syndrome; delirium; sudden death; in-custody death; hyperthermia; sympathomimetic drug use; cocaine; phencyclidine; lysergic acid diethylamide; ketamine; haloperidol; taser; conductive energy weapon; Agitated Chaotic Event&tm;; ACE; medical emergency; emergency medical services; police

Buy Now

Author: Amin S

Top

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

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

Abstract

Objective: We sought to characterize the risk of a heart attack in a 48-year-old asymptomatic US Special Operations Command (SOCOM) Soldier without known coronary artery disease (CAD). Background: CAD continues to be a leading cause of morbidity and mortality among most age groups in the United States. Much research is dedicated to establishing new techniques to predict myocardial infarction (MI). Methods: Coronary computed tomography (CT) angiography, also known as CCTA, along with 7-protein serum biomarker risk assessment was performed for risk evaluation. Results: A 48-year-old SOCOM Soldier with a family history of heart disease had skeletal chest pain from war injuries and a 5-fold higher risk of heart attack over the next 5 years on the basis of protein markers. A nonobstructive left anterior descending coronary artery (LAD) plaque with a lipid-rich core and a thin fibrous cap (i.e., vulnerable plaque) was detected by CCTA. The patient was warned about his risk and prescribed four cardiac medications and scheduled for angioplasty even though he fell outside the guidelines by not having a severe obstructive blockage. Four days later, unfortunately, he had a heart attack before starting his medications and before angioplasty. Conclusion: CCTA with biomarker testing may have an important role in predicating acute coronary syndrome (ACS) in Special Operations Forces (SOF) Soldiers with at least one risk factor. Conventional stress testing and nuclear scanning would not detect non-flow-limiting vulnerable plaques in vulnerable patients. In order to collect more data, the PROTECT Registry has been started to evaluate asymptomatic Soldiers with at least one risk factor referred to the clinic by military physicians.

Keywords: cardiac risk; heart attack; CCTA; risk assessment

Buy Now

Author: Amodt ZT

Top

Identification and Management of Bed Bug Infestations in Austere Environments

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

Abstract

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

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

Buy Now

Author: Amrani DL

Top

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

Hillis GR, Yi CJ, Amrani DL, Akers TW, Schwartz RB, Wedmore I, McManus JG. 14(4). 41 - 47. (Journal Article)

Abstract

Background: Uncontrolled hemorrhage remains one of the most challenging problems facing emergency medical professionals and a leading cause of traumatic death in both battlefield and civilian environments. Survival is determined by the ability to rapidly control hemorrhage. Several commercially available topical adjunct agents have been shown to be effective in controlling hemorrhage, and one, Combat Gauze™ (CG), is used regularly on the battlefield and for civilian applications. However, recent literature reviews have concluded that no ideal topical agent exists for all injuries and scenarios. The authors compared a novel nonimpregnated dressing composed of cellulose and silica, NuStat® (NS), to CG in a lethal hemorrhagic groin injury. These dressings were selected for their commercial availability and design intended for control of massive hemorrhage. Methods: A complex penetrating femoral artery groin injury was made using a 5.5mm vascular punch followed by 45 seconds of uncontrolled hemorrhage in 15 swine. The hemostatic dressings were randomized using a random sequence generator and then assigned to the animals. Three minutes of manual pressure was applied with each agent after the free bleed. Hextend™ bolus (500mL) was subsequently rapidly infused using a standard pressure bag along with the addition of maintenance fluids to maintain blood pressure. Hemodynamic parameters were recorded every 10 minutes and additionally at critical time points defined in the protocol. Primary end points included immediate hemostasis upon release of manual pressure (T0), hemostasis at 60 minutes, and rebleeding during the 60-minute observation period. Results: NS was statistically superior to CG in a 5.5mm traumatic hemorrhage model at T0 for immediate hemostasis (ρ = .0475), duration of application time (ρ = .0093), use of resuscitative fluids (ρ = .0042) and additional blood loss after application (ρ = .0385). NS and CG were statistically equivalent for hemostasis at 60 minutes, rebleeding during the study, and the additional secondary metrics, although the trend indicated that in a larger sample size, NS could prove statistical superiority in selected categories. Conclusions: In this porcine model of uncontrolled hemorrhage, NS improved immediate hemorrhage control, stability, and use of fluid in a 60-minute severe porcine hemorrhage model. In this study, NS demonstrated equivalence to CG at achieving long-term hemostasis and the prevention of rebleed after application. NS was shown to be an efficacious choice for hemorrhage control in combat and civilian emergency medical service environments.

Keywords: EMS; hemostatic dressing; hemorrhage, uncontrolled; hemorrhage, severe; traumatic injuries; NuStat; NS; CG; silica; bamboo; cellulose; Combat Gauze™; kaolin

Buy Now

Author: Andersen BL

Top

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

Klotz JK, Leo M, Andersen BL, Nkodo AA, Garcia G, Wichern AM, Chambers MJ, Gonzalez ON, Pahle MU, Wagner JA, Robinson JB, Kragh JF. 14(2). 1 - 5. (Journal Article)

Abstract

Junctional hemorrhage, bleeding that occurs at the junction of the trunk and its appendages, is the most common preventable cause of death from compressible hemorrhage on the battlefield. As of January 2014, four types of junctional tourniquets have been developed and cleared by the U.S. Food and Drug Administration (FDA). Successful use of the Abdominal Aortic Tourniquet (AAT™) and Combat Ready Clamp (CRoC™) has already been reported. We report here the first known prehospital use of the SAM® Junctional Tourniquet (SJT) for a battlefield casualty with inguinal junctional hemorrhage.

Keywords: SAM® Junctional Tourniquet; junctional hemorrhage; prehospital care; hemorrhage control; wounds and injuries

Buy Now

Author: Anderson PI

Top

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

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.

Buy Now

Author: Anderson V

Top

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

Walker TB, Lennemann LM, Anderson V, Lyons W, Zupan MF. 11(2). 37 - 44. (Journal Article)

Abstract

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

Buy Now

Author: Anderson W

Top

The Supply of Pharmaceuticals in Humanitarian Assistance Missions: Implications for Military Operations

Mahmood M, Riley K, Bennett D, Anderson W. 11(4). 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.

Buy Now

Global Health Language and Culture Competency

Beadling C, Maza J, Nakano G, Mahmood M, Jawad S, Al-Ameri A, Zuerlein S, Anderson W. 12(1). 10 - 16. (Journal Article)

Abstract

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

Buy Now

Global Health Language and Culture Competency

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.

Buy Now

Author: Andrews J

Top

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

Delmonaco BL, Andrews J, May A. 08(2). 61 - 64. (Journal Article)

Abstract

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

Author: Andrews JE

Top

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

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

Abstract

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

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

Buy Now

Author: Anglim AM

Top

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

Anglim AM, Boyd DW. 12(2). 48 - 57. (Journal Article)

Abstract

Objective: For travel to high altitudes, most experts advise a gradual ascent regimen to prevent acute mountain sickness (AMS). Such standard recommendations are applied to the general public. It is generally thought, however, that those whose work requires frequent rapid ascents, such as military personnel, porters and guides, often make these ascents without adequate preventive measures and then, experience significant morbidity and potential mortality due to AMS. The aim of this study were to demonstrate that the risk of rapid ascents can be mitigated if performed with adherence to a structured nutrition and hydration plan, carrying controlled loads, and taking specific prescribed rest periods during the ascent. Methods: This study used a randomized controlled trial of a group of Nepali porters, guides, and a Westerner with similar characteristics, all participating in their first ascent of the early Himalayan season. Data collected each day included oxygen saturation (SpO(2)), heart rate (HR), weight, and blood pressure (BP). Data was collected every 300 meters(m) (1,000 feet [ft]) and at the same time and altitude at each days end. Ascent profiles, age, gender, ethnic origin, altitude of residence and experience at altitude were also obtained. In four days, a control group of Nepali porters and a Sherpa guide and an equal number of Nepali porters and a Sherpa guide in an intervention group, (led by a Westerner) went from Kathmandu (1,300m), to the summit of Kala Pattar (5,640m), and Everest Base Camp (5,380m), averaging approximately 1,000m (3,500ft) gain a day in altitude, with no acclimatization rest days. During the rapid ascent from 4,300ft to 18,500ft, a regimented program was followed by the intervention group, while the control group ascended using their traditional methods as Nepali porters and Sherpa guides. Values are given as mean ± SE. T-test, ANOVA, and Mann-Whitney tests were used to compare variables. Results: Based on mean SpO(2) measurements on the summit of Kala Pattar at 5,640m (18,500ft), the intervention group had a SpO(2) of 79.5% ± 3.209 and the control group's mean SpO(2) was 74.5% ± 3.109 (ρ = .076). Importantly, two participants dropped out of the control group at 4,900m with SpO(2) scores of 77 and 71. The ANOVA results between the groups SpO(2) at 5,640m was significant at p ≥ .04. Mann Whitney U test results demonstrate a significant (U = 21.5, p = .04) difference in median SpO(2) levels between the intervention and the control groups. This indicates that employing a regimented program is vital to the objective of sustaining adequate SpO(2) levels and yielding a successful climb. The intervention group that followed the regimented nutrition, hydration, and rest period program performed physiologically superior to the control group, especially on the longest (10 hours), highest (5,640m), and greatest altitude gain (1,090m) day-despite resting for five minutes every 25 minutes of hiking. This was achieved with no acclimatization days, and each participant residing at low altitude. Conclusions: Participants who followed a structured nutrition, hydration plan, and adhered to prescribed rest periods, performed physiologically superior to the control group who did not. Two control group participants dropped out with poor physiological measurements. This aggressive ascent profile mirrors encountered work demands on military personnel, professional porters, and guides. The beneficial effect was significant and could provide superior methods to those whose duties require aggressive ascent profiles. The implications of frequent rest periods (10 minutes an hour), a high-carbohydrate diet, and at least 3,000ml of fluid a day appear to factually present a physiologically superior method to trekking at high to very-high altitudes. The health implications for trekkers to the Himalaya (or to any place at high altitude) by using a similar regimented program are that it may allow for an AMS-free, more enjoyable experience at altitude.

Keywords: high altitude; prevention of AMS; rapid ascent; military; Nepal; Sherpa; Porter

Buy Now

Author: Anonymous A

Top

Abdominal Aortic Tourniquet™ Use in Afghanistan

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

Abstract

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

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

Buy Now

TCCC Updates: TCCC Abstracts

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

Abstract

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

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

Abstract

TCCC Updates

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

Abstract

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

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

Abstract

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

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

Abstract

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

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

Abstract

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

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

Abstract

TCCC Updates

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

Abstract

Author: Antico D

Top

TCCC Standardization: The Time Is Now

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

Abstract

Author: Arcure J

Top

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

Arcure J, Harrison EE. 09(2). 22 - 25. (Journal Article)

Abstract

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

Author: Ard J

Top

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

Johnson D, Dial J, Ard J, Yourk T, Burke E, Paine C, Gegel B, Burgert J. 14(1). 79 - 85. (Journal Article)

Abstract

Introduction: The military recommends that a 500mL bolus of Hextend® be administered via an intravenous (IV) 18-gauge needle or via an intraosseous (IO) needle for patients in hypovolemic shock. Purposes: The purposes of this study were to compare the time of administration of Hextend and the hemodynamics of IV and IO routes in a Class II hemorrhage swine model. Methods: This was an experimental study using 27 swine. After 30% of their blood volume was exsanguinated, 500mL of Hextend was administered IV or IO, but not to the control group. Hemodynamic data were collected every 2 minutes until administration was complete. Results: Time for administration was not significant (p = .78). No significant differences existed between the IO and IV groups relative to hemodynamics (p > .05), but both were significantly different than the control group (p < .05). Conclusions: The IO route is an effective method of administering Hextend.

Keywords: hemorrhage; shock; Hextend®; hetastarch; battlefield

Buy Now

Author: Argon NT

Top

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

Mills AF, Argon NT, Ziya S, Hiestand B, Winslow J. 14(1). 30 - 39. (Journal Article)

Abstract

Objective: Current guidelines for mass-casualty triage do not explicitly use information about resource availability. Even though this limitation has been widely recognized, how it should be addressed remains largely unexplored. The authors present a novel framework developed using operations research methods to account for resource limitations when determining priorities for transportation of critically injured patients. To illustrate how this framework can be used, they also develop two specific example methods, named ReSTART and Simple- ReSTART, both of which extend the widely adopted triage protocol Simple Triage and Rapid Treatment (START) by using a simple calculation to determine priorities based on the relative scarcity of transportation resources. Methods: The framework is supported by three techniques from operations research: mathematical analysis, optimization, and discrete-event simulation. The authors' algorithms were developed using mathematical analysis and optimization and then extensively tested using 9,000 discrete-event simulations on three distributions of patient severity (representing low, random, and high acuity). For each incident, the expected number of survivors was calculated under START, ReSTART, and Simple-ReSTART. A web-based decision support tool was constructed to help providers make prioritization decisions in the aftermath of mass-casualty incidents based on ReSTART. Results: In simulations, ReSTART resulted in significantly lower mortality than START regardless of which severity distribution was used (paired t test, ρ < .01). Mean decrease in critical mortality, the percentage of immediate and delayed patients who die, was 8.5% for low-acuity distribution (range -2.2% to 21.1%), 9.3% for random distribution (range -0.2% to 21.2%), and 9.1% for high-acuity distribution (range -0.7% to 21.1%). Although the critical mortality improvement due to ReSTART was different for each of the three severity distributions, the variation was less than 1 percentage point, indicating that the ReSTART policy is relatively robust to different severity distributions. Conclusions: Taking resource limitations into account in mass-casualty situations, triage has the potential to increase the expected number of survivors. Further validation is required before field implementation; however, the framework proposed in here can serve as the foundation for future work in this area.

Keywords: triage; mass-casualty event; prioritization

Buy Now

Author: Armonda R

Top

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

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

Abstract

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

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

Buy Now

Author: Armstrong EL

Top

Warzone Stressor Exposure, Unit Support, and Emotional Distress Among U.S. Air Force Pararescuemen

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

Buy Now

Author: Armstrong M

Top

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

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

Abstract

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

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

Buy Now

Author: Arne BC

Top

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

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

Abstract

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

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

Abstract

Management of Scalp hemorrhage and lacerations

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

Buy Now

Author: Arnold RG

Top

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

Gerhardt RT, Berry J, Mabry RL, Flournoy L, Arnold RG, Hults C, Robinson JB, Thaxton RA, Cestero R, Heiner JD, Koller AR, Cox KM, Patterson JN, Dalton WR, McKeague AL, Gilbert G, Manemeit C, Adams BD. 14(1). 50 - 57. (Journal Article)

Abstract

Objective: We sought to determine whether Contingency Telemedical Support (CTS) improves the success rate and efficiency of primary care providers performing critical actions during simulated combat trauma resuscitation. Critical actions included advanced airway, chest decompression, extremity hemorrhage control, hypothermia prevention, antibiotics and analgesics, and hypotensive resuscitation, among others. Background: Recent studies report improved survival associated with skilled triage and treatment in the out-of-hospital/preoperative phase of combat casualty care. Historically, ground combat units are assigned primary care physicians and physician assistants as medical staff, due to resource limitations. Although they are recognized as optimal resuscitators, demand for military trauma surgeons and emergency physicians exceeds supply and is unlikely to improve in the near term. Methods: A prospective trial of telemedical mentoring during a casualty resuscitation encounter was studied using a high-fidelity patient simulator (HFPS). Subjects were randomized and formed into experimental (CTS) or control teams. CTS team leaders were equipped with a headset/microphone interface and telementored by a combat-experienced emergency physician or trauma surgeon. A standardized, scripted clinical scenario and HFPS were used with 14 critical actions. At completion, subjects were surveyed. Statistical approach included contingency table analysis, two-tailed t-test, and correlation coefficient. This study was reviewed and approved by our institutional review board (IRB). Results: Eighteen CTS teams and 16 control teams were studied. By intention-to-treat ITT analysis, 89% of CTS teams versus 56% of controls completed all life-threatening inventions (LSIs) (p < .01); 78% versus 19% completed all critical actions (p < .01); and 89% versus 56% established advanced airways within 8 minutes (p < .06). Average time to completion in minutes (95% confidence interval [CI] 95) was 12 minutes (10-14) for CTS versus 18 (16-20) for controls, with 75% of control teams not completing all critical actions. Conclusion: In this model, real-time telementoring of simulated trauma resuscitation was feasible and improved accuracy and efficiency of non-emergency-trained resuscitators. Clinical validation and replicated study of these findings for guiding remote damage control resuscitation are warranted.

Keywords: military medicine; war; emergency medical services; resuscitation; telemedicine; wounds and injuries

Buy Now

Author: Arvidsson CJ

Top

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

Alderman SM, Arvidsson CJ, Boedecker 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.

Buy Now

Author: Asuku ME

Top

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

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

Abstract

Buy Now

Author: Auerbach PS

Top

The Expanded Scope of Emergency Medical Practice Necessary for Initial Disaster Response: Lessons from Haiti

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.

Buy Now

Author: Aufderheide T

Top

The Impedance Threshold Device (ITD-7) A New Device For Combat Casualty Care To Augment Circulation And Blood Pressure In Hypotensive Spontaneously Breathing Warfighters

Parsons DL, Convertino VA, Idris A, Smith S, Lindstrom D, Parquette B, Aufderheide T. 09(1). 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

Author: Austin KG

Top

Monitoring Training for Human Performance Optimization

Austin KG, Deuster PA. 15(2). 102 - 108. (Journal Article)

Abstract

Physical fitness can significantly impact the mission success of Special Operations Forces (SOF). Much like athletes, Operators have multiple training components including technical, tactical, physical and mental conditioning, which must simultaneously be developed for mission success. Balancing multiple physical stressors to ensure positive results from training can be achieved through periodization-the intentional planning for success. Monitoring the training load can assist SOF in managing training stress and designing periodization that minimizes fatigue. The present article provides an overview of modern technology developed to quantify the stress of training. The training load maintained by SOF consists of external loads created through physical work and internal units of load determined by the rate of perceived effort during training that must be integrated in a manner that minimizes the accumulation of fatigue. Methods for determining training load are discussed in this article and examples are provided for determining training load, developing conditioning sessions and utilizing training load to maintain physical fitness, and improve return from injury.

Keywords: training, monitoring; load, training; load, external; load, internal; rate of perceived effort

Buy Now

Author: Auten JD

Top

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

Bassett AK, Auten JD, Zieber TJ, Lunceford NL. 16(2). 5 - 8. (Journal Article)

Abstract

Balanced component therapy (BCT) remains the mainstay in trauma resuscitation of the critically battle injured. In austere medical environments, access to packed red blood cells, apheresis platelets, and fresh frozen plasma is often limited. Transfusion of warm, fresh whole blood (FWB) has been used to augment limited access to full BCT in these settings. The main limitation of FWB is that it is not readily available for transfusion on casualty arrival. This small case series evaluates the impact early, mechanism-of-injury (MOI)-based, preactivation of the walking blood bank has on time to transfusion. We report an average time of 18 minutes to FWB transfusion from patient arrival. Early activation of the walking blood bank based on prehospital MOI may further reduce the time to FWB transfusion.

Keywords: blood bank, walking; blood, fresh whole; therapy, blood component

Buy Now

Author: Auzenne JW

Top

Resourcing Interventions Enhance Psychology Support Capabilities in Special Operations Forces

Myatt CA, Auzenne JW. 12(4). 54 - 59. (Journal Article)

Abstract

This study provides an examination of approaches to United States Government (USG) resourcing interventions on a national scale that enhance psychology support capabilities in the Special Operations Forces (SOF) community. A review of Congressional legislation and resourcing trends in the form of authorizations and appropriations since 2006 demonstrates how Congress supported enhanced psychology support capabilities throughout the Armed Forces and in SOF supporting innovative command interests that address adverse affects of operations tempo behavioral effects (OTBE). The formulation of meaningful metrics to address SOFspecific command interests led to a personnel tempo (PERSTEMPO) analysis in response to findings compiled by the Preservation of the Force and Families (POTFF) Task Force. The review of PERSTEMPO data at subordinate command and unit levels enhances the capability of SOF leaders to develop policy and guidance on training and operational planning that mitigates OTBE and maximizes resourcing authorizations. A major challenge faced by the DoD is in providing behavioral healthcare that meets public and legislative demands while proving suitable and sustainable at all levels of military operations: strategic, operational, and tactical. Current legislative authorizations offer a mechanism of command advocacy for resourced multi-functional program development that enhances psychology support capabilities while reinforcing SOF readiness and performance.

Keywords: resourcing interventions; psychology support capabilities; operations tempo behavioral effects (OTBE); personnel tempo (PERSTEMPO); Preservation of the Force and Families (POTFF)

Buy Now

Author: Baer DG

Top

Combat Ready Clamp Medic Technique

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

Abstract

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

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

Buy Now

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

Clumpner BR, Polston RW, Kragh JF, Westmoreland T, Harcke HT, Jones JA, Dubick MA, Baer DG, Blackbourne LH. 13(1). 34 - 41. (Journal Article)

Abstract

Background: Common first aid tourniquets, like the Combat Application Tourniquet (CAT) of a windlass and band design, can have the band routed through the buckle in three different ways, and recent evidence indicates users may be confused with complex doctrine. Objective: The purpose of the present study is to measure the differential performance of the three possible routings in order to better understand good tourniquet practice. Methods: A training manikin was used by two investigators to measure tourniquet effectiveness, time to stop bleeding, and blood loss. Results: The effectiveness rate was 99.6% (239/240) overall. Results were similar for both single-slit routings (inside vs. outside, p > 0.05). Effectiveness rates (yes-no results for hemorrhage control expressed as a proportion of iterations) were not statistically different between single and double routing. However, the time to stop bleeding and blood loss were statistically different (ρ < 0.05). Conclusions: CAT band routing, through the buckle either singly or doubly, affects two key performance criteria: time to stop bleeding and volume of blood lost. Single routing proved to be faster, thereby saving more blood. Learning curves required to optimize user performance varied over 30-fold depending on which variable was selected (e.g., effectiveness vs. blood loss).

Keywords: hemorrhage; first aid; trauma; damage control; emergency medical services

Buy Now

No Slackers in Tourniquet Use to Stop Bleeding

Polston RW, Clumpner BR, Kragh JF, Jones JA, Dubick MA, Baer DG. 13(2). 12 - 19. (Journal Article)

Abstract

Background: Tourniquets on casualties in war have been loose in 4%-9% of uses, and such slack risks death from uncontrolled bleeding. A tourniquet evidence gap persists if there is a mechanical slack-performance association. Objective: The purpose of the present study was to determine the results of tourniquet use with slack in the strap versus no slack before windlass turning, in order to develop best practices. Methods: The authors used a tourniquet manikin 254 times to measure tourniquet effectiveness, windlass turns, time to stop bleeding, and blood volume lost at 5 degrees of strap slack (0mm, 25mm, 50mm, 100mm, and 200mm maximum). Results: When comparing no slack (0mm) to slack (any positive amount), there were increases with slack in windlass turns (ρ < .0001, 3-fold), time to stop bleeding (ρ < .0001, 2-fold), and blood volume lost (ρ < .0001, 2-fold). When comparing no slack to 200mm slack, the median results showed an increase in slack for windlass turns (ρ < .0001), time to stop bleeding (ρ < .0001), and blood volume lost (ρ < .0001). Conclusions: Any slack presence in the strap impaired tourniquet performance. More slack had worse results. Trainers can now instruct tourniquet users with concrete guidance.

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

Buy Now

Tragedy Into Drama: An American History of Tourniquet Use in the Current War

Kragh JF, Walters TJ, Westmoreland T, Miller RM, Mabry RL, Kotwal RS, Ritter BA, Hodge DC, Greydanus DJ, Cain JS, Parsons DL, Edgar EP, Harcke HT, Baer DG, Dubick MA, Blackbourne LH, Montgomery HR, Holcomb JB, Butler FK. 13(3). 5 - 25. (Journal Article)

Abstract

Background: Although the scientific results of recent tourniquet advances in first aid are well recorded, the process by which tourniquet use advances were made is not. The purpose of the present report is to distill historical aspects of this tourniquet story during the current wars in Afghanistan and Iraq to aid scientists, leaders, and clinicians in the process of development of future improvements in first aid. Methods: The process of how developments of this tourniquet story happened recently is detailed chronologically and thematically in a "who did what, when, where, why, and how" way. Results: Initially in these wars, tourniquets were used rarely or were used as a means of last resort. Such delay in tourniquet use was often lethal; subsequently, use was improved incrementally over time by many people at several organizations. Three sequential keys to success were (1) unlocking the impasse of enacting doctrinal ideas already approved, (2) reaching a critical density of both tourniquets and trained users on the battlefield, and (3) capturing their experience with tourniquets. Other keys included translating needs among stakeholders (such as casualties, combat medics, providers, trainers, and decision-makers) and problem-solving logistic snags and other issues. Eventually, refined care was shown to improve survival rates. From all medical interventions evidenced in the current wars, the tourniquet broke rank and moved to the forefront as the prehospital medical breakthrough of the war. Conclusion: The recorded process of how tourniquet developments in prehospital care occurred may be used as a reference for parallel efforts in first aid such as attempts to improve care for airway and breathing problems.

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

Buy Now

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

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

Abstract

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

Keywords: junctional hemorrhage; Tactical Combat Casualty Care guidelines

Buy Now

U.S. Military Experience With Junctional Wounds in War From 2001 to 2010

Kragh JF, Dubick MA, Aden JK, McKeague AL, Rasmussen TE, Baer DG, 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

Buy Now

Emergency Tourniquet Effectiveness in Four Positions on the Proximal Thigh

Kragh JF, Wallum TE, Aden JK, Dubick MA, Baer DG. 14(1). 26 - 29. (Journal Article)

Abstract

Objective: The purpose of the present study is to determine the performance of tourniquet use by the placement of the tourniquet's windlass on the extremity in four positions-medial, lateral, anterior, and posterior-to inform tourniquet instructors and develop best tourniquet practices. Methods: A HapMed™ Leg Tourniquet Trainer was used as a manikin to test the effectiveness of an emergency tourniquet, the Special Operations Forces Tactical Tourniquet. Two users made 10 tests, each in four positions. Results: Effectiveness rates of tourniquet use were 100% in all four positions. The two tourniquet users were both right-hand dominant and used their right hand to turn the windlass. One user turned the windlass clockwise, and the other turned it counterclockwise. The association between time to stop bleeding and tourniquet position was statistically significant but associations between time to stop bleeding and the user, user-by-position, and windlass turn number were not statistically significant. The association between tourniquet position and pressure under the tourniquet was statistically significant, and the association between user and pressure under the tourniquet was statistically significant, but the user-by-position and windlass turn number were not statistically significant. The associations between tourniquet position and blood loss volume, user and blood loss volume, and user-by-position and blood loss volume were statistically significant. Conclusions: The present study found that tourniquet effectiveness rates were uniformly 100% irrespective of whether the windlass position was medial, lateral, anterior, or posterior. These excellent clinical and statistical results indicate that users may continue to place the tourniquets as they prefer upon the proximal thigh.

Keywords: first aid; resuscitation; damage control; hematoma; trauma; shock

Buy Now

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

Kragh JF, Parsons DL, Kotwal RS, Kheirabadi BS, Aden JK, Gerhardt RT, Baer DG, Dubick MA. 14(3). 58 - 63. (Journal Article)

Abstract

Background: Junctional hemorrhage is a common cause of death on the battlefield, but there is no documented direct comparison for the use of junctional tourniquet models by US medics. The purpose of this testing is to assess military medic experience with the use of junctional tourniquets in simulated out-of-hospital trauma care. Methods: Nine medics (seven men and two women) used four different junctional tourniquets: Combat Ready Clamp™ (CRoC™; http://www.combatmedicalsystems .com), Abdominal Aortic and Junctional Tourniquet™ (AAJT™; http://www.compressionworks.net), Junctional Emergency Treatment Tool (JETT™; http://www.narescue .com), and SAM Junctional Tourniquet® (SJT®; http:// www.sammedical.com/products). These medics also acted as simulated casualties. Effectiveness percentages, as measured by stopped distal pulse by Doppler auscultation, and time to effectiveness were recorded in two tests per tourniquet (72 total tests). Tourniquet users ranked their preference of model by answering the question: "If you had to go to war today and you could only choose one, which tourniquet would you choose to bring?" Results: All tourniquets used were safe under the conditions of this study. Both the SJT and the CRoC had high effectiveness percentages; their rate difference was not statistically significant. The SJT and the CRoC had fast times to effectiveness; their time difference was not statistically significant. Users preferred the SJT and the CRoC; their ranked difference was not statistically significant. Conclusion: The SJT and the CRoC were equally effective and fast and were preferred by the participants.

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

Buy Now

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

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

Abstract

Author: Baer L

Top

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

Gates K, Baer L, Holcomb JB. 14(1). 40 - 44. (Journal Article)

Abstract

Objective: Junctional bleeding from the groin is a leading cause of potentially preventable death on the battlefield. To address this problem, a novel device called the Junctional Emergency Treatment Tool (JETT™) was developed. The JETT was designed to stabilize pelvic ring fractures while controlling lower extremity bleeding sustained during high-energy traumatic events on the battlefield and in the civilian environment. Our purpose was to assess the effectiveness of the JETT in the control of simulated life threatening hemorrhage from proximal injuries in the groin of a perfused cadaver. Methods: The JETT was compared with the standard issue combat tourniquet and a Food and Drug Administration (FDA)-cleared junctional hemorrhage control clamp (CRoC™) in a perfused human cadaver model. The JETT's ability to stop pulsatile flow at the common femoral artery was assessed through proximal aorta and distal measurements of arterial flow rates and pressures. Results: In three cadavers, when the JETT or the CRoC was applied in the groin, there was an immediate cessation of fluid flow from the common femoral artery while the inlet flow aortic pulsatile pressure was maintained. However, the time to bilateral application of the JETT was faster (10 seconds vs. 68 seconds) than bilateral sequential application of two CRoC devices. Conclusions: The JETT is a single device capable of effectively and quickly controlling bilateral lower extremity junctional hemorrhage at normal physiological blood pressures.

Keywords: hemorrhage; tourniquet; wounds and injuries; junctional hemorrhage; combat casualty care; femoral artery

Buy Now

Author: Baggett MR

Top

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

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

Abstract

The Military Acute Concussion Evaluation (MACE)

French L, McCrea M, Baggett MR. 08(4). 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.

Author: Bailey HH

Top

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

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

Abstract

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

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

Buy Now

This Is Africa

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

Buy Now

Author: Bailey JA

Top

The Tactical Combat Casualty Care Casualty CardTCCC Guidelines - Proposed Change 1301

Kotwal RS, Butler FK, Montgomery HR, Brunstetter T, Diaz GY, Kirkpatrick JW, Summers NL, Shackelford S, 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.

Buy Now

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

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

Abstract

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

Keywords: pneumothorax; chest seal; TCCC Guideline

Buy Now

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

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

Abstract

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

Keywords: junctional hemorrhage; Tactical Combat Casualty Care guidelines

Buy Now

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

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

Abstract

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

Keywords: battlefield analgesia; fentanyl; ketamine; morphine

Buy Now

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

Butler FK, Holcomb JB, Schreiber MA, Kotwal RS, Jenkins DA, Champion HR, Bowling F, Cap AP, DuBose JJ, Dorlac WC, Dorlac GR, McSwain NE, Timby JW, Blackbourne LH, Stockinger Z, Strandenes G, Weiskopf RB, Gross K, Bailey JA. 14(3). 13 - 38. (Journal Article)

Abstract

This report reviews the recent literature on fluid resuscitation from hemorrhagic shock and considers the applicability of this evidence for use in resuscitation of combat casualties in the prehospital Tactical Combat Casualty Care (TCCC) environment. A number of changes to the TCCC Guidelines are incorporated: (1) dried plasma (DP) is added as an option when other blood components or whole blood are not available; (2) the wording is clarified to emphasize that Hextend is a less desirable option than whole blood, blood components, or DP and should be used only when these preferred options are not available; (3) the use of blood products in certain Tactical Field Care (TFC) settings where this option might be feasible (ships, mounted patrols) is discussed; (4) 1:1:1 damage control resuscitation (DCR) is preferred to 1:1 DCR when platelets are available as well as plasma and red cells; and (5) the 30-minute wait between increments of resuscitation fluid administered to achieve clinical improvement or target blood pressure (BP) has been eliminated. Also included is an order of precedence for resuscitation fluid options. Maintained as recommendations are an emphasis on hypotensive resuscitation in order to minimize (1) interference with the body's hemostatic response and (2) the risk of complications of overresuscitation. Hextend is retained as the preferred option over crystalloids when blood products are not available because of its smaller volume and the potential for long evacuations in the military setting.

Keywords: hemorrhage; fluid resuscitation; shock; plasma; blood products; damage control resuscitation

Buy Now

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

Shackelford S, Butler FK, Kragh JF, Stevens RA, Seery JM, Parsons DL, Montgomery HR, Kotwal RS, Mabry RL, Bailey JA. 15(1). 17 - 31. (Journal Article)

Abstract

Keywords: tourniquet; Tactical Combat Casualty Care guidelines; external hemorrhage control; shock; resuscitation; emergency medical services

Buy Now

Saving Lives on the Battlefield (Part II) - One Year Later: A Joint Theater Trauma System and Joint Trauma System Review of Prehospital Trauma Care in Combined Joint Operations Area-Afghanistan (CJOA-A)

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.

Buy Now

Author: Baker A

Top

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

Delmonaco BL, Baker A, Clay J, Kilbourn J. 16(1). 103 - 108. (Journal Article)

Abstract

An eight-person team of conventional US Air Force (USAF) medical providers deployed to support US Special Operations Forces (SOF) in North and West Africa for the first time in November 2014. The predeployment training, operations while deployed, and lessons learned from the challenges of performing surgery and medical evacuations in the remote desert environment of Chad and Niger on the continent of Africa are described. The vast area of operations and far-forward posture of these teams requires cooperation between partner African nations, the French military, and SOF to make these medical teams effective providers of surgical and critical care in Africa. The continuous deployment of conventional USAF medical providers since 2014 in support of US Special Operations Command Africa is challenging and will benefit from more medical teams and effective air assets to provide casualty evacuation across the vast area of operations.

Keywords: US Special Operations Command North and West Africa; far-forward surgery; conventional US Air Force; Mobile Field Surgical Team; Niamey, Niger; N'Dhamena, Chad; CASEVAC; Boko Haram; al-Qaeda I the Islamic Maghreb; French Military

Buy Now

Author: Baker BL

Top

The Ultrasound Detection Of Simulated Long Bone Fractures By U. S. Army Special Forces Medics

Heiner JD, Baker BL, McArthur TJ. 10(1). 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.

Prolonged Field Care Working Group Fluid Therapy Recommendations

Baker BL, Powell D, Riesberg J, Keenan S. 16(1). 112 - 117. (Journal Article)

Abstract

The Prolonged Field Care Working Group concurs that fresh whole blood (FWB) is the fluid of choice for patients in hemorrhagic shock, and the capability to transfuse FWB should be a basic skill set for Special Operations Forces (SOF) Medics. Prolonged field care (PFC) must also address resuscitative and maintenance fluid requirements in nonhemorrhagic conditions.

Keywords: prolonged field care; blood, fresh whole; shock, hemorrhagic; transfusion

Buy Now

Author: Baker JL

Top

Gunshotwounds In Militaryworking Dogs

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

Abstract

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

Baker JL, Truesdale CA, Schlanser JR. 09(1). 105 - 108. (Previously Published)
Previously published in The United States Army Medical Department Journal / The Unites States Army Veterinary Corps January - March 2009.

Abstract

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

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.

Buy Now

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

Stojsih SE, Baker JL, Les CM, Bir CA. 14(4). 86 - 91. (Journal Article)

Abstract

Background: Working dogs have been proven effective in multiple military and law enforcement applications. Similar to their human counterparts, understanding mortality while still in service can help improve treatment of injuries, and improve equipment and training, to potentially reduce deaths. This is a retrospective study to characterize mortality of working dogs used in civilian law enforcement. Methods: Reported causes of death were gathered from two working dog and law enforcement officer memorial websites. Results: Of the 867 civilian law enforcement dogs reported to these memorial websites from 2002 to 2012 with reported causes of death while in service, the deaths of 318 were categorized as traumatic. The leading reported causes of traumatic death or euthanasia include trauma as a result of a vehicle strike, 25.8% (n = 82); heatstroke, 24.8% (n = 79); and penetrating ballistic trauma, 23.0% (n = 73). Conclusion: Although the information gathered was from online sources, this study casts some light on the risks that civilian law enforcement dogs undergo as part of the tasks to which they are assigned. These data underscore the need for a comprehensive database for this specialized population of working dogs to provide the robust, reliable data needed to develop prevention and treatment strategies for this valuable resource.

Keywords: canine; mortality; law enforcement; trauma

Buy Now

Author: Baldridge T

Top

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

Bobko JP, Lai TT, Smith R, Shapiro G, Baldridge T, Callaway DW. 13(4). 94 - 107. (Journal Article)

Abstract

Background: Active shooter events and active violent incidents are increasingly targeting civilians, placing children at heightened risk for complex and devastating trauma. The U.S. Department of Homeland Security has identified as a priority preparing domestic first responders to manage complex mass casualty incidents as a primary step in strengthening our medical system. Existing literature suggests that many prehospital providers are uncomfortable treating critically ill or injured pediatric patients and that there is a gap in the consistent provision of high-quality trauma care to these patients. The success of threat-based care developed by the military has led to an exponential rise in the familiarity and utilization of these concepts within certain specialized elements of civilian care. Evolution of these concepts is accelerating to meet the demands of the nonmilitary civilian environment through the formation and subsequent work of the Committee for Tactical Emergency Casualty Care (C-TECC). However, a gap remains in the available literature describing the application of these principles to specialized populations. Methods: In the absence of an evidence-based set of guidelines for prehospital care of the pediatric casualty, the C-TECC sought to establish a set of peer-reviewed guidelines to serve as a foundation describing current best practices. The Pediatric Working Group (PWG) utilized the adult TECC guidelines as a starting point and identified a series of key questions regarding trauma interventions. The PWG conducted a standard PubMed search to identify key relevant or potentially relevant literature. The literature review was presented to the C-TECC Guidelines Committee for review and approval of recommended principles. Recommendations: Given the dearth of supporting literature on the subject, the TECC committee was purposefully conservative in the adaptation of the adult TECC guidelines to a pediatric standard. The guidelines highlight information tailored to the pediatric population and were designed to be a resource for individual agencies seeking guidance for high-threat operations. To our knowledge, the TECC Pediatric Appendix is the first published recommendation for the widespread use of tourniquets in pediatric hemorrhage. In addition, the Guidelines are meant to highlight gaps in trauma literature and stimulate discussion regarding future research in the area of prehospital care of the pediatric casualty.

Keywords: TCCC; pediatric hemorrhage; pediatrics; C-TCCC

Buy Now

Author: Baldwin TM

Top

Tinnitus, A Military Epidemic: Is Hyperbaric Oxygen Therapy The Answer?

Baldwin TM. 09(2). 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.

Author: Ball CG

Top

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

Kirkpatrick AW, McKee JL, McKee I, Panebianco NL, Ball CG. 15(4). 71 - 74. (Journal Article)

Abstract

Bleeding to death has been identified as the leading cause of potentially preventable injury-related death worldwide. Temporary hemorrhage control could allow the patient to be transported to a site capable of damage- control surgery. A novel device that may offer a fast and effective means of controlling nontruncal bleeding (junctional and extremity) is the iTClamp (Innovative Trauma Care; http://innovativetraumacare.com). This case study demonstrated that a motivated and intelligent, but untrained, first responder could successfully localize the actual anatomic site of an exsanguinating bleed and then could relatively easily compress this site to control the bleeding site by using ultrasound-guided manual-compression techniques.

Keywords: hemorrhage; iTClamp; ultrasound; bleeding; control

Buy Now

Author: Ball JA

Top

Thoughts on Aid Bags Part One

Hetzler MR, Ball JA. 08(2). 47 - 53. (Journal Article)

Abstract

Thoughts On Aid Bags Part Two

Ball JA, Hetzler MR. 08(3). 30 - 35. (Journal Article)

Abstract

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

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

Abstract

Buy Now

Author: Ball V

Top

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

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.

Buy Now

Author: Ballard M

Top

What Is the Optimal Device Length and Insertion Site for Needle Thoracostomy in UK Military Casualties? A Computed Tomography Study

Blenkinsop G, Mossadegh S, Ballard M, Parker P. 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

Buy Now

Author: Ballard SR

Top

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

Ballard SR, Enzenauer RW, O'Donnell T, Fleming JC, Risk G, Waite AN. 09(2). 26 - 32. (Journal Article)

Abstract

Retrobulbar hemorrhage is an uncommon, but potentially devastating complication associated with facial trauma. It can rapidly fill the orbit and cause an "orbital compartment syndrome" that subsequently cuts off perfusion to vital ocular structures, leading to permanent visual loss. Treatment must be initiated within a limited time in order to prevent these effects; however, specialty consultation is not always available in remote field environments. This article addresses the mechanism, diagnosis, and treatment of retrobulbar hemorrhage via lateral canthotomy and cantholysis, and recommends that 18D medical sergeants be properly trained to evaluate and perform this sight-saving procedure in emergent settings where upper echelons of care are not immediately available.

Author: Banting J

Top

Sore Throat

Banting J, Meriano T. 14(4). 124 - 128. (Journal Article)

Abstract

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

Keywords: sore throat; ENT; procedure

Buy Now

Abdominal Pain

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

Abstract

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

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

Buy Now

"It's What Color?"

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

Abstract

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

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

Buy Now

Journal Club: Ketamine in the Emergency Department

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

Abstract

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

Keywords: ketamine; pain, acute

Buy Now

Red Rash

Banting J, Meriano T. 16(1). 76 - 80. (Journal Article)

Abstract

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

Keywords: rash; rash, red; dermatology

Buy Now

Sea State Green

Banting J, Meriano T. 16(2). 78 - 81. (Journal Article)

Abstract

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

Keywords: motion sickness; medication, antimotion sickness

Buy Now

Walking the Plank

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

Buy Now

Basic Biostatistics and Clinical Medicine

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

Abstract

Keywords: biostatics, statistics; tests; specificity; sensitivity

Buy Now

Author: Barbee GA

Top

Traumatic Pelvic Hematoma After a Military Static-Line Parachute Jump: A Case Series

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

Buy Now

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

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.

Buy Now

Author: Barbet AF

Top

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

McCown ME, Alleman A, Sayler KA, Chandrashekar R, Thatcher B, Tyrrell P, Stillman B, Beall M, Barbet AF. 14(4). 81 - 85. (Journal Article)

Abstract

Background: Based on the high tick-borne pathogen results from a 2011 surveillance study in three Colombian cities, an in-depth point prevalence survey was conducted to determine the seroprevalence of tick-borne pathogens at a specific point in time in 70 working dogs, 101 shelter dogs, and 47 client-owned dogs in Barranquilla, Colombia. Results: Of the 218 serum samples, 163 (74%) were positive for Ehrlichia canis and 116 (53%) for Anaplasma platys. Exposure to tick-borne pathogens was highest in shelter and working dogs where more than 90% of the samples were seropositive or positive on polymerase chain reaction for one or more organisms as compared to 51% in client-owned animals. Conclusion: Surveillance for exposure to tickborne pathogens provides vital information necessary to protect and conserve the health of local humans and animals, deployed military service members, and working dogs in various parts of the world. This study and resultant data demonstrate the value of following a broadbased surveillance study with a more specific, focused analysis in an area of concern. This area's high levels of exposure warrant emphasis by medical planners and advisors on precautionary measures for military dogs, Special Operations Forces personnel, and the local public.

Keywords: tick-borne pathogens; point prevalence; surveillance; US Military SOF; military working dogs; Colombia

Buy Now

Author: Barnard EB

Top

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

Barnard EB, Ervin AT, Mabry RL, Bebarta VS. 14(4). 35 - 39. (Journal Article)

Abstract

Introduction: Airway compromise is the third most common cause of potentially preventable combat death. Surgical cricothyrotomy is an infrequently performed but lifesaving airway intervention. There are limited published data on prehospital cricothyrotomy in civilian or military settings. Our aim was to prospectively describe the survival rate and complications associated with cricothyrotomy performed in the military prehospital and en route setting. Methods: The Life-Saving Intervention (LSI) study is a prospective, institutional review boardapproved, multicenter trial examining LSIs performed in the prehospital combat setting. We prospectively recorded LSIs performed on patients in theater who were transported to six combat hospitals. Trained site investigators evaluated patients on arrival and recorded demographics, vital signs, and LSIs performed. LSIs were predefined and include cricothyrotomies, chest tubes, intubations, tourniquets, and other procedures. From the large dataset, we analyzed patients who had a cricothyrotomy performed. Hospital outcomes were cross-referenced from the Department of Defense Trauma Registry. Descriptive statistics or Wilcoxon test (nonparametric) were used for data comparisons; statistical significance was set at ρ < .05. The primary outcome was success of prehospital and en route cricothyrotomy. Results: Of the 1,927 patients enrolled, 34 patients had a cricothyrotomy performed (1.8%). Median age was 24 years (interquartile range [IQR]: 22.5-25 years), 97% were men. Mechanisms of injury were blast (79%), penetrating (18%), and blunt force (3%), and 83% had major head, face, or neck injuries. Median Glasgow Coma Scale score (GCS) was 3 (IQR: 3-7.5) and four patients had GCS higher than 8. Cricothyrotomy was successful in 82% of cases. Reasons for failure included left main stem intubation (n = 1), subcutaneous passage (n = 1), and unsuccessful attempt (n = 4). Five patients had a prehospital basic airway intervention. Unsuccessful endotracheal intubation preceded 15% of cricothyrotomies. Of the 24 patients who had the provider type recorded, six had a cricothyrotomy by a combat medic (pre-evacuation), and 18 by an evacuation helicopter medic. Combat-hospital outcome data were available for 26 patients, 13 (50%) of whom survived to discharge. The cricothyrotomy patients had more LSIs than noncricothyrotomy patients (four versus two LSIs per patient; ρ < .0011). Conclusion: In our prospective, multicenter study evaluating cricothyrotomy in combat, procedural success was higher than previously reported. In addition, the majority of cricothyrotomies were performed by the evacuation helicopter medic rather than the prehospital combat medic. Prehospital military medics should receive training in decision making and be provided with adjuncts to facilitate this lifesaving procedure.

Keywords: airway management; airway obstruction; military medicine; war; emergency medical services; cricothyrotomy; airway

Buy Now

Author: Barneis Y

Top

Special Forces Medicine in Israel

Ostfeld I, Paran H, Chen J, Barneis Y, Dreyfuss U, Kedem H, Glassberg E. 14(3). 116 - 120. (Journal Article)

Abstract

The Special Forces (SF) of the Israel Defense Force (IDF) have a long and pioneering history in tactical and medical aspects. Moreover, the importance of medical assistance is highly regarded in the Israeli SF community. Consequently, as current military challenges of Israel increase, the need for SF activity and for its medical support increases as well. Therefore, the authors anticipate that further development of SF medicine (SFM), as a specific branch of military medicine in Israel, will continue.

Keywords: Special Forces; Special Forces medicine; military medicine; Israel Defense Force; My Brother's Keeper

Buy Now

Author: Barnhart G

Top

Prolonged Field Care of a Casualty With Penetrating Chest Trauma

Barnhart G, Cullinan W, Pickett JR. 16(4). 99 - 101. (Case Reports)

Abstract

As Special Operations mission sets shift to regions with less coalition medical infrastructure, the need for quality long-term field care has increased. More and more, Special Operations Medics will be expected to maintain casualties in the field well past the "golden hour" with limited resources and other tactical limitations. This case report describes an extended-care scenario (>12 hours) of a casualty with a chest wound, from point of injury to eventual casualty evacuation and hand off at a Role II facility. This case demonstrates the importance of long-term tactical medical considerations and the effectiveness of minimal fluid resuscitation in treating penetrating thoracic trauma.

Keywords: prolonged field care; chest trauma, penetrating; resuscitation, fluid

Buy Now

Author: Barnhill JC

Top

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

Washington MA, Kajiura L, Leong MK, Agee W, Barnhill JC. 15(1). 100 - 104. (Journal Article)

Abstract

Staphylococcus sciuri is an emerging gram-positive bacterial pathogen that is infrequently isolated from cases of human disease. This organism is capable of rapid conversion from a state of methicillin sensitivity to a state of methicillin resistance and has been shown to express a set of highly effective virulence factors. The antibioticresistance breakpoints of S. sciuri differ significantly from the more common Staphylococcus species. Therefore, the rapid identification of S. sciuri in clinical material is a prerequisite for the proper determination of the antibiotic- resistance profile and the rapid initiation of antimicrobial therapy. Here, we present a brief literature review of S. sciuri and an entomological case study in which we describe the colonization of an American cockroach with this agent. In addition, we discuss potential implications for the distribution and evolution of antibiotic- resistant members of the genus Staphylococcus.

Keywords: bacteriology; entomology; operating environment; preventive medicine

Buy Now

Recovery of Bacteria and Fungi From a Leg Wound

Washington MA, Barnhill JC, Duff MA, Griffin J. 15(4). 113 - 116. (Journal Article)

Abstract

Acute and chronic wound infections can both be encountered in the deployed setting. These wounds are often contaminated by bacteria and fungi derived from the external environment. In this article, we present the case of a wound infection simultaneously colonized by Enterobacter cloacae (a bacterial pathogen) and Trichosporon asahii (an unusual fungal pathogen). We describe the examination and treatment of the patient and review the distinguishing characteristics of each organism

Keywords: infection; bacteria; fungi; Enterobacter cloacae; Trichosporon asahii

Buy Now

Author: Barringer N

Top

Omega-3 Fatty Acid Ingestion as a TBI Prophylactic

Barringer N, Conkright W. 12(3). 5 - 7. (Journal Article)

Abstract

Given the hazardous nature of combat operations and training exercises (e.g. airborne operations) conducted by the United States military, servicemembers are at high risk for sustaining a traumatic brain injury (TBI). Since the beginning of the Iraq and Afghanistan wars, almost a quarter of a million servicemembers have sustained a TBI.1 A large number of TBIs are a result of the concussive forces generated by improvised explosive devices (IED). A smaller number are a result of penetrating head wounds. Others may be caused by activities resulting in powerful acceleration, deceleration, or rotational forces. Therapies for treating TBI thus far have been limited. Much of the research conducted to date has focused on post-injury pharmacological interventions.2 Additionally, better protective equipment could help in preventing TBIs; however, these issues are outside the scope of this paper. A relatively new area of research is investigating prophylactic measures taken to lessen the effects of TBI. One such measure involves nutritional interventions and their effects on TBI severity. Therefore, the purpose of this paper is to elucidate the potential benefits of omega-3 fatty acid intake as it relates to TBI severity.

Buy Now

Author: Barstow C

Top

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

Hing M, Cabrera J, Barstow C, Forsten RD. 12(3). 23 - 35. (Journal Article)

Abstract

To determine the rates of Post-traumatic Stress Disorder (PTSD) positive symptom scores in Special Operations Forces (SOF) personnel, an anonymous survey of SOF was employed, incorporating the PTSD Checklist (PCLM) with both demographic and deployment data. Results indicate that all SOF units studied scored above the accepted cut-offs for PTSD positive screening.1 When total symptom severity score exceeded established cutoff points and were combined with criteria for Diagnostic and Statistical Manual of Mental Disorders, Edition 4 (DSM-IV) diagnosis of PTSD,2 approximately 16-20% of respondents met scoring threshold for positive screening, almost double those of conventional Army units. Collectively, Special Forces (SF) Soldiers and SOF combat- arms Soldiers had significantly higher PLC-M scores than their non-combat-arms SOF counterparts. SOF Soldiers with three or more deployments to Afghanistan had significantly higher PCL-M scores. Considering the evidence suggesting that SOF Soldiers are hyper-resilient to stress, these results should drive further research schemata and challenge clinical assumptions of PTSD within Special Operations.

Buy Now

Author: Bassett AK

Top

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

Bassett AK, Auten JD, Zieber TJ, Lunceford NL. 16(2). 5 - 8. (Journal Article)

Abstract

Balanced component therapy (BCT) remains the mainstay in trauma resuscitation of the critically battle injured. In austere medical environments, access to packed red blood cells, apheresis platelets, and fresh frozen plasma is often limited. Transfusion of warm, fresh whole blood (FWB) has been used to augment limited access to full BCT in these settings. The main limitation of FWB is that it is not readily available for transfusion on casualty arrival. This small case series evaluates the impact early, mechanism-of-injury (MOI)-based, preactivation of the walking blood bank has on time to transfusion. We report an average time of 18 minutes to FWB transfusion from patient arrival. Early activation of the walking blood bank based on prehospital MOI may further reduce the time to FWB transfusion.

Keywords: blood bank, walking; blood, fresh whole; therapy, blood component

Buy Now

Author: Batjom E

Top

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

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

Abstract

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

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

Buy Now

Author: Beadling C

Top

Global Health Language and Culture Competency

Beadling C, Maza J, Nakano G, Mahmood M, Jawad S, Al-Ameri A, Zuerlein S, Anderson W. 12(1). 10 - 16. (Journal Article)

Abstract

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

Buy Now

Global Health Language and Culture Competency

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.

Buy Now

Author: Beall M

Top

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

McCown ME, Alleman A, Sayler KA, Chandrashekar R, Thatcher B, Tyrrell P, Stillman B, Beall M, Barbet AF. 14(4). 81 - 85. (Journal Article)

Abstract

Background: Based on the high tick-borne pathogen results from a 2011 surveillance study in three Colombian cities, an in-depth point prevalence survey was conducted to determine the seroprevalence of tick-borne pathogens at a specific point in time in 70 working dogs, 101 shelter dogs, and 47 client-owned dogs in Barranquilla, Colombia. Results: Of the 218 serum samples, 163 (74%) were positive for Ehrlichia canis and 116 (53%) for Anaplasma platys. Exposure to tick-borne pathogens was highest in shelter and working dogs where more than 90% of the samples were seropositive or positive on polymerase chain reaction for one or more organisms as compared to 51% in client-owned animals. Conclusion: Surveillance for exposure to tickborne pathogens provides vital information necessary to protect and conserve the health of local humans and animals, deployed military service members, and working dogs in various parts of the world. This study and resultant data demonstrate the value of following a broadbased surveillance study with a more specific, focused analysis in an area of concern. This area's high levels of exposure warrant emphasis by medical planners and advisors on precautionary measures for military dogs, Special Operations Forces personnel, and the local public.

Keywords: tick-borne pathogens; point prevalence; surveillance; US Military SOF; military working dogs; Colombia

Buy Now

Author: Bebarta VS

Top

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

Barnard EB, Ervin AT, Mabry RL, Bebarta VS. 14(4). 35 - 39. (Journal Article)

Abstract

Introduction: Airway compromise is the third most common cause of potentially preventable combat death. Surgical cricothyrotomy is an infrequently performed but lifesaving airway intervention. There are limited published data on prehospital cricothyrotomy in civilian or military settings. Our aim was to prospectively describe the survival rate and complications associated with cricothyrotomy performed in the military prehospital and en route setting. Methods: The Life-Saving Intervention (LSI) study is a prospective, institutional review boardapproved, multicenter trial examining LSIs performed in the prehospital combat setting. We prospectively recorded LSIs performed on patients in theater who were transported to six combat hospitals. Trained site investigators evaluated patients on arrival and recorded demographics, vital signs, and LSIs performed. LSIs were predefined and include cricothyrotomies, chest tubes, intubations, tourniquets, and other procedures. From the large dataset, we analyzed patients who had a cricothyrotomy performed. Hospital outcomes were cross-referenced from the Department of Defense Trauma Registry. Descriptive statistics or Wilcoxon test (nonparametric) were used for data comparisons; statistical significance was set at ρ < .05. The primary outcome was success of prehospital and en route cricothyrotomy. Results: Of the 1,927 patients enrolled, 34 patients had a cricothyrotomy performed (1.8%). Median age was 24 years (interquartile range [IQR]: 22.5-25 years), 97% were men. Mechanisms of injury were blast (79%), penetrating (18%), and blunt force (3%), and 83% had major head, face, or neck injuries. Median Glasgow Coma Scale score (GCS) was 3 (IQR: 3-7.5) and four patients had GCS higher than 8. Cricothyrotomy was successful in 82% of cases. Reasons for failure included left main stem intubation (n = 1), subcutaneous passage (n = 1), and unsuccessful attempt (n = 4). Five patients had a prehospital basic airway intervention. Unsuccessful endotracheal intubation preceded 15% of cricothyrotomies. Of the 24 patients who had the provider type recorded, six had a cricothyrotomy by a combat medic (pre-evacuation), and 18 by an evacuation helicopter medic. Combat-hospital outcome data were available for 26 patients, 13 (50%) of whom survived to discharge. The cricothyrotomy patients had more LSIs than noncricothyrotomy patients (four versus two LSIs per patient; ρ < .0011). Conclusion: In our prospective, multicenter study evaluating cricothyrotomy in combat, procedural success was higher than previously reported. In addition, the majority of cricothyrotomies were performed by the evacuation helicopter medic rather than the prehospital combat medic. Prehospital military medics should receive training in decision making and be provided with adjuncts to facilitate this lifesaving procedure.

Keywords: airway management; airway obstruction; military medicine; war; emergency medical services; cricothyrotomy; airway

Buy Now

Author: Becker T

Top

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

Becker T, Ray PD, Link M, Ziemba M. 11(2). 12 - 15. (Journal Article)

Abstract

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

Buy Now

Author: Beebe DF

Top

Survey Of The Indications For Use Of Emergency Tourniquets

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

Abstract

Indications and evidence are limited, multiple and complex for emergency tourniquet use. Good recent outcomes challenge historically poor outcomes. Optimal tourniquet use in trauma care appears to depend on adequate devices, modern doctrine, refined training, speedy evacuation, and performance improvement. Challenges remain in estimation of blood loss volumes, lesion lethality, and casualty propensity to survive hemorrhage. Summary Background Data: Evidence gaps persist regarding emergency tourniquet use indications in prehospital and emergency department settings as indication data are rarely reported. Methods: Data on emergency tourniquet use was analyzed from a large clinical study (NCT00517166 at ClinicalTrials.gov). The study included 728 casualties with 953 limbs with tourniquets. The median casualty age was 26 years (range, 4-70). We compared all other known datasets to this clinical study. Results: Tourniquet use was prehospital in 671 limbs (70%), hospital only in 104 limbs (11%), and both prehospital and hospital in 169 limbs (18%).Major hemorrhage was observed at or before the hospital in 487 (51%) limbs and minor hemorrhage was observed at the hospital in 463 limbs (49%). Anatomic lesions indicating tourniquets included open fractures (27%), amputations (26%), soft tissue wounds (20%), and vascular wounds (17%). Situations, as opposed to anatomic lesions, indicating tourniquets included bleeding from multiple sites other than limbs (24%), hospital mass casualty situations (1%), one multiple injury casualty needed an airway procedure, and one casualty had an impaled object. Conclusions: The current indication for emergency tourniquet use is any compressible limb wound that the applier assesses as having possibly lethal hemorrhage. This indication has demonstrated good outcomes only when devices, training, doctrine, evacuation, and research have been optimal. Analysis of emergency tourniquet indications is complex and inadequately evidenced, and further study is prudent. Prehospital data reporting may fill knowledge gaps. Objective: The purpose of this study is to report and analyze emergency tourniquet use indications to stop limb bleeding.

Author: Beekley AC

Top

Survey Of The Indications For Use Of Emergency Tourniquets

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

Abstract

Indications and evidence are limited, multiple and complex for emergency tourniquet use. Good recent outcomes challenge historically poor outcomes. Optimal tourniquet use in trauma care appears to depend on adequate devices, modern doctrine, refined training, speedy evacuation, and performance improvement. Challenges remain in estimation of blood loss volumes, lesion lethality, and casualty propensity to survive hemorrhage. Summary Background Data: Evidence gaps persist regarding emergency tourniquet use indications in prehospital and emergency department settings as indication data are rarely reported. Methods: Data on emergency tourniquet use was analyzed from a large clinical study (NCT00517166 at ClinicalTrials.gov). The study included 728 casualties with 953 limbs with tourniquets. The median casualty age was 26 years (range, 4-70). We compared all other known datasets to this clinical study. Results: Tourniquet use was prehospital in 671 limbs (70%), hospital only in 104 limbs (11%), and both prehospital and hospital in 169 limbs (18%).Major hemorrhage was observed at or before the hospital in 487 (51%) limbs and minor hemorrhage was observed at the hospital in 463 limbs (49%). Anatomic lesions indicating tourniquets included open fractures (27%), amputations (26%), soft tissue wounds (20%), and vascular wounds (17%). Situations, as opposed to anatomic lesions, indicating tourniquets included bleeding from multiple sites other than limbs (24%), hospital mass casualty situations (1%), one multiple injury casualty needed an airway procedure, and one casualty had an impaled object. Conclusions: The current indication for emergency tourniquet use is any compressible limb wound that the applier assesses as having possibly lethal hemorrhage. This indication has demonstrated good outcomes only when devices, training, doctrine, evacuation, and research have been optimal. Analysis of emergency tourniquet indications is complex and inadequately evidenced, and further study is prudent. Prehospital data reporting may fill knowledge gaps. Objective: The purpose of this study is to report and analyze emergency tourniquet use indications to stop limb bleeding.

Author: Beeler AM

Top

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

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

Abstract

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

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

Buy Now

Author: Ben-Galim P

Top

Internal Decapitation: Survival After Head To Neck Dissociation Injuries

Ben-Galim P, Sibai TA, Hipp JA, Heggeness MH, Reitman CA. 10(1). 35 - 39. (Previously Published)
Previously published in Spine, Volume 33, Number 16, pp 1744–1749. Permission to republish granted by Lippincott Williams & Wilkins

Abstract

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

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

Internal Decapitation - High Ligamentus Cervical Injury

Ben-Galim P. 10(1). 31 - 34. (Previously Published)
Permission to publish this presentation in the JSOM was granted by author

Abstract

Author: Bennett BL

Top

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

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

Abstract

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

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

Buy Now

The Use of Pelvic Binders in Tactical Combat Casualty Care: TCCC Guidelines Change 1602 7 November 2016

Shackelford S, Hammesfahr R, Morissette D, Montgomery HR, Kerr W, Broussard M, Bennett BL, Dorlac WC, Bree S, Butler FK. 17(1). 135 - 147. (Classical Conference)

Abstract

Keywords: pelvic binder; prehospital guidelines; TCCC Guideline

Author: Bennett D

Top

The Supply of Pharmaceuticals in Humanitarian Assistance Missions: Implications for Military Operations

Mahmood M, Riley K, Bennett D, Anderson W. 11(4). 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.

Buy Now

Author: Bennett DR

Top

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

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

Abstract

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

Keywords: pneumothorax; chest seal; TCCC Guideline

Buy Now

Author: Bennett S

Top

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

Adkins DE, Mahon RT, Bennett S. 07(3). 28 - 32. (Journal Article)

Abstract

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

Author: Benov A

Top

Junctional Tourniquet Training Experience

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

Abstract

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

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

Buy Now

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

Chen J, Benov A, Nadler R, Landau G, Sorkin A, Aden JK, Kragh JF, Glassberg E. 16(1). 36 - 42. (Journal Article)

Abstract

Background: Junctional hemorrhage is a common cause of battlefield death but little is known about testing of junctional tourniquet models by medics. The purpose of the testing described herein is to assess military experience in junctional tourniquet use in simulated prehospital care. Methods: Fourteen medics were to use the following four junctional tourniquets: Combat Ready Clamp (CRoC), Abdominal Aortic Junctional Tourniquet (AAJT), Junctional Emergency Treatment Tool (JETT), and SAM Junctional Tourniquet (SJT). The five assessment categories were safety, effectiveness, time to effectiveness, and two categories of user preference: (1) by all models assessed, and (2) by only the model most preferred. Users ranked preference by answering, "If you had to go to war today and you could only choose one, which tourniquet would you choose to bring?" Results: All tourniquet uses were safe. By the time the first five testers were done, all three AAJT models had been broken. CRoC and AAJT had the highest percentage effectiveness as their difference was not statistically significant. SJT and JETT had fastest mean times to effectiveness as their difference was not significant. For preference, using each user's ranking of all models assessed, SJT and AAJT were most preferred as their difference was not significant. For each user's most preferred model, SJT, AAJT, and JETT were most preferred as their difference was not significant. Conclusion: In the five assessment categories, multiple tourniquet models performed similarly well; SJT and AAJT performed best in four categories, JETT was best in three, and CRoC was best in two. Differences between the top-ranked models in each category were not statistically significant.

Keywords: tourniquets; hemorrhage; resuscitation; groin; inguinal; medical device; injuries; wounds

Buy Now

Author: Benson PJ

Top

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

Morgan AR, Vasios WN, Hubler DA, Benson PJ. 10(1). 16 - 24. (Journal Article)

Abstract

Over the past few decades, ultrasound has evolved from a radiology and subspecialist-centric instrument, to a common tool for bedside testing in a variety of specialties. The SOF community is now recognizing the relevancy of training medics to employ this technology for multiple clinical indications in the austere operating environment. In the Fall 2008 issue of Journal of Special Operations Medicine two of the authors described the concept of training SOF medics to employ portable ultrasound as a diagnostic aid. After over two years of concerted effort, the authors trained 29 out of 40 medics of a Special Forces battalion. Retrospective analysis of the quality assurance data for ultrasound studies conducted placed the 109 studies into six categories, allowing inference of trends in clinical indication for ultrasound exams as determined by the SOF medic-ultrasonographer. The resulting distribution suggests that indications for fractures and superficial applications are as prevalent as those for focused abdominal sonography in trauma (FAST) and pneumothorax exams. This analysis focuses on Special Operator Level Clinical Ultrasound (SOLCUS), an ultrasound training curriculum specifically for SOF medics, and helps appropriately prioritize its objectives. Despite the success of this experience, there are several issues requiring resolution before being able to integrate ultrasound training and fielding into the SOF medical armamentarium.

Author: Beriano T

Top

Journal Club: Ketamine in the Emergency Department

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

Abstract

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

Keywords: ketamine; pain, acute

Buy Now

Author: Bernhagen MA

Top

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

Boedecker BH, Nicholas TA, Carpenter J, Leighton S, Bernhagen MA, Murray WB, Wadman MC. 11(2). 21 - 29. (Journal Article)

Abstract

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

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

Buy Now

Author: Berns KS

Top

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

Zietlow JM, Zietlow SP, Morris DS, Berns KS, Jenkins DH. 15(2). 48 - 53. (Journal Article)

Abstract

Background: While the military use of tourniquets and hemostatic gauze is well established, few data exist regarding civilian emergency medical services (EMS) systems experience. Methods: A retrospective review was performed of consecutive patients with prehospital tourniquet and hemostatic gauze application in a single ground and rotor-wing rural medical transport service. Standard EMS registry data were reviewed for each case. Results: During the study period, which included 203,301 Gold Cross Ambulance and 8,987 Mayo One Transport records, 125 patients were treated with tourniquets and/or hemostatic gauze in the prehospital setting. Specifically, 77 tourniquets were used for 73 patients and 62 hemostatic dressings were applied to 52 patients. Seven patients required both interventions. Mechanisms of injury (MOIs) for tourniquet use were blunt trauma (50%), penetrating wounds (43%), and uncontrolled hemodialysis fistula bleeding (7%). Tourniquet placement was equitably distributed between upper and lower extremities, as well as proximal and distal locations. Mean tourniquet time was 27 minutes, with 98.7% success. Hemostatic bandage MOIs were blunt trauma (50%), penetrating wounds (35%), and other MOIs (15%). Hemostatic bandage application was head and neck (50%), extremities (36%), and torso (14%), with a 95% success rate. Training for both interventions was computer-based and hands-on, with maintained proficiency of > 95% after 2 years. Conclusion: Civilian prehospital use of tourniquets and hemostatic gauze is feasible and effective at achieving hemostasis. Online and practical training programs result in proficiency of skills, which can be maintained despite infrequent use.

Keywords: dressing, hemostatic; tourniquet; trauma care; prehospital civilian

Buy Now

Author: Berrett OM

Top

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

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

Abstract

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

Keywords: tactical emergency medical support; tactical medicine

Buy Now

Author: Berry J

Top

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

Gerhardt RT, Berry J, Mabry RL, Flournoy L, Arnold RG, Hults C, Robinson JB, Thaxton RA, Cestero R, Heiner JD, Koller AR, Cox KM, Patterson JN, Dalton WR, McKeague AL, Gilbert G, Manemeit C, Adams BD. 14(1). 50 - 57. (Journal Article)

Abstract

Objective: We sought to determine whether Contingency Telemedical Support (CTS) improves the success rate and efficiency of primary care providers performing critical actions during simulated combat trauma resuscitation. Critical actions included advanced airway, chest decompression, extremity hemorrhage control, hypothermia prevention, antibiotics and analgesics, and hypotensive resuscitation, among others. Background: Recent studies report improved survival associated with skilled triage and treatment in the out-of-hospital/preoperative phase of combat casualty care. Historically, ground combat units are assigned primary care physicians and physician assistants as medical staff, due to resource limitations. Although they are recognized as optimal resuscitators, demand for military trauma surgeons and emergency physicians exceeds supply and is unlikely to improve in the near term. Methods: A prospective trial of telemedical mentoring during a casualty resuscitation encounter was studied using a high-fidelity patient simulator (HFPS). Subjects were randomized and formed into experimental (CTS) or control teams. CTS team leaders were equipped with a headset/microphone interface and telementored by a combat-experienced emergency physician or trauma surgeon. A standardized, scripted clinical scenario and HFPS were used with 14 critical actions. At completion, subjects were surveyed. Statistical approach included contingency table analysis, two-tailed t-test, and correlation coefficient. This study was reviewed and approved by our institutional review board (IRB). Results: Eighteen CTS teams and 16 control teams were studied. By intention-to-treat ITT analysis, 89% of CTS teams versus 56% of controls completed all life-threatening inventions (LSIs) (p < .01); 78% versus 19% completed all critical actions (p < .01); and 89% versus 56% established advanced airways within 8 minutes (p < .06). Average time to completion in minutes (95% confidence interval [CI] 95) was 12 minutes (10-14) for CTS versus 18 (16-20) for controls, with 75% of control teams not completing all critical actions. Conclusion: In this model, real-time telementoring of simulated trauma resuscitation was feasible and improved accuracy and efficiency of non-emergency-trained resuscitators. Clinical validation and replicated study of these findings for guiding remote damage control resuscitation are warranted.

Keywords: military medicine; war; emergency medical services; resuscitation; telemedicine; wounds and injuries

Buy Now

Author: Berry-Caban CS

Top

MEDEVAC Use of Ketamine for Postintubation Transport

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

Abstract

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

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

Buy Now

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

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

Abstract

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

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

Buy Now

Author: Berry-Caban CS

Top

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

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

Abstract

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

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

Buy Now

Author: Beute TC

Top

Erythema Ab Igne

Gregory JF, Beute TC. 13(4). 115 - 119. (Journal Article)

Abstract

Erythema ab igne is a reticulated, erythematous, hyperpigmented dermatosis resulting from chronic mild to moderate heat exposure. The authors present two cases of erythema ab igne, one from a hot water bottle to treat chronic low back pain and another from a heated automobile seat. They review other reported etiologies and highlight scenarios in which military medical providers may encounter erythema ab igne.

Keywords: erythema ab igne; thermal injury; heating blanket; heated seat; reticular dermatosis; hyperpigmentation

Buy Now

Erythema Multiforme

Sola CA, Beute TC. 14(3). 90 - 92. (Journal Article)

Abstract

An active duty male Soldier presents to your clinic with concerns of blister-like lesions on both hands and feet several weeks after receiving immunizations. He is diagnosed with erythema multiforme (EM), a hypersensitivity reaction that is typically self-resolving. This article reviews the etiologies, pathophysiology, course, diagnosis, and treatment of erythema multiforme.

Keywords: erythema multiforme; vaccines; smallpox; typhoid; anthrax

Buy Now

Author: Bianchina N

Top

Effectiveness of Pulse Oximetry Versus Doppler for Tourniquet Monitoring

Wall PL, Buising CM, Grulke L, Troester A, Bianchina N, White S, Freymark R, Hassan A, Hopkins JW, Renner CH, Sahr SM. 17(1). 36 - 44. (Journal Article)

Abstract

Background: Pulse oximeters are common and include arterial pulse detection as part of their methodology. The authors investigated the possible usefulness of pulse oximeters for monitoring extremity tourniquet arterial occlusion. Methods: Tactical Ratcheting Medical Tourniquets were tightened to the least Doppler-determined occluding pressure at mid-thigh or mid-arm locations on one limb at a time on all four limbs of 15 volunteers. A randomized block design was used to determine the placement locations of three pulse oximeter sensors on the relevant digits. The times and pressures of pulsatile signal absences and returns were recorded for 200 seconds, with the tourniquet being tightened only when the Doppler ultrasound and all three pulse oximeters had pulsatile signals present (pulsatile waveform traces for the pulse oximeters). Results: From the first Doppler signal absence to tourniquet release, toe-located pulse oximeters missed Doppler signal presence 41% to 50% of the times (discrete 1-second intervals) and missed 39% to 49% of the pressure points (discrete 1mmHg intervals); fingerlocated pulse oximeters had miss rates of 11% to 15% of the times and 13% to 19% of the pressure points. On toes, the pulse oximeter ranges of sensitivity and specificity for Doppler pulse detection were 71% to 90% and 44% to 51%, and on fingers, the respective ranges were 65% to 77% and 78% to 83%. Conclusion: Use of a pulse oximeter to monitor limb tourniquet effectiveness will result in some instances of an undetected weak arterial pulse being present. If a pulse oximeter waveform is obtained from a location distal to a tourniquet, the tourniquet should be tightened. If a pulsatile waveform is not detected, vigilance should be maintained.

Keywords: tourniquet; hemorrhage; first aid; emergency treatment

Buy Now

Author: Biever KA

Top

Junctional Tourniquet Training Experience

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

Abstract

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

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

Buy Now

Author: Biggane PJ

Top

Fever and Thrombocytopenia in a Returning Soldier

Downs JW, Biggane PJ. 15(4). 75 - 78. (Journal Article)

Abstract

A case of fever and thrombocytopenia in a 33-year-old Special Forces Soldier with recent deployment to the Philippines is discussed, as are differential diagnosis and initial medical management at an overseas, fixed US military medical treatment facility. The authors discuss lessons learned that are applicable for Special Operations Forces (SOF) medical providers and recommend a renewed and continued emphasis on tropical medicine and infectious disease training for SOF medical providers.

Keywords: dengue fever; military medicine; tropical medicine; fever of unknown origin

Buy Now

Author: Bingham MT

Top

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

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

Abstract

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

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

Buy Now

Author: Bir CA

Top

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

Stojsih SE, Baker JL, Les CM, Bir CA. 14(4). 86 - 91. (Journal Article)

Abstract

Background: Working dogs have been proven effective in multiple military and law enforcement applications. Similar to their human counterparts, understanding mortality while still in service can help improve treatment of injuries, and improve equipment and training, to potentially reduce deaths. This is a retrospective study to characterize mortality of working dogs used in civilian law enforcement. Methods: Reported causes of death were gathered from two working dog and law enforcement officer memorial websites. Results: Of the 867 civilian law enforcement dogs reported to these memorial websites from 2002 to 2012 with reported causes of death while in service, the deaths of 318 were categorized as traumatic. The leading reported causes of traumatic death or euthanasia include trauma as a result of a vehicle strike, 25.8% (n = 82); heatstroke, 24.8% (n = 79); and penetrating ballistic trauma, 23.0% (n = 73). Conclusion: Although the information gathered was from online sources, this study casts some light on the risks that civilian law enforcement dogs undergo as part of the tasks to which they are assigned. These data underscore the need for a comprehensive database for this specialized population of working dogs to provide the robust, reliable data needed to develop prevention and treatment strategies for this valuable resource.

Keywords: canine; mortality; law enforcement; trauma

Buy Now

Author: Bird D

Top

Tourniquet Conversion: A Recommended Approach in the Prolonged Field Care Setting

Drew B, Bird D, Matteucci M, Keenan S. 15(3). 81 - 85. (Journal Article)

Abstract

Life-saving interventions take precedence over diagnostic maneuvers in the Care Under Fire stage of Tactical Combat Casualty Care. The immediate threat to life with an actively hemorrhaging extremity injury is addressed with the liberal and proper use of tourniquets. The emphasis on hemorrhage control has and will continue to result in the application of tourniquets that may not be needed past the Care Under Fire stage. As soon as tactically allowable, all tourniquets must be reassessed for conversion. Reassessment of all tourniquets should occur as soon as the tactical situation permits, but no more than 2 hours after initial placement. This article describes a procedure for qualified and trained medical personnel to safely convert extremity tourniquets to local wound dressings, using a systematic process in the field setting.

Keywords: prolonged field care; tourniquets; tourniquet conversion; Tactical Combat Casualty Care

Buy Now

Author: Birkholz S

Top

Tourniquet Pressures: Strap Width and Tensioning System Widths

Wall PL, Coughlin O, Rometti MR, Birkholz S, Gildemaster Y, Grulke L, Sahr SM, Buising CM. 14(4). 19 - 29. (Journal Article)

Abstract

Background: Pressure distribution over tourniquet width is a determinant of pressure needed for arterial occlusion. Different width tensioning systems could result in arterial occlusion pressure differences among nonelastic strap designs of equal width. Methods: Ratcheting Medical Tourniquets™ (RMTs; m2® inc., http://www.ratcheting buckles.com) with a 1.9cm-wide (Tactical RMT) or 2.3cmwide (Mass Casualty RMT) ladder were directly compared (16 recipients, 16 thighs and 16 upper arms for each tourniquet ® 2). Then, RMTs were retrospectively compared with the windlass Combat Application Tourniquet (C-A-T ["CAT"], http://combattourniquet.com) with a 2.5cm-wide internal tensioning strap. Pressure was measured with an air-filled No. 1 neonatal blood pressure cuff under each 3.8cm-wide tourniquet. Results: RMT circumferential pressure distribution was not uniform. Tactical RMT pressures were not higher, and there were no differences between the RMTs in the effectiveness, ease of use ("97% easy"), or discomfort. However, a difference did occur regarding tooth skipping of the pawl during ratchet advancement: it occurred in 1 of 64 Tactical RMT applications versus 27 of 64 Mass Casualty RMT applications. CAT and RMT occlusion pressures were frequently over 300mmHg. RMT arm occlusion pressures (175-397mmHg), however, were lower than RMT thigh occlusion pressures (197-562mmHg). RMT effectiveness was better with 99% reached occlusion and 1% lost occlusion over 1 minute versus the CAT with 95% reached occlusion and 28% lost occlusion over 1 minute. RMT muscle tension changes (up to 232mmHg) and pressure losses over 1 minute (24 ± 11mmHg arm under strap to 40 ± 12mmHg thigh under ladder) suggest more occlusion losses may have occurred if tourniquet duration was extended. Conclusions: The narrower tensioning system Tactical RMT has better performance characteristics than the Mass Casualty RMT. The 3.8cmwide RMTs have some pressure and effectiveness similarities and differences compared with the CAT. Clinically significant pressure changes occur under nonelastic strap tourniquets with muscle tension changes and over time periods as short as 1 minute. An examination of pressure and occlusion changes beyond 1 minute would be of interest.

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

Buy Now

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

Wall PL, Weasel J, Rometti MR, Birkholz S, Gildemaster Y, Grulke L, Sahr SM, Buising CM. 16(2). 28 - 35. (Journal Article)

Abstract

Background: Applications of wider tourniquet are expected to occlude arterial flow at lower pressures. We examined pressures under 3.8cm-wide, 5.1cm-wide, and side-by-side-3.8cm-wide nonelastic strap-based tourniquets. Methods: Ratcheting Medical Tourniquets (RMT) were applied mid-thigh and mid-arm for 120 seconds with Doppler-indicated occlusion. The RMTs were a Single Tactical RMT (3.8cm-wide), a Wide RMT (5.1cm-wide), and Paired Tactical RMTs (7.6cm-total width). Tightening completion was measured at one-tooth advance past arterial occlusion, and paired applications involved alternating tourniquet tightening. Results: All 96 applications on the 16 recipients reached occlusion. Paired tourniquets had the lowest occlusion pressures (ρ < .05). All pressures are given as median mmHg, minimum-maximum mmHg. Thigh application occlusion pressures were Single 256, 219-299; Wide 259, 203-287; Distal of Pair 222, 183-256; and Proximal of Pair 184, 160-236. Arm application occlusion pressures were Single 230, 189-294; Wide 212, 161-258; Distal of Pair 204, 193-254, and Proximal of Pair 168, 148-227. Pressure increases with the final tooth advance were greater for the 2 teeth/cm Wide than for the 2.5 teeth/cm Tacticals (ρ < .05). Thigh final tooth advance pressure increases were Single 40, 33-49; Wide 51, 37-65; Distal of Pair 13, 1-35; and Proximal of Pair 15, 0-30. Arm final tooth advance pressure increases were Single 49, 41-71; Wide 63, 48-77; Distal of Pair 3, 0-14; and Proximal of Pair 23, 2-35. Pressure decreases occurred under all tourniquets over 120 seconds. Thigh pressure decreases were Single 41, 32-75; Wide 43, 28-62; Distal of Pair 25, 16-37; and Proximal of Pair 22, 15-37. Arm pressure decreases were Single 28, 21-43; Wide 26, 16-36; Distal of Pair 16, 12-35; and Proximal of Pair 12, 5-24. Occlusion losses before 120 seconds occurred predominantly on the thigh and with paired applications (ρ < .05). Occlusion losses occurred in six Paired thigh applications, two Single thigh applications, and one Paired arm application. Conclusions: Side-by-side tourniquets achieve occlusion at lower pressures than single tourniquets. Additionally, pressure decreases under tourniquets over time; so all tourniquet applications require reassessments for continued effectiveness.

Keywords: tourniquet; hemorrhage; first aid; emergency treatment

Buy Now

Author: Bishop J

Top

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

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

Abstract

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

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

Buy Now

Author: Black IH

Top

Pain Management In Current Combat Operations

Black IH, McManus JG. 10(4). 75 - 79. (Previously Published)
Permission granted to republish. Reproduced from Prehospital Emergency Care 2009, Vol. 13, No. 2, Pages 223-227

Abstract

Pain management in the U.S. military, particularly in combat, shares many of the same principles found in civilian heathcare organizations and institutions. Pain is one of the most common reasons for which Soldiers seek medical attention in the combat environment, which mirrors the civilian experience. However, the combat environment exacerbates the typical challenges found in treating acute pain and has the additional obstacles of a lack of supplies and equipment, delayed or prolonged evacuation times and distances, devastating injuries, provider inexperience, and dangerous tactical situations. These factors contribute to the difficulty in controlling a Soldier's pain in combat. Furthermore, civilian healthcare providers have also learned the importance of practicing pain management principles in austere and tactical environments because of recent natural and man-made domestic disasters. Pain management research, education, and treatment strategies have been created to try to achieve adequate battlefield analgesia, and these lessons learned may aid civilian healthcare providers if the circumstances arise. This article presents a brief history and current overview of pain management for combat casualties on today's battlefield. Recent natural disasters and increased threats for terrorist acts have proven the need for civilian healthcare providers to be properly trained in pain management principles in an austere or tactical environment.

Author: Blackbourne LH

Top

Survey Of The Indications For Use Of Emergency Tourniquets

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

Abstract

Indications and evidence are limited, multiple and complex for emergency tourniquet use. Good recent outcomes challenge historically poor outcomes. Optimal tourniquet use in trauma care appears to depend on adequate devices, modern doctrine, refined training, speedy evacuation, and performance improvement. Challenges remain in estimation of blood loss volumes, lesion lethality, and casualty propensity to survive hemorrhage. Summary Background Data: Evidence gaps persist regarding emergency tourniquet use indications in prehospital and emergency department settings as indication data are rarely reported. Methods: Data on emergency tourniquet use was analyzed from a large clinical study (NCT00517166 at ClinicalTrials.gov). The study included 728 casualties with 953 limbs with tourniquets. The median casualty age was 26 years (range, 4-70). We compared all other known datasets to this clinical study. Results: Tourniquet use was prehospital in 671 limbs (70%), hospital only in 104 limbs (11%), and both prehospital and hospital in 169 limbs (18%).Major hemorrhage was observed at or before the hospital in 487 (51%) limbs and minor hemorrhage was observed at the hospital in 463 limbs (49%). Anatomic lesions indicating tourniquets included open fractures (27%), amputations (26%), soft tissue wounds (20%), and vascular wounds (17%). Situations, as opposed to anatomic lesions, indicating tourniquets included bleeding from multiple sites other than limbs (24%), hospital mass casualty situations (1%), one multiple injury casualty needed an airway procedure, and one casualty had an impaled object. Conclusions: The current indication for emergency tourniquet use is any compressible limb wound that the applier assesses as having possibly lethal hemorrhage. This indication has demonstrated good outcomes only when devices, training, doctrine, evacuation, and research have been optimal. Analysis of emergency tourniquet indications is complex and inadequately evidenced, and further study is prudent. Prehospital data reporting may fill knowledge gaps. Objective: The purpose of this study is to report and analyze emergency tourniquet use indications to stop limb bleeding.

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

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

Abstract

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

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

Buy Now

Combat Ready Clamp Medic Technique

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

Abstract

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

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

Buy Now

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

Clumpner BR, Polston RW, Kragh JF, Westmoreland T, Harcke HT, Jones JA, Dubick MA, Baer DG, Blackbourne LH. 13(1). 34 - 41. (Journal Article)

Abstract

Background: Common first aid tourniquets, like the Combat Application Tourniquet (CAT) of a windlass and band design, can have the band routed through the buckle in three different ways, and recent evidence indicates users may be confused with complex doctrine. Objective: The purpose of the present study is to measure the differential performance of the three possible routings in order to better understand good tourniquet practice. Methods: A training manikin was used by two investigators to measure tourniquet effectiveness, time to stop bleeding, and blood loss. Results: The effectiveness rate was 99.6% (239/240) overall. Results were similar for both single-slit routings (inside vs. outside, p > 0.05). Effectiveness rates (yes-no results for hemorrhage control expressed as a proportion of iterations) were not statistically different between single and double routing. However, the time to stop bleeding and blood loss were statistically different (ρ < 0.05). Conclusions: CAT band routing, through the buckle either singly or doubly, affects two key performance criteria: time to stop bleeding and volume of blood lost. Single routing proved to be faster, thereby saving more blood. Learning curves required to optimize user performance varied over 30-fold depending on which variable was selected (e.g., effectiveness vs. blood loss).

Keywords: hemorrhage; first aid; trauma; damage control; emergency medical services

Buy Now

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

King DR, Kragh JF, Blackbourne LH. 13(2). 20 - 24. (Journal Article)

Abstract

Background: Recent efforts to improve the quality of care in the Afghanistan theater have focused on extremity compartment syndrome, a common, disabling, and costly problem. To identify opportunities to improve care, the present survey was undertaken to observe the use of two standard methods-the traditional, improvised method and the common, off-the-shelf method-for determining intracompartmental pressures in the lower extremities of combat casualties. Methods: As part of a quality of care improvement effort during Operation Enduring Freedom, all combat casualties presenting to a forward surgical team at Forward Operating Base Shank from August to November 2011 with lower-extremity major trauma were evaluated for signs and symptoms of compartment syndrome. Results: Ten casualties had pressure measurement surveyed simultaneously using both methods. A two one-sided test analysis demonstrated a mean difference of -0.13 (90% confidence interval, -0.36 to 0.096), which indicated that the methods were similar. A repeated-measures analysis yielded a p value of .72, indicating no statistical difference between the methods. The receiver operating characteristic curve demonstrated excellent agreement within the prespecified limits (±2mm Hg, area under the curve 1.0), which indicated that the methods were similar. Conclusion: The main finding of the quality of care effort was that clinicians received similar information from use of two standard methods for far forward measurement of pressures to detect extremity compartment syndrome. This finding may help clinicians improve the quality of care in the theater in detecting, diagnosing, and monitoring compartment syndrome.

Keywords: fascia wounds; injuries; emergency medical services; Afghan Campaign 2001-present; military medicine

Buy Now

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

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

Abstract

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

Keywords: pneumothorax; chest seal; TCCC Guideline

Buy Now

Tragedy Into Drama: An American History of Tourniquet Use in the Current War

Kragh JF, Walters TJ, Westmoreland T, Miller RM, Mabry RL, Kotwal RS, Ritter BA, Hodge DC, Greydanus DJ, Cain JS, Parsons DL, Edgar EP, Harcke HT, Baer DG, Dubick MA, Blackbourne LH, Montgomery HR, Holcomb JB, Butler FK. 13(3). 5 - 25. (Journal Article)

Abstract

Background: Although the scientific results of recent tourniquet advances in first aid are well recorded, the process by which tourniquet use advances were made is not. The purpose of the present report is to distill historical aspects of this tourniquet story during the current wars in Afghanistan and Iraq to aid scientists, leaders, and clinicians in the process of development of future improvements in first aid. Methods: The process of how developments of this tourniquet story happened recently is detailed chronologically and thematically in a "who did what, when, where, why, and how" way. Results: Initially in these wars, tourniquets were used rarely or were used as a means of last resort. Such delay in tourniquet use was often lethal; subsequently, use was improved incrementally over time by many people at several organizations. Three sequential keys to success were (1) unlocking the impasse of enacting doctrinal ideas already approved, (2) reaching a critical density of both tourniquets and trained users on the battlefield, and (3) capturing their experience with tourniquets. Other keys included translating needs among stakeholders (such as casualties, combat medics, providers, trainers, and decision-makers) and problem-solving logistic snags and other issues. Eventually, refined care was shown to improve survival rates. From all medical interventions evidenced in the current wars, the tourniquet broke rank and moved to the forefront as the prehospital medical breakthrough of the war. Conclusion: The recorded process of how tourniquet developments in prehospital care occurred may be used as a reference for parallel efforts in first aid such as attempts to improve care for airway and breathing problems.

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

Buy Now

U.S. Military Experience With Junctional Wounds in War From 2001 to 2010

Kragh JF, Dubick MA, Aden JK, McKeague AL, Rasmussen TE, Baer DG, 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

Buy Now

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

Butler FK, Holcomb JB, Schreiber MA, Kotwal RS, Jenkins DA, Champion HR, Bowling F, Cap AP, DuBose JJ, Dorlac WC, Dorlac GR, McSwain NE, Timby JW, Blackbourne LH, Stockinger Z, Strandenes G, Weiskopf RB, Gross K, Bailey JA. 14(3). 13 - 38. (Journal Article)

Abstract

This report reviews the recent literature on fluid resuscitation from hemorrhagic shock and considers the applicability of this evidence for use in resuscitation of combat casualties in the prehospital Tactical Combat Casualty Care (TCCC) environment. A number of changes to the TCCC Guidelines are incorporated: (1) dried plasma (DP) is added as an option when other blood components or whole blood are not available; (2) the wording is clarified to emphasize that Hextend is a less desirable option than whole blood, blood components, or DP and should be used only when these preferred options are not available; (3) the use of blood products in certain Tactical Field Care (TFC) settings where this option might be feasible (ships, mounted patrols) is discussed; (4) 1:1:1 damage control resuscitation (DCR) is preferred to 1:1 DCR when platelets are available as well as plasma and red cells; and (5) the 30-minute wait between increments of resuscitation fluid administered to achieve clinical improvement or target blood pressure (BP) has been eliminated. Also included is an order of precedence for resuscitation fluid options. Maintained as recommendations are an emphasis on hypotensive resuscitation in order to minimize (1) interference with the body's hemostatic response and (2) the risk of complications of overresuscitation. Hextend is retained as the preferred option over crystalloids when blood products are not available because of its smaller volume and the potential for long evacuations in the military setting.

Keywords: hemorrhage; fluid resuscitation; shock; plasma; blood products; damage control resuscitation

Buy Now

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

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

Abstract

Buy Now

Author: Blakeman T

Top

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

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

Abstract

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

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

Buy Now

Author: Blankenship R

Top

Ultrasound In Special Operations Medicine: A Proposal For Applicatoin And Training

Keenan S, Morgan AR, Blankenship R, Hubler DA. 08(3). 47 - 54. (Journal Article)

Abstract

Emergency ultrasound is gaining ground as a powerful diagnostic tool in the hospital setting. With ever-expanding indications, validated with scientific studies, it has become an accepted and relied-upon technology with daily use in emergency departments, and surgical and critical care settings around the world. Additionally, with the current worldwide combat operations and the resultant deployment of far-forward medical assets, the technology's use outside of the standard hospital setting has been demonstrated. This technology, however, has had limited use outside the forward surgical or medical officer-positioned assets, despite being standard equipment with some Special Operations units. We hope to stimulate discussion about its use in Special Operations medicine by educating the reader to the possibilities of this technology, and suggesting a reasonable training and fielding plan for its optimal use.

Ultrasound Detection Of Pneumothorax With Minimally Trained Sonographers: A Preliminary Study

Monti JD, Younggren B, Blankenship R. 09(4). 43 - 46. (Journal Article)

Abstract

Background: Prompt recognition and treatment of a tension pneumothorax is critical to reducing mortality in both military and civilian settings. Physician assistants, Special Operations Forces (SOF) and conventional force Medics are often the first medical providers to care for combat trauma patients with penetrating chest trauma and frequently have limited diagnostic capabilities available to them due to mission constraints. The purpose of this study is to examine the potential for non-physician providers to determine the absence or presence of a pneumothorax in a porcine model, with the use of a portable ultrasound machine, after receiving minimal training. Methods: Physician assistants, SOF and conventional force Medics, veterinary technicians, and food service inspectors, all naïve to ultrasound, were recruited for this study. Participants underwent a brief presentation on detection of a pneumothorax by ultrasound and were then asked to perform a thoracic ultrasound examination on euthanized, ventilated swine. Some of the swine were induced with a pneumothorax prior to these examinations, and all participants were blinded to the absence or presence of a pneumothorax. Results: Twenty-two participants examined a total of 44 hemithoraces. A total of 21 out of 22 pneumothoraces were correctly identified with one false-negative. All 22 normal hemithoraces were correctly identified for a sensitivity of 95.4% (95 % CI 0.75-0.99), and a specificity of 100% (95% CI 0.81-1.00), with PPV of 100%, NPV of 95.6%. Conclusions: Non-physician healthcare providers can accurately detect a pneumothorax with portable ultrasound after receiving minimal focused training.

Keywords: ultrasound; pneumothorax; military

Author: Blaylock JM

Top

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

Caci JB, Blaylock JM, De La Barrera R, Thomas SJ, Lyons AG. 14(3). 111 - 115. (Journal Article)

Abstract

The endemicity of dengue fever (DF) and, consequently, sequelae of DF are increasing worldwide. The increases are largely a result of widespread international travel and the increased range of the mosquito vectors. US Army Special Operations Command (USASOC) personnel are at an increased risk of exposure to dengue based on their frequent deployments to and presence in dengue endemic areas worldwide. Repeated deployments to different endemic areas can increase the risk for developing the more serious sequelae of dengue: dengue hemorrhagic fever (DHF) and dengue shock syndrome (DSS). Information about the seroprevalence rate of dengue in USASOC personnel, in particular, is lacking and is critical to assessing the risk, tailoring preventive medicine countermeasures, leveraging field diagnostics, and maintaining mission capability. In the first part of a two-part project to assess baseline seroprevalence in USASOC units, a random, unit-stratified sample of 500 anonymous serum specimens from personnel assigned to the highest-risk units in USASOC were screened for dengue using a microneutralization assay. Of the 500 specimens screened, 56 (11.2%) of 500 had neutralizing titers (NT) (MN(50) ≥ 10) against at least one DENV serotype. Subsequent sample titration resulted in 48 (85.7%) of 56 of the samples with NT (MN(50) ≥ 10) against at least one dengue serotype for an overall dengue exposure rate of 9.6% (48 of 500). The second part of the ongoing project, started in 2012, was a multicenter, serosurveillance project using predeployment and postdeployment sera collected from USASOC personnel deployed to South and Central America, Africa, and Southeast Asia. Preliminary results show a 13.2% (55 of 414) seropositivity rate. The significance of these findings as they relate to personal risk and operational impact is discussed.

Keywords: dengue fever; USASOC; dengue hemorrhagic fever; dengue shock syndrome

Buy Now

Author: Blazier SJ

Top

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

Blazier SJ, Leach RA, Perez G, Holmes BW, Blough RS, Keenan S. 07(4). 51 - 57. (Journal Article)

Abstract

The purpose of this article is to present a strategy for establishing and running a local national medical clinic in support of our counter-insurgency strategy, practiced by our Special Forces Task Force in support of Operation Enduring Freedom. In the course of multiple rotations to Afghanistan, we have acquired a feasible strategy to take advantage of the non-kinetic operations of a local national medical clinic. This article seeks to identify mission essential tasks and provides examples from Special Forces Teams (Operational Detachment -Alpha, or ODA) throughout our area of operations (AO) in different settings.

Author: Blenkinsop G

Top

What Is the Optimal Device Length and Insertion Site for Needle Thoracostomy in UK Military Casualties? A Computed Tomography Study

Blenkinsop G, Mossadegh S, Ballard M, Parker P. 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

Buy Now

Author: Blough RS

Top

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

Blazier SJ, Leach RA, Perez G, Holmes BW, Blough RS, Keenan S. 07(4). 51 - 57. (Journal Article)

Abstract

The purpose of this article is to present a strategy for establishing and running a local national medical clinic in support of our counter-insurgency strategy, practiced by our Special Forces Task Force in support of Operation Enduring Freedom. In the course of multiple rotations to Afghanistan, we have acquired a feasible strategy to take advantage of the non-kinetic operations of a local national medical clinic. This article seeks to identify mission essential tasks and provides examples from Special Forces Teams (Operational Detachment -Alpha, or ODA) throughout our area of operations (AO) in different settings.

Author: Blythe J

Top

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

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

Abstract

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

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

Buy Now

The Hidden Complexity of Biological "Dirty Bombs": Implications for Special Operations Medical Personnel

Washington MA, Blythe J. 16(4). 82 - 84. (Journal Article)

Abstract

The recent capture of a terrorist in Belgium carrying explosives, fecal matter, and animal tissue may indicate a shift from conventional weapons to crude bacteriological preparations as instruments of terror. It is important to note that although such weapons lack technological sophistication, bacteria are inherently complex, unpredictable, and undetectable in the field. Therefore, it is important that Special Operations medical personnel understand the complications that such seemingly simple devices can add to the treatment of casualties in the field and subsequent evaluation in the clinic.

Keywords: dirty bombs; terrorists; warfare, biological

Buy Now

Author: Bobko JP

Top

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

Bobko JP, Lai TT, Smith R, Shapiro G, Baldridge T, Callaway DW. 13(4). 94 - 107. (Journal Article)

Abstract

Background: Active shooter events and active violent incidents are increasingly targeting civilians, placing children at heightened risk for complex and devastating trauma. The U.S. Department of Homeland Security has identified as a priority preparing domestic first responders to manage complex mass casualty incidents as a primary step in strengthening our medical system. Existing literature suggests that many prehospital providers are uncomfortable treating critically ill or injured pediatric patients and that there is a gap in the consistent provision of high-quality trauma care to these patients. The success of threat-based care developed by the military has led to an exponential rise in the familiarity and utilization of these concepts within certain specialized elements of civilian care. Evolution of these concepts is accelerating to meet the demands of the nonmilitary civilian environment through the formation and subsequent work of the Committee for Tactical Emergency Casualty Care (C-TECC). However, a gap remains in the available literature describing the application of these principles to specialized populations. Methods: In the absence of an evidence-based set of guidelines for prehospital care of the pediatric casualty, the C-TECC sought to establish a set of peer-reviewed guidelines to serve as a foundation describing current best practices. The Pediatric Working Group (PWG) utilized the adult TECC guidelines as a starting point and identified a series of key questions regarding trauma interventions. The PWG conducted a standard PubMed search to identify key relevant or potentially relevant literature. The literature review was presented to the C-TECC Guidelines Committee for review and approval of recommended principles. Recommendations: Given the dearth of supporting literature on the subject, the TECC committee was purposefully conservative in the adaptation of the adult TECC guidelines to a pediatric standard. The guidelines highlight information tailored to the pediatric population and were designed to be a resource for individual agencies seeking guidance for high-threat operations. To our knowledge, the TECC Pediatric Appendix is the first published recommendation for the widespread use of tourniquets in pediatric hemorrhage. In addition, the Guidelines are meant to highlight gaps in trauma literature and stimulate discussion regarding future research in the area of prehospital care of the pediatric casualty.

Keywords: TCCC; pediatric hemorrhage; pediatrics; C-TCCC

Buy Now

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

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

Abstract

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

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

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

Abstract

The Ranger First Responder Program and Tactical Emergency Casualty Care Implementation: A Whole-Community Approach to Reducing Mortality From Active Violent Incidents

Fisher AD, Callaway DW, Robertson JN, Hardwick SA, Bobko JP, Kotwal RS. 15(3). 46 - 53. (Journal Article)

Abstract

Active violent incidents are dynamic and challenging situations that can produce a significant amount of preventable deaths. Lessons learned from the military's experience in Afghanistan and Iraq through the Committee on Tactical Combat Casualty Care and the 75th Ranger Regiment's Ranger First Responder Program have helped create the Committee for Tactical Emergency Casualty Care (C-TECC) to address the uniqueness of similar wounding patterns and to end preventable deaths. We propose a whole-community approach to active violent incidents, using the C-TECC Trauma Chain of Survival and a tiered approach for training and responsibilities: the first care provider, nonmedical professional first responders, medical first responders, and physicians and trauma surgeons. The different tiers are critical early links in the Chain of Survival and this approach will have a significant impact on active violent incidents.

Keywords: Committee on Tactical Combat Casualty Care; Ranger First Responder Program; Committee on Emergency Casualty Care; wounding patterns; Chain of Survival; preventable death

Buy Now

Author: Bodo M

Top

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

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

Abstract

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

Buy Now

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

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

Abstract

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

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

Buy Now

Author: Boedecker BH

Top

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

Boedecker BH, Nicholas TA, Carpenter J, Leighton S, Bernhagen MA, Murray WB, Wadman MC. 11(2). 21 - 29. (Journal Article)

Abstract

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

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

Buy Now

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

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

Abstract

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

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

Buy Now

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

Alderman SM, Arvidsson CJ, Boedecker 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.

Buy Now

Author: Boland M

Top

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

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

Abstract

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

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

Buy Now

Author: Bollard GA

Top

Atlas of Conducted Electrical Weapon Wounds and Forensic Analysis

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

Abstract

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

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

Schwartz RB, Lerner B, Llewellyn C, Pennardt A, Wedmore I, Callaway DW, Wightman JM, Casillas R, Eastman A, Gerold KB, Giebner S, Davidson R, Kamin R, Piazza G, Bollard GA, Carmona PA, Sonstrom B, Seifarth W, Nicely B, Croushorn J, Carmona PA. 14(2). 122 - 138. (Classical Conference)

Abstract

Author: Bongiorno MA

Top

Treatment of Psoriasis in the Deployed Setting

Bongiorno MA, Rivard SC, Meyerle JH. 15(2). 12 - 15. (Journal Article)

Abstract

Psoriasis is a chronic immune-mediated disorder that can be triggered by environmental changes, illness, smoking, or medications. This case describes a 25-year-old, activeduty Marine Corps Sergeant with a severe perideployment psoriatic flare, and illustrates treatment limitations, restricted access to specialized care, and the importance of mitigating triggers in the deployed setting.

Keywords: psoriasis; psoriasis, plaque; psoriasis, guttate; arthritis, psoriatic; smoking, cessation; ultraviolet light, exposure; deployment; military provider

Buy Now

Author: Bonk C

Top

A Case Of Tapework Infestation

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

Abstract

Author: Booms Z

Top

Traumatic Pelvic Hematoma After a Military Static-Line Parachute Jump: A Case Series

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

Buy Now

Author: Bordes J

Top

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

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

Abstract

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

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

Buy Now

Author: Bottoms M

Top

SOF Leadership in The Face Of Stress

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

Abstract

Author: Boujie L

Top

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

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

Abstract

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

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

Buy Now

Pectoralis Major Injury During Basic Airborne Training

McIntire S, Boujie L, Leasiolagi J. 16(3). 11 - 14. (Journal Article)

Abstract

Injuries involving rupture of the pectoralis major are relatively rare. When they do occur, it is mostly frequently in a young, athletic man. The most common cause is weight lifting that results in eccentric muscle contraction (muscle contraction against an overbearing force, leading to muscle lengthening)-specifically, the bench press. Other mechanisms for this injury include forceful abduction and external rotation of the arm. Injury can occur anywhere along the pectoralis major from its medial origin on the sternum and clavicle to its lateral tendinous insertion on the humerus. At the time of injury, patients may report feeling a tearing sensation or hearing a pop, with immediate onset of pain. Physical examination findings can include a deformed appearance of the chest, ecchymosis of the chest and upper arm, pain and weakness with arm adduction and internal rotation, or noticeable asymmetry of the anterior axilla with arm abduction. Magnetic resonance imaging is the imaging study of choice to aid diagnosis. In a young and active population, such as the Special Operations community, appropriate and timely diagnosis is important because surgical intervention often is recommended. This report presents the case of an active-duty Servicemember who sustained a pectoralis major injury while exiting an aircraft during the Basic Airborne Course.

Keywords: pectoralis major; rupture; avulsion; tear; airborne; parachute; static line

Buy Now

Author: Bourgeois B

Top

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

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

Abstract

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

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

Buy Now

Author: Bove AA

Top

Diving Medicine: A Review Of Current Evidence

Lynch JH, Bove AA. 09(3). 72 - 79. (Previously Published)
Previously published in The Journal of the American Board of Family Medicine 22 (4): 399-407 (2009) Reprinted in the JSOM with permission granted by the Chief Editor of the The Journal of the American Board of Family Medicine

Abstract

Recreational scuba diving is a growing sport worldwide, with an estimated 4 million sport divers in the United States alone. Because divers may seek medical care for a disorder acquired in a remote location, physicians everywhere should be familiar with the physiology, injury patterns, and treatment of injuries and illnesses unique to the underwater environment. Failure to properly recognize, diagnose, and appropriately treat some diving injuries can have catastrophic results. In addition, recreational dive certification organizations require physical examinations for medical clearance to dive. This article will review both common and potentially life-threatening conditions associated with diving and will review current evidence behind fitness to dive considerations for elderly divers and those with common medical conditions.

Author: Bowden L

Top

Fascioliasis and Fasciolopsiasis: Similar Names, Similar Diseases?

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

Abstract

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

Author: Bowles JM

Top

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

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

Abstract

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

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

Buy Now

Author: Bowley DM

Top

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

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

Abstract

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

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

Buy Now

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

Eisenstein NM, Naumann DN, Bowley DM, Midwinter MJ. 16(4). 59 - 63. (Editorial)

Abstract

Keywords: trauma, prevention and control; wounds and injuries; prehospital emergency care; organizational innovation; Editorials

Author: Bowling F

Top

The Use Of Fresh Whole Blood Transfusions By The Sof Medic For Hemostatic Resuscitation In The Austere Environment

Bowling F, Pennardt A. 10(2). 25 - 35. (Journal Article)

Abstract

Fresh Whole Blood Transfusions In The Austere Environment

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

Abstract

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

Buy Now

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

Butler FK, Holcomb JB, Schreiber MA, Kotwal RS, Jenkins DA, Champion HR, Bowling F, Cap AP, DuBose JJ, Dorlac WC, Dorlac GR, McSwain NE, Timby JW, Blackbourne LH, Stockinger Z, Strandenes G, Weiskopf RB, Gross K, Bailey JA. 14(3). 13 - 38. (Journal Article)

Abstract

This report reviews the recent literature on fluid resuscitation from hemorrhagic shock and considers the applicability of this evidence for use in resuscitation of combat casualties in the prehospital Tactical Combat Casualty Care (TCCC) environment. A number of changes to the TCCC Guidelines are incorporated: (1) dried plasma (DP) is added as an option when other blood components or whole blood are not available; (2) the wording is clarified to emphasize that Hextend is a less desirable option than whole blood, blood components, or DP and should be used only when these preferred options are not available; (3) the use of blood products in certain Tactical Field Care (TFC) settings where this option might be feasible (ships, mounted patrols) is discussed; (4) 1:1:1 damage control resuscitation (DCR) is preferred to 1:1 DCR when platelets are available as well as plasma and red cells; and (5) the 30-minute wait between increments of resuscitation fluid administered to achieve clinical improvement or target blood pressure (BP) has been eliminated. Also included is an order of precedence for resuscitation fluid options. Maintained as recommendations are an emphasis on hypotensive resuscitation in order to minimize (1) interference with the body's hemostatic response and (2) the risk of complications of overresuscitation. Hextend is retained as the preferred option over crystalloids when blood products are not available because of its smaller volume and the potential for long evacuations in the military setting.

Keywords: hemorrhage; fluid resuscitation; shock; plasma; blood products; damage control resuscitation

Buy Now

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

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

Abstract

Author: Boyd DW

Top

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

Anglim AM, Boyd DW. 12(2). 48 - 57. (Journal Article)

Abstract

Objective: For travel to high altitudes, most experts advise a gradual ascent regimen to prevent acute mountain sickness (AMS). Such standard recommendations are applied to the general public. It is generally thought, however, that those whose work requires frequent rapid ascents, such as military personnel, porters and guides, often make these ascents without adequate preventive measures and then, experience significant morbidity and potential mortality due to AMS. The aim of this study were to demonstrate that the risk of rapid ascents can be mitigated if performed with adherence to a structured nutrition and hydration plan, carrying controlled loads, and taking specific prescribed rest periods during the ascent. Methods: This study used a randomized controlled trial of a group of Nepali porters, guides, and a Westerner with similar characteristics, all participating in their first ascent of the early Himalayan season. Data collected each day included oxygen saturation (SpO(2)), heart rate (HR), weight, and blood pressure (BP). Data was collected every 300 meters(m) (1,000 feet [ft]) and at the same time and altitude at each days end. Ascent profiles, age, gender, ethnic origin, altitude of residence and experience at altitude were also obtained. In four days, a control group of Nepali porters and a Sherpa guide and an equal number of Nepali porters and a Sherpa guide in an intervention group, (led by a Westerner) went from Kathmandu (1,300m), to the summit of Kala Pattar (5,640m), and Everest Base Camp (5,380m), averaging approximately 1,000m (3,500ft) gain a day in altitude, with no acclimatization rest days. During the rapid ascent from 4,300ft to 18,500ft, a regimented program was followed by the intervention group, while the control group ascended using their traditional methods as Nepali porters and Sherpa guides. Values are given as mean ± SE. T-test, ANOVA, and Mann-Whitney tests were used to compare variables. Results: Based on mean SpO(2) measurements on the summit of Kala Pattar at 5,640m (18,500ft), the intervention group had a SpO(2) of 79.5% ± 3.209 and the control group's mean SpO(2) was 74.5% ± 3.109 (ρ = .076). Importantly, two participants dropped out of the control group at 4,900m with SpO(2) scores of 77 and 71. The ANOVA results between the groups SpO(2) at 5,640m was significant at p ≥ .04. Mann Whitney U test results demonstrate a significant (U = 21.5, p = .04) difference in median SpO(2) levels between the intervention and the control groups. This indicates that employing a regimented program is vital to the objective of sustaining adequate SpO(2) levels and yielding a successful climb. The intervention group that followed the regimented nutrition, hydration, and rest period program performed physiologically superior to the control group, especially on the longest (10 hours), highest (5,640m), and greatest altitude gain (1,090m) day-despite resting for five minutes every 25 minutes of hiking. This was achieved with no acclimatization days, and each participant residing at low altitude. Conclusions: Participants who followed a structured nutrition, hydration plan, and adhered to prescribed rest periods, performed physiologically superior to the control group who did not. Two control group participants dropped out with poor physiological measurements. This aggressive ascent profile mirrors encountered work demands on military personnel, professional porters, and guides. The beneficial effect was significant and could provide superior methods to those whose duties require aggressive ascent profiles. The implications of frequent rest periods (10 minutes an hour), a high-carbohydrate diet, and at least 3,000ml of fluid a day appear to factually present a physiologically superior method to trekking at high to very-high altitudes. The health implications for trekkers to the Himalaya (or to any place at high altitude) by using a similar regimented program are that it may allow for an AMS-free, more enjoyable experience at altitude.

Keywords: high altitude; prevention of AMS; rapid ascent; military; Nepal; Sherpa; Porter

Buy Now

Author: Bozeman WP

Top

Medical Provider Ballistic Protection at Active Shooter Events

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

Abstract

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

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

Buy Now

Author: Brüggemann G

Top

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

Goldmann J, Braunstein B, Sanno M, Kurzner S, Brüggemann G, Mester J. 14(2). 80 - 83. (Journal Article)

Abstract

Objectives: Short-term exposure (2-30 seconds) to segmental mechanical vibrations with frequencies between 20 and 80 Hz affects proprioception of the central nervous system and manual dexterity and strength of man. It could be supposed that during fast-roping, Soldiers are exposed to hand-arm vibrations caused by the geometry of the rope. After the maneuver, Soldiers are encouraged to operate with high precision (e.g., aiming and shooting) within a few seconds. For safety, disturbances of the sensory system should be strongly avoided. The purpose of the study was to determine the vibrations induced by different rope geometries during fast-roping. Methods: Eight men of the German Special Forces performed 10 fast-roping maneuvers with two different shaped ropes (slightly molded versus deeply molded). Vibration data and frequency spectrum for each trial were measured by using fast Fourier transformation. Results: The analysis of data showed that fast-roping with a slightly molded rope produced frequencies of up to 10 Hz, while the frequencies with a deeply molded rope accounted for 18 to 60 Hz. The ropes differed significantly (ρ < .001) in frequencies between 20 and 50 Hz. The exposure time of vibration lasted between 3 and 5 seconds. Conclusion: Considering the negative effects associated with vibrations, prudence is required when using deeply molded ropes due to the increased vibrations of about 20 Hz.

Keywords: fast-roping; vibrations; motion; rope; sensations; rappelling; abseiling; kinesthetic illusions; Special Operations Forces

Buy Now

Author: Brandon J

Top

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

Brandon J, Hill GJ. 11(1). 27 - 29. (Journal Article)

Abstract

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

Author: Branson R

Top

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

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

Abstract

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

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

Buy Now

Author: Braunstein B

Top

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

Goldmann J, Braunstein B, Sanno M, Kurzner S, Brüggemann G, Mester J. 14(2). 80 - 83. (Journal Article)

Abstract

Objectives: Short-term exposure (2-30 seconds) to segmental mechanical vibrations with frequencies between 20 and 80 Hz affects proprioception of the central nervous system and manual dexterity and strength of man. It could be supposed that during fast-roping, Soldiers are exposed to hand-arm vibrations caused by the geometry of the rope. After the maneuver, Soldiers are encouraged to operate with high precision (e.g., aiming and shooting) within a few seconds. For safety, disturbances of the sensory system should be strongly avoided. The purpose of the study was to determine the vibrations induced by different rope geometries during fast-roping. Methods: Eight men of the German Special Forces performed 10 fast-roping maneuvers with two different shaped ropes (slightly molded versus deeply molded). Vibration data and frequency spectrum for each trial were measured by using fast Fourier transformation. Results: The analysis of data showed that fast-roping with a slightly molded rope produced frequencies of up to 10 Hz, while the frequencies with a deeply molded rope accounted for 18 to 60 Hz. The ropes differed significantly (ρ < .001) in frequencies between 20 and 50 Hz. The exposure time of vibration lasted between 3 and 5 seconds. Conclusion: Considering the negative effects associated with vibrations, prudence is required when using deeply molded ropes due to the increased vibrations of about 20 Hz.

Keywords: fast-roping; vibrations; motion; rope; sensations; rappelling; abseiling; kinesthetic illusions; Special Operations Forces

Buy Now

Author: Bree S

Top

The Use of Pelvic Binders in Tactical Combat Casualty Care: TCCC Guidelines Change 1602 7 November 2016

Shackelford S, Hammesfahr R, Morissette D, Montgomery HR, Kerr W, Broussard M, Bennett BL, Dorlac WC, Bree S, Butler FK. 17(1). 135 - 147. (Classical Conference)

Abstract

Keywords: pelvic binder; prehospital guidelines; TCCC Guideline

Author: Bremer J

Top

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

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.

Buy Now

Author: Brenner J

Top

The Operational Canine and K9 Tactical Emergency Casualty Care Initiative

Palmer LE, Maricle R, Brenner J. 15(3). 32 - 38. (Journal Article)

Abstract

Background: Approximately 20% to 25% of traumarelated, prehospital fatalities in humans are due to preventable deaths. Data are lacking, however, on the nature and the prevalence of operational canine (OC) prehospital deaths. It is plausible that OCs engaged in high-threat operations are also at risk for suffering some type of preventable death. Tactical Combat Casualty Care has significantly reduced human fatality rates on the battlefield. Standardized guidelines specifically for prehospital trauma care have not been developed for the OC caregiver. An initiation has been approved by the Committee for Tactical Emergency Casualty Care to form a K9-Tactical Emergency Casualty Care (TECC) working group to develop such guidelines. Significance: The intent of the K9-TECC initiative is to form best practice recommendations for the civilian high-risk OC caregiver. These recommendations are to focus on interventions that (1) eliminate the major causes of canine out-of-hospital preventable deaths, (2) are easily learned and applied by any civilian first responder, and (2) minimize resource consumption.

Keywords: canine; trauma; preventable death; Tactical Emergency Casualty Care; K9-TECC; guidelines

Buy Now

Author: Brenner M

Top

Resuscitative Endovascular Balloon Occlusion of the Aorta: Pushing Care Forward

Teeter W, Romagnoli A, Glaser J, Fisher AD, Pasley J, Scheele B, Hoehn M, Brenner M. 17(1). 17 - 21. (Case Reports)

Abstract

Background: Resuscitative endovascular balloon occlusion of the aorta (REBOA), used to temporize noncompressible and junctional hemorrhage, may be deployable to the forward environment. Our hypothesis was that nonsurgeon physicians and high-level military medical technicians would be able to learn the theory and insertion of REBOA. Methods: US Army Special Operations Command medical personnel without prior endovascular experience were included. All participants received didactic instruction of the Basic Endovascular Skills for Trauma Course™ together, with individual evaluation of technical skills. A pretest and a posttest were administered to assess comprehension. Results: Four members of US Army Special Operations Command-two nonsurgeon physicians, one physician assistant, and one Special Operations Combat Medic-were included. REBOA procedural times moving from trial 1 to trial 6 decreased significantly from 186 ± 18.7 seconds to 83 ± 10.3 seconds (ρ < .0001). All participants demonstrated safe REBOA insertion and verbalized the indications for REBOA insertion and removal through all trials. All five procedural tasks were performed correctly by each participant. Comprehension and knowledge between the pretest and posttest improved significantly from 67.6 ± 7.3% to 81.3 ± 8.1% (ρ = .039). Conclusion: This study demonstrates that nonsurgeon and nonphysician providers can learn the steps required for REBOA after arterial access is established. Although insertion is relatively straightforward, the inability to gain arterial access percutaneously is prohibitive in providers without a surgical skillset and should be the focus of further training.

Keywords: REBOA; resuscitative endovascular balloon occlusion of the aorta; training; virtual reality simulation; junctional hemorrhage; noncompressable torso hemorrhage

Buy Now

Author: Brink PR

Top

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

Zengerink I, Brink PR, Laupland KB, Raber EL, Zygun D, Kortbeek JB. 08(1). 92 - 95. (Previously Published)
Previously published in The Journal of Trauma Injury, Infection, and Critical Care. 2008;64:111–114. Permission granted by Lippincott Williams & Wilkins to republish in JSOM.

Abstract

Background: A tension pneumothorax requires immediate decompression using a needle thoracostomy. According to advanced trauma life support guidelines this procedure is performed in the second intercostal space (ICS) in the midclavicular line (MCL), using a 4.5cm (2-inch) catheter (5cm needle). Previous studies have shown a failure rate of up to 40% using this technique. Case reports have suggested that this high failure rate could be because of insufficient length of the needle. Objectives: To analyze the average chest wall thickness (CWT) at the second ICS in the MCL in a trauma population and to evaluate the length of the needle used in needle thoracostomy for emergency decompression of tension pneumothoraces. Methods: Retrospective review of major trauma admissions (Injury Severity Score >12) at the Foothills Medical Centre in Calgary, Canada, who underwent a computed tomography chest scan admitted in the period from October 2001 until March 2004. Subgroup analysis on men and women, <40 years of age and >40 years of age was defined a priori. CWT was measured to the nearest 0.01cm at the second ICS in the MCL. Results: The mean CWT in the 604 male patients and 170 female patients studied averaged 3.50cm at the left second ICS MCL and 3.51cm on the right. The mean CWT was significantly higher for women than men (ρ < 0.0001). About 9.9% to 19.3% of the men had a CWT >4.5 cm and 24.1% to 35.4% of the women studied. Conclusions: A catheter length of 4.5cm may not penetrate the chest wall of a substantial amount (9.9% - 35.4%) of the population, depending on age and gender. This study demonstrates the need for a variable needle length for relief of a tension pneumothorax in certain population groups to improve effectiveness of needle thoracostomy.

Author: Brink W

Top

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

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

Abstract

Author: Brisson P

Top

Management of the Mangled Face by a Forward Surgical Team

Brisson P, Woll M, Welden B. 11(4). 25 - 27. (Case Reports)

Abstract

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

Buy Now

Garlic Burn to the Face

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

Abstract

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

Keywords: burns, chemical; garlic; military personnel

Buy Now

Author: Brodie S

Top

Tourniquet Use In Combat Trauma: Uk Military Experience

Brodie S, Hodgetts TJ, Ollerton J, McLeod J, Lambert P, Mahoney P. 09(4). 74 - 77. (Previously Published)
Previously published in J R Army Med Corps 2007; 153(4): 310-313. Reprinted in the JSOM with kind permission of the editor of the Journal of the Royal Army Medical Corps’.

Abstract

Aim: To determine the prevalence of tourniquet use in combat trauma, the contribution to lives saved and the complications of their use in this environment. Population: All casualties treated at UK field hospital facilities in Iraq and Afghanistan and meeting criteria for entry into UK Joint Theatre Trauma Registry (JTTR) from 04 Feb 03 to 30 Sep 07. Methods: Cases were identified from UK JTTR. Casualties from Permanent Joint Overseas Bases (PJOBs) were excluded. ISS, NISS, TRISS and ASCOT were calculated automatically within JTTR from AIS 2005 (Military) codes. Results: 1375 patients met UK JTTR entry criteria for the period specified (excluding PJOBs). 70/1375 patients (5.1%) were treated with one or more tourniquets (total 107 tourniquet applications). 61/70 (87%) survived their injuries. 17/70 (24%) patients had 2 or more tourniquets applied. 64/70 patients received a tourniquet after April 2006, when tourniquets were introduced as an individual first aid item. 43/70 (61%) patients were UK military. Conclusions: ISS and TRISS are poorly representative of injury severity and outcome for combat trauma involving isolated multiple limb injuries and cannot be used to discriminate whether a tourniquet is life-saving. The presence of severe isolated limb injuries, profound hypovolaemic shock and the requirement for massive transfusion reasonably identifies a cohort where the use of one or more tourniquets pre-hospital to control external bleeding can be said to be life-saving.

Author: Broussard DW

Top

Learning Curves of Emergency Tourniquet Use Exploring for Utility in Training

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

Abstract

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

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

Buy Now

Author: Broussard M

Top

The Use of Pelvic Binders in Tactical Combat Casualty Care: TCCC Guidelines Change 1602 7 November 2016

Shackelford S, Hammesfahr R, Morissette D, Montgomery HR, Kerr W, Broussard M, Bennett BL, Dorlac WC, Bree S, Butler FK. 17(1). 135 - 147. (Classical Conference)

Abstract

Keywords: pelvic binder; prehospital guidelines; TCCC Guideline

Author: Brown IP

Top

The Expanded Scope of Emergency Medical Practice Necessary for Initial Disaster Response: Lessons from Haiti

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.

Buy Now

Author: Brown SG

Top

Management of Anaphylaxis in an Austere or Operational Environment

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

Abstract

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

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

Buy Now

Author: Bruce W

Top

The Use of Dexamethasone in Support of High-Altitude Ground Operations and Physical Performance: Review of the Literature

O'Hara R, Serres J, Dodson W, Bruce W, Ordway J, Powell E, Wade M. 14(4). 53 - 58. (Journal Article)

Abstract

Objective: Military Special Operators (SOs) are exposed environmental conditions that can alter judgment and physical performance: uneven terrain, dryness of ambient air, reduction of air density, and a diminished partial pressure of oxygen. The primary purpose of this review was to determine the medical efficacy of dexamethasone as an intervention for the prevention and treatment of high-altitude illness. The secondary purpose was to determine its ability to maintain physical performance of SOs at high altitudes. Methods: A search of the literature from 1970 to 2014 was performed, locating 61 relevant articles, with 43 addressing the primary and secondary purposes of this literature review. Conclusions: The review indicates that dexamethasone is an effective prevention and treatment intervention for high-altitude illness. Commonly used dosages of either 2mg every 6 hours or 4mg every 12 hours can prevent high-altitude illnesses in adults. Currently in USSOCOM operations, there is an option to use 4mg every 6 hours (concurrently with acetazolamide 125mg bid) if ascending rapidly to or above 11,500 ft without time for acclimatization. Researchers also determined that acute exposure to high altitude, even in asymptomatic subjects, resulted in small cognitive deficits that could be reversed with dexamethasone. Dexamethasone may also help improve cognition and maximal aerobic capacity in SOs who are susceptible to high-altitude pulmonary edema.

Keywords: high altitude; mountain; performance; strength; endurance; physical; military; Special Operations

Buy Now

Author: Brunstetter T

Top

The Tactical Combat Casualty Care Casualty CardTCCC Guidelines - Proposed Change 1301

Kotwal RS, Butler FK, Montgomery HR, Brunstetter T, Diaz GY, Kirkpatrick JW, Summers NL, Shackelford S, 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.

Buy Now

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

Brunstetter T, Diaz GY, Wasner C, Hart S, Burrows S. 13(3). 26 - 28. (Journal Article)

Abstract

From 5% to 22% of all U.S. Department of Defense combat casualties between 2001 and 2010 suffered some form of ocular trauma. Ocular injuries have an inordinately dramatic impact on return to duty, retention, and reintegration; only 25% of warfighters with severe ocular trauma return to duty. After a traumatic ocular event, the likelihood of saving an eye and preserving vision depends on several factors, especially the treatment quality at the point of injury. Every major organization associated with combat casualty care (e.g., the U.S. Army Institute of Surgical Research, the Committee on Tactical Combat Casualty Care, and the Department of Defense/VA Vision Center of Excellence) emphasizes the importance of placing a rigid eye shield on known/suspected eye injuries at point of injury. On the battlefield, there is no better way to protect an injured eye from further damage than with an eye shield, but shields are not readily available in individual first aid kits. Therefore, it is highly recommended that each Service rapidly integrate at least one rigid eye shield into every individual first aid kit, making them immediately available to every warfighter.

Keywords: rigid eye shield; ocular trauma; ballistic eye protection; eye injuries; open globe injuries; first aid kit

Buy Now

Author: Bryan AO

Top

Warzone Stressor Exposure, Unit Support, and Emotional Distress Among U.S. Air Force Pararescuemen

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

Buy Now

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

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

Abstract

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

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

Buy Now

Author: Bryan CJ

Top

Warzone Stressor Exposure, Unit Support, and Emotional Distress Among U.S. Air Force Pararescuemen

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

Buy Now

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

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

Abstract

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

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

Buy Now

Author: Bryant D

Top

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

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

Abstract

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

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

Buy Now

Author: Buckenmaier CC

Top

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

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

Abstract

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

Keywords: battlefield analgesia; fentanyl; ketamine; morphine

Buy Now

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

Buckenmaier CC, Galloway KT, Polomano RC, Deuster PA. 16(2). 82 - 87. (Journal Article)

Abstract

The intense physical demands and dangerous operational environments common to Special Operations Forces (SOF) result in a variety of painful conditions, including musculoskeletal pain, headaches, and acute and chronic pain from combat injuries. Pain is a wellaccepted barrier to human performance. The Pain Management Task Force and the development of the Defense Veterans Pain Rating Scale (DVPRS) are discussed to provide a framework for changing the culture of pain management away from intensity of pain to interference with function and performance. The emergence of complementary and integrative pain management (CIM) practices is briefly reviewed as viable alternatives to the traditional reliance on opioids and other prescription medications. The SOF community can be the change agent for the DVPRS and CIM approaches to pain management, which will in the end serve to accelerate recovery and return SOF operators to duty faster and with an enhanced ability to perform with less pain.

Buy Now

Author: Buising CM

Top

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

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

Abstract

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

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

Buy Now

Tourniquet Pressures: Strap Width and Tensioning System Widths

Wall PL, Coughlin O, Rometti MR, Birkholz S, Gildemaster Y, Grulke L, Sahr SM, Buising CM. 14(4). 19 - 29. (Journal Article)

Abstract

Background: Pressure distribution over tourniquet width is a determinant of pressure needed for arterial occlusion. Different width tensioning systems could result in arterial occlusion pressure differences among nonelastic strap designs of equal width. Methods: Ratcheting Medical Tourniquets™ (RMTs; m2® inc., http://www.ratcheting buckles.com) with a 1.9cm-wide (Tactical RMT) or 2.3cmwide (Mass Casualty RMT) ladder were directly compared (16 recipients, 16 thighs and 16 upper arms for each tourniquet ® 2). Then, RMTs were retrospectively compared with the windlass Combat Application Tourniquet (C-A-T ["CAT"], http://combattourniquet.com) with a 2.5cm-wide internal tensioning strap. Pressure was measured with an air-filled No. 1 neonatal blood pressure cuff under each 3.8cm-wide tourniquet. Results: RMT circumferential pressure distribution was not uniform. Tactical RMT pressures were not higher, and there were no differences between the RMTs in the effectiveness, ease of use ("97% easy"), or discomfort. However, a difference did occur regarding tooth skipping of the pawl during ratchet advancement: it occurred in 1 of 64 Tactical RMT applications versus 27 of 64 Mass Casualty RMT applications. CAT and RMT occlusion pressures were frequently over 300mmHg. RMT arm occlusion pressures (175-397mmHg), however, were lower than RMT thigh occlusion pressures (197-562mmHg). RMT effectiveness was better with 99% reached occlusion and 1% lost occlusion over 1 minute versus the CAT with 95% reached occlusion and 28% lost occlusion over 1 minute. RMT muscle tension changes (up to 232mmHg) and pressure losses over 1 minute (24 ± 11mmHg arm under strap to 40 ± 12mmHg thigh under ladder) suggest more occlusion losses may have occurred if tourniquet duration was extended. Conclusions: The narrower tensioning system Tactical RMT has better performance characteristics than the Mass Casualty RMT. The 3.8cmwide RMTs have some pressure and effectiveness similarities and differences compared with the CAT. Clinically significant pressure changes occur under nonelastic strap tourniquets with muscle tension changes and over time periods as short as 1 minute. An examination of pressure and occlusion changes beyond 1 minute would be of interest.

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

Buy Now

Initial Tourniquet Pressure Does Not Affect Tourniquet Arterial Occlusion Pressure

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

Abstract

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

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

Buy Now

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

Wall PL, Sahr SM, Buising CM. 15(4). 28 - 38. (Journal Article)

Abstract

Background: Tourniquets are used on distal limb segments. We examined calf and forearm use of four thigh-effective, commercial tourniquets with different widths and tightening systems: 3.8cm windlass Combat Application Tourniquet® (CAT, combattourrniquet.com) and Special Operations Forces® Tactical Tourniquet-Wide (SOFTTW, www.tacmedsolutions.com), 3.8cm ratchet Ratcheting Medical Tourniquet - Pediatric (RMT-P, www.ratchetingbuckles. com), and 10.4cm elastic Stretch-Wrap-And-Tuck Tourniquet® (SWATT, www.swattourniquet.com). Methods: From Doppler-indicated occlusion, windlass completion was the next securing opportunity; ratchet completion was one additional tooth advance; elastic completion was end tucked under a wrap. Results: All applications on the 16 recipients achieved occlusion. Circumferences were calf 38.1 ± 2.5cm and forearm 25.1 ± 3.0cm (p < .0001, t-test, mean ± SD). Pressures at Occlusion, Completion, and 120-seconds after Completion differed within each design (p < .05, one-way ANOVA; calf: CAT 382 ± 100, 510 ± 108, 424 ± 92mmHg; SOFTT-W 381 ± 81, 457 ± 103, 407 ± 88mmHg; RMT-P 295 ± 35, 350 ± 38, 301 ± 30mmHg; SWATT 212 ± 46, 294 ± 59, 287 ± 57mmHg; forearm: CAT 301 ± 100, 352 ± 112, 310 ± 98mmHg; SOFTT-W 321 ± 70, 397 ± 102, 346 ± 91mmHg; RMT-P 237 ± 48, 284 ± 60, 256 ± 51mmHg; SWATT 181 ± 34, 308 ± 70, 302 ± 70mmHg). Comparing designs, pressures at each event differed (p < .05, one-way ANOVA), and the elastic design had the least pressure decrease over time (p < .05, one-way ANOVA). Occlusion losses differed among designs on the calf (p < .05, χ²; calf: CAT 1, SOFTT-W 5, RMT-P 1, SWATT 0; forearm: CAT 0, SOFTT-W 1, RMT-P 2, SWATT 0). Conclusions: All four designs can be effective on distal limb segments, the SWATT doing so with the lowest pressures and least pressure losses over time. The pressure change from Occlusion to Completion varies by tourniquet tightening system and can involve a pressure decrease with the windlass tightening systems. Pressure losses occur in as little as 120 seconds following Completion and so can loss of Occlusion. This is especially true for nonelastic strap tourniquet designs.

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

Buy Now

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

Wall PL, Weasel J, Rometti MR, Birkholz S, Gildemaster Y, Grulke L, Sahr SM, Buising CM. 16(2). 28 - 35. (Journal Article)

Abstract

Background: Applications of wider tourniquet are expected to occlude arterial flow at lower pressures. We examined pressures under 3.8cm-wide, 5.1cm-wide, and side-by-side-3.8cm-wide nonelastic strap-based tourniquets. Methods: Ratcheting Medical Tourniquets (RMT) were applied mid-thigh and mid-arm for 120 seconds with Doppler-indicated occlusion. The RMTs were a Single Tactical RMT (3.8cm-wide), a Wide RMT (5.1cm-wide), and Paired Tactical RMTs (7.6cm-total width). Tightening completion was measured at one-tooth advance past arterial occlusion, and paired applications involved alternating tourniquet tightening. Results: All 96 applications on the 16 recipients reached occlusion. Paired tourniquets had the lowest occlusion pressures (ρ < .05). All pressures are given as median mmHg, minimum-maximum mmHg. Thigh application occlusion pressures were Single 256, 219-299; Wide 259, 203-287; Distal of Pair 222, 183-256; and Proximal of Pair 184, 160-236. Arm application occlusion pressures were Single 230, 189-294; Wide 212, 161-258; Distal of Pair 204, 193-254, and Proximal of Pair 168, 148-227. Pressure increases with the final tooth advance were greater for the 2 teeth/cm Wide than for the 2.5 teeth/cm Tacticals (ρ < .05). Thigh final tooth advance pressure increases were Single 40, 33-49; Wide 51, 37-65; Distal of Pair 13, 1-35; and Proximal of Pair 15, 0-30. Arm final tooth advance pressure increases were Single 49, 41-71; Wide 63, 48-77; Distal of Pair 3, 0-14; and Proximal of Pair 23, 2-35. Pressure decreases occurred under all tourniquets over 120 seconds. Thigh pressure decreases were Single 41, 32-75; Wide 43, 28-62; Distal of Pair 25, 16-37; and Proximal of Pair 22, 15-37. Arm pressure decreases were Single 28, 21-43; Wide 26, 16-36; Distal of Pair 16, 12-35; and Proximal of Pair 12, 5-24. Occlusion losses before 120 seconds occurred predominantly on the thigh and with paired applications (ρ < .05). Occlusion losses occurred in six Paired thigh applications, two Single thigh applications, and one Paired arm application. Conclusions: Side-by-side tourniquets achieve occlusion at lower pressures than single tourniquets. Additionally, pressure decreases under tourniquets over time; so all tourniquet applications require reassessments for continued effectiveness.

Keywords: tourniquet; hemorrhage; first aid; emergency treatment

Buy Now

Significant Pressure Loss Occurs Under Tourniquets Within Minutes of Application

Rometti MR, Wall PL, Buising CM, Gildemaster Y, Hopkins JW, Sahr SM. 16(4). 15 - 26. (Journal Article)

Abstract

Background: Pressure decreases occur after tourniquet application, risking arterial occlusion loss. Our hypothesis was that the decreases could be mathematically described, allowing creation of evidence-based, tourniquet-reassessment- time recommendations. Methods: Four tourniquets with width (3.8cm, 3.8cm, 13.7cm, 10.4cm), elasticity (none, none, mixed elastic/nonelastic, elastic), and mechanical advantage differences (windlass, ratchet, inflation, recoil) were applied to 57.5cm-circumference 10% and 20% ballistic gels for 600 seconds and a 57.5cmcircumference thigh and 31.5cm-circumference arm for 300 seconds. Time 0 target completion-pressures were 262mmHg and 362mmHg. Results: Two-phase decay equations fit the pressure-loss curves. Tourniquet type, gel or limb composition, circumference, and completionpressure affected the curves. Curves were clinically significant with the nonelastic Combat Application Tourniquet (C-A-T), nonelastic Ratcheting Medical Tourniquet (RMT), and mixed elastic/nonelastic blood pressure cuff (BPC), and much less with the elastic Stretch Wrap And Tuck-Tourniquet (SWATT). At both completion-pressures, pressure loss was faster on 10% than 20% gel, and even faster and greater on the thigh. The 362mmHg completion-pressure had the most pressure loss. Arm curves were different from thigh but still approached plateau pressure losses (maximal calculated losses at infinity) in similar times. With the 362mmHg completion-pressure, thigh curve plateaus were -68mmHg C-A-T, -62mmHg RMT, -34mmHg BPC, and -13mmHg SWATT. The losses would be within 5mmHg of plateau by 4.67 minutes C-A-T, 6.00 minutes RMT, 4.98 minutes BPC, and 6.40 minutes SWATT and within 1mmHg of plateau by 8.18 minutes C-A-T, 10.52 minutes RMT, 10.07 minutes BPC, and 17.68 minutes SWATT. Timesequenced images did not show visual changes during the completion to 300 or 600 seconds pressure-drop interval. Conclusion: Proper initial tourniquet application does not guarantee maintenance of arterial occlusion. Tourniquet applications should be reassessed for arterial occlusion 5 or 10 minutes after application to be within 5mmHg or 1mmHg of maximal pressure loss. Elastic tourniquets have the least pressure loss.

Keywords: tourniquet; hemorrhage; first aid; emergency treatment

Buy Now

Effectiveness of Pulse Oximetry Versus Doppler for Tourniquet Monitoring

Wall PL, Buising CM, Grulke L, Troester A, Bianchina N, White S, Freymark R, Hassan A, Hopkins JW, Renner CH, Sahr SM. 17(1). 36 - 44. (Journal Article)

Abstract

Background: Pulse oximeters are common and include arterial pulse detection as part of their methodology. The authors investigated the possible usefulness of pulse oximeters for monitoring extremity tourniquet arterial occlusion. Methods: Tactical Ratcheting Medical Tourniquets were tightened to the least Doppler-determined occluding pressure at mid-thigh or mid-arm locations on one limb at a time on all four limbs of 15 volunteers. A randomized block design was used to determine the placement locations of three pulse oximeter sensors on the relevant digits. The times and pressures of pulsatile signal absences and returns were recorded for 200 seconds, with the tourniquet being tightened only when the Doppler ultrasound and all three pulse oximeters had pulsatile signals present (pulsatile waveform traces for the pulse oximeters). Results: From the first Doppler signal absence to tourniquet release, toe-located pulse oximeters missed Doppler signal presence 41% to 50% of the times (discrete 1-second intervals) and missed 39% to 49% of the pressure points (discrete 1mmHg intervals); fingerlocated pulse oximeters had miss rates of 11% to 15% of the times and 13% to 19% of the pressure points. On toes, the pulse oximeter ranges of sensitivity and specificity for Doppler pulse detection were 71% to 90% and 44% to 51%, and on fingers, the respective ranges were 65% to 77% and 78% to 83%. Conclusion: Use of a pulse oximeter to monitor limb tourniquet effectiveness will result in some instances of an undetected weak arterial pulse being present. If a pulse oximeter waveform is obtained from a location distal to a tourniquet, the tourniquet should be tightened. If a pulsatile waveform is not detected, vigilance should be maintained.

Keywords: tourniquet; hemorrhage; first aid; emergency treatment

Buy Now

Author: Bull K

Top

Management of Burn Wounds Under Prolonged Field Care

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

Author: Burgert J

Top

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

Johnson D, Dial J, Ard J, Yourk T, Burke E, Paine C, Gegel B, Burgert J. 14(1). 79 - 85. (Journal Article)

Abstract

Introduction: The military recommends that a 500mL bolus of Hextend® be administered via an intravenous (IV) 18-gauge needle or via an intraosseous (IO) needle for patients in hypovolemic shock. Purposes: The purposes of this study were to compare the time of administration of Hextend and the hemodynamics of IV and IO routes in a Class II hemorrhage swine model. Methods: This was an experimental study using 27 swine. After 30% of their blood volume was exsanguinated, 500mL of Hextend was administered IV or IO, but not to the control group. Hemodynamic data were collected every 2 minutes until administration was complete. Results: Time for administration was not significant (p = .78). No significant differences existed between the IO and IV groups relative to hemodynamics (p > .05), but both were significantly different than the control group (p < .05). Conclusions: The IO route is an effective method of administering Hextend.

Keywords: hemorrhage; shock; Hextend®; hetastarch; battlefield

Buy Now

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

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

Abstract

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

Keywords: intraosseous; succinylcholine; rapid sequence induction

Buy Now

The Effects of Movement on Hemorrhage When QuikClot® Combat Gauze™ Is Used in a Hypothermic Hemodiluted Porcine Model

Garcia-Blanco J, Gegel B, Burgert J, Johnson S, Johnson D. 15(1). 57 - 60. (Journal Article)

Abstract

Background: The purpose of this study was to compare the effectiveness of QuikClot® Combat Gauze™ (QCG) to a control wound dressing to withstand movement in a porcine model with hemodilution and hypothermia. Design: This was a prospective study with a between-subjects experimental design. Twenty-six Yorkshire swine were randomly assigned to two groups: QCG (n = 13) or a control dressing (n = 13). Methods: The subjects were exsanguinated to 30% of the blood volume; hypothermia was induced for 10 minutes. The hemostatic agent, QCG, was placed into the wound, followed by standard wound packing. If hemostasis was achieved, 5L of crystalloid solution were rapidly administered intravenously, and the wound was again observed for rebleeding. If no bleeding occurred, the extremity on the side of the injury was systematically moved through flexion, extension, abduction, and adduction sequentially 10 times or until rebleeding occurred. Results: An independent t test indicated there were significant differences in the number of movements before rebleeding between the QCG group (mean ± standard deviation [SD], 32.92 ± 14.062) and the control group (mean ± SD, 6.15 ± 15.021) (ρ < .0001). Conclusion: QCG produces a robust clot that can withstand more movement than a control dressing.

Keywords: movement; hemorrhage; QuikClot®; Combat Gauze™; hypothermic hemodiluted porcine model

Buy Now

Author: Burgess AR

Top

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

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

Abstract

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

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

Buy Now

Author: Burke E

Top

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

Johnson D, Dial J, Ard J, Yourk T, Burke E, Paine C, Gegel B, Burgert J. 14(1). 79 - 85. (Journal Article)

Abstract

Introduction: The military recommends that a 500mL bolus of Hextend® be administered via an intravenous (IV) 18-gauge needle or via an intraosseous (IO) needle for patients in hypovolemic shock. Purposes: The purposes of this study were to compare the time of administration of Hextend and the hemodynamics of IV and IO routes in a Class II hemorrhage swine model. Methods: This was an experimental study using 27 swine. After 30% of their blood volume was exsanguinated, 500mL of Hextend was administered IV or IO, but not to the control group. Hemodynamic data were collected every 2 minutes until administration was complete. Results: Time for administration was not significant (p = .78). No significant differences existed between the IO and IV groups relative to hemodynamics (p > .05), but both were significantly different than the control group (p < .05). Conclusions: The IO route is an effective method of administering Hextend.

Keywords: hemorrhage; shock; Hextend®; hetastarch; battlefield

Buy Now

Author: Burkert MG

Top

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

Burkert MG, Kroencke A. 12(1). 62 - 70. (Journal Article)

Abstract

In 2011, a Mercedes Benz (MB) conducted the F-Cell World Drive tour around the globe in 125 days. While crossing Asia from SHANGHAI (CHINA) to HELSINKI (FINLAND) by car, en route medical care was provided by embedded emergency physicians. The designated route crossed four different countries, multiple climate zones, and challenging road conditions. There was only limited information provided about hospitals and emergency medical services within different hostnations in the planning phase, so we adopted tactical medical principles for mission planning and execution, as we were facing remote conditions and limitations to equipment, staffing, and patient transport.

Buy Now

Author: Burnett MW

Top

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

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

Abstract

Buy Now

Dengue Infections

Burnett MW. 13(2). 64 - 68. (Journal Article)

Abstract

Background: Dengue fever is one of the most common mosquito-borne viral illnesses in the world. It is usually transmitted to humans through the bite of an infected Aedes aegypti or Aedes albopictus mosquito. Dengue infections are caused by four antigenically distinct but closely related viruses (DEN 1-4). Infection with any one of the viruses is thought to provide lifetime immunity to future infections from the same virus but only short-term cross-immunity to the other types, leading to the possibility of secondary infections. Dengue hemorrhagic fever/dengue shock syndrome (DHF/DSS), more severe types of dengue infections, sometimes result when an individual is subsequently infected with a second virus serotype during their lifetime. The most commonly accepted theory for the development of these more severe dengue infections is that of antibody-dependent enhancement, although other factors likely play a role. Infections complicated by DHF/DSS in areas where dengue is endemic are most often seen in the later half of the first year of life, when waning maternal antibodies may enhance the development of a more severe infection, and in young school-age children experiencing secondary infections. Widespread infections are most commonly seen during the rainy season of endemic areas when the breeding habitat of the Aedes mosquito is most favorable.

Keywords: dengue hemorrhagic fever; dengue shock syndrome; mosquito-borne viral illness

Buy Now

Rabies

Burnett MW. 13(3). 102 - 104. (Journal Article)

Abstract

Rabies has been a scourge of mankind since antiquity. The name itself, "rabies" is derived from the ancient Sanskrit rabhas meaning "to do violence" and has been found described in medical writings several thousand years old. The rabies virus is an RNA virus of the family Rhabdoviridae (Greek for "rod-shaped virus"), genus Lyssavirus (Lyssa being the Greek God of frenzy and rage). Rabies infections have a worldwide spread, with only a few, mostly island nations laying claim to being "rabies free."

Buy Now

Pertussis

Burnett MW. 13(4). 113 - 114. (Journal Article)

Abstract

Background: Pertussis, a disease that has been well described since the Middle Ages, has a worldwide distribution and can infect all ages. It is caused by the gram-negative, pleomorphic bacillus Bordetella pertussis, which is transmitted from human to human via aerosolized droplets at close range. Descriptions such as the one-hundred day cough in Chinese and whooping cough in English, describe the severity of this disease seen in both the developed and the developing world.

Buy Now

Salmonella Infections Including Typhoid Disease

Burnett MW. 14(1). 96 - 98. (Journal Article)

Abstract

It is estimated that more than 20 million cases of Salmonella enterica serotype Typhi and 6 million cases of paratyphoid disease occur worldwide annually, with typhoid disease alone causing more than 200,000 deaths. The clinical manifestations, diagnosis, treatment, and vaccination guidelines are discussed.

Keywords: Salmonella; typhoid disease; vaccination

Buy Now

Infectious Diseases: Cholera

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

Abstract

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

Keywords: Vibrio cholerae; enterotoxin; diarrheal disease

Buy Now

Ebola Hemorrhagic Fever

Burnett MW. 14(3). 93 - 94. (Journal Article)

Abstract

Ebola hemorrhagic fever is an often-fatal disease caused by a virus of the Filoviridae family, genus Ebolavirus. Initial signs and symptoms of the disease are nonspecific, often progressing on to a severe hemorrhagic illness. Special Operations Forces Medical Providers should be aware of this disease, which occurs in sporadic outbreaks throughout Africa. Treatment at the present time is mainly supportive. Special care should be taken to prevent contact with bodily fluids of those infected, which can transmit the virus to caregivers.

Keywords: Ebolavirus; hemorrhagic fever

Buy Now

Chikungunya

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

Abstract

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

Keywords: Chikungunya; infectious disease; virus; mosquito vector

Buy Now

Cutaneous Leishmaniasis

Burnett MW. 15(1). 128 - 129. (Journal Article)

Abstract

Cutaneous leishmaniasis is the most common form of leishmaniasis, which also appears in mucosal and visceral forms. It is a disease found worldwide, caused by an intracellular protozoan parasite of which there are more than 20 different species. The disease is transmitted by the bite of an infected, female, phlebotomine sand fly, causing skin lesions that can appear weeks to years after a bite. A typical lesion will start out in a papular form, progressing to a nodular plaque and, eventually, to a persistent ulcerative lesion. Special Operations Forces medical providers should be aware of this disease, which must be in the differential diagnosis of a patient who has lived in endemic areas and who has a persistent skin lesion nonresponsive to typical therapies.

Keywords: leishmaniasis; parasitic disease

Buy Now

Q Fever

Burnett MW. 15(2). 109 - 111. (Journal Article)

Abstract

Q fever is a zoonotic disease found throughout the world. It is caused by the intracellular gram-negative bacterium Coxiella burnetii. Infection by C. burnetii occurs primarily by inhalation of the aerosolized bacteria from birthing animals or contaminated dust. The bacterium is very resistant to drying and heat, and is considered highly endemic in the Middle East, where it is likely underdiagnosed. Special Operations Forces medical providers should be aware of this disease, which must be in the differential diagnosis of a patient who has a history of fever, elevated liver enzymes, pneumonia in its acute form, and endocarditis, especially in those with existing valvular heart disease in its chronic form.

Keywords: Q fever; disease, zoonotic

Buy Now

Rabies: 2015 Update

Burnett MW. 15(3). 105 - 107. (Journal Article)

Abstract

Rabies is an almost universally fatal viral disease transmitted to humans primarily by bites and scratches from infected animals, and less commonly through other routes, including transplantation of infected organs, exposure to infected neural tissue, and possibly through airborne and aerosolized routes. This disease is endemic to all continents worldwide except Antarctica, and only a few islands elsewhere can be considered "rabies free." Special Operations Forces medical providers should be aware of this disease. Prevention and recognition of risk are key due to its extreme lethality.

Keywords: rabies, vaccine

Buy Now

Crimean-Congo Hemorrhagic Fever

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

Abstract

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

Keywords: Crimean-Congo hemorrhagic fever; infectious disease

Buy Now

Zika Virus

Burnett MW. 16(1). 86 - 87. (Journal Article)

Abstract

Keywords: Zika Virus

Buy Now

Japanese Encephalitis

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

Abstract

Buy Now

Rocky Mountain Spotted Fever

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

Abstract

Buy Now

Tularemia

Burnett MW. 16(4). 71 - 73. (Journal Article)

Abstract

Keywords: tularemia; Francisella tularensis

Buy Now

Meningococcal Disease

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

Abstract

Keywords: infection, meningococcal; disease, infectious

Buy Now

Author: Burnett WT

Top

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

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

Abstract

Buy Now

Author: Burns GD

Top

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

Burns GD, DeLellis SM. 08(4). 54 - 57. (Journal Article)

Abstract

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

Author: Burns T

Top

Blood Flow Restriction Rehabilitation for Extremity Weakness: A Case Series

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

Abstract

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

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

Buy Now

Author: Burrell E

Top

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

Onifer DJ, Butler FK, Gross K, Otten EJ, Patton R, Russell RJ, Stockinger Z, Burrell E. 15(2). 17 - 24. (Journal Article)

Abstract

The current Tactical Combat Casualty Care (TCCC) Guidelines recommend parenteral promethazine as the single agent for the treatment of opioid-induced nausea and/or vomiting and give a secondary indication of "synergistic analgesic effect." Promethazine, however, has a well-documented history of undesired side effects relating to impairment and dysregulation of the central and autonomic nervous systems, such as sedation, extrapyramidal symptoms, dystonia, impairment of psychomotor function, neuroleptic malignant syndrome, and hypotension. These may be particularly worrisome in the combat casualty. Additionally, since 16 September 2009, there has been a US Food and Drug Administration (FDA) black box warning for the injectable form of promethazine, due to "the risk of serious tissue injury when this drug is administered incorrectly." Conversely, ondansetron, which is now available in generic form, has a well-established favorable safety profile and demonstrated efficacy in undifferentiated nausea and vomiting in the emergency department and prehospital settings. It has none of the central and autonomic nervous system side effects noted with promethazine and carries no FDA black box warning. Ondansetron is available in parenteral form and an orally disintegrating tablet, providing multiple safe and effective routes of administration. Despite the fact that it is an off-label use, ondansetron is being increasingly given for acute, undifferentiated nausea and vomiting and is presently being used in the field on combat casualties by some US and Allied Forces. Considering the risks involved with promethazine use, and the efficacy and safety of ondansetron and ondansetron's availability in a generic form, we recommend removing promethazine from the TCCC Guidelines and replacing it with ondansetron.

Buy Now

Author: Burrows S

Top

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

Brunstetter T, Diaz GY, Wasner C, Hart S, Burrows S. 13(3). 26 - 28. (Journal Article)

Abstract

From 5% to 22% of all U.S. Department of Defense combat casualties between 2001 and 2010 suffered some form of ocular trauma. Ocular injuries have an inordinately dramatic impact on return to duty, retention, and reintegration; only 25% of warfighters with severe ocular trauma return to duty. After a traumatic ocular event, the likelihood of saving an eye and preserving vision depends on several factors, especially the treatment quality at the point of injury. Every major organization associated with combat casualty care (e.g., the U.S. Army Institute of Surgical Research, the Committee on Tactical Combat Casualty Care, and the Department of Defense/VA Vision Center of Excellence) emphasizes the importance of placing a rigid eye shield on known/suspected eye injuries at point of injury. On the battlefield, there is no better way to protect an injured eye from further damage than with an eye shield, but shields are not readily available in individual first aid kits. Therefore, it is highly recommended that each Service rapidly integrate at least one rigid eye shield into every individual first aid kit, making them immediately available to every warfighter.

Keywords: rigid eye shield; ocular trauma; ballistic eye protection; eye injuries; open globe injuries; first aid kit

Buy Now

Author: Butcher JJ

Top

Prevalence of Posttraumatic Stress Disorder in Special Operations Forces

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

Abstract

Author: Butler FK

Top

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

Kotwal RS, Butler FK, Murray CK, Hill GJ, Rayfield JC, Miles EA. 09(2). 59 - 63. (Previously Published)
Previously published in Military Medicine, 174, 5:544, 2009. Permission granted to republish in the JSOM.

Abstract

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

The Tactical Combat Casualty Care Casualty CardTCCC Guidelines - Proposed Change 1301

Kotwal RS, Butler FK, Montgomery HR, Brunstetter T, Diaz GY, Kirkpatrick JW, Summers NL, Shackelford S, 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.

Buy Now

Tragedy Into Drama: An American History of Tourniquet Use in the Current War

Kragh JF, Walters TJ, Westmoreland T, Miller RM, Mabry RL, Kotwal RS, Ritter BA, Hodge DC, Greydanus DJ, Cain JS, Parsons DL, Edgar EP, Harcke HT, Baer DG, Dubick MA, Blackbourne LH, Montgomery HR, Holcomb JB, Butler FK. 13(3). 5 - 25. (Journal Article)

Abstract

Background: Although the scientific results of recent tourniquet advances in first aid are well recorded, the process by which tourniquet use advances were made is not. The purpose of the present report is to distill historical aspects of this tourniquet story during the current wars in Afghanistan and Iraq to aid scientists, leaders, and clinicians in the process of development of future improvements in first aid. Methods: The process of how developments of this tourniquet story happened recently is detailed chronologically and thematically in a "who did what, when, where, why, and how" way. Results: Initially in these wars, tourniquets were used rarely or were used as a means of last resort. Such delay in tourniquet use was often lethal; subsequently, use was improved incrementally over time by many people at several organizations. Three sequential keys to success were (1) unlocking the impasse of enacting doctrinal ideas already approved, (2) reaching a critical density of both tourniquets and trained users on the battlefield, and (3) capturing their experience with tourniquets. Other keys included translating needs among stakeholders (such as casualties, combat medics, providers, trainers, and decision-makers) and problem-solving logistic snags and other issues. Eventually, refined care was shown to improve survival rates. From all medical interventions evidenced in the current wars, the tourniquet broke rank and moved to the forefront as the prehospital medical breakthrough of the war. Conclusion: The recorded process of how tourniquet developments in prehospital care occurred may be used as a reference for parallel efforts in first aid such as attempts to improve care for airway and breathing problems.

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

Buy Now

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

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

Abstract

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

Keywords: pneumothorax; chest seal; TCCC Guideline

Buy Now

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

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

Abstract

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

Keywords: junctional hemorrhage; Tactical Combat Casualty Care guidelines

Buy Now

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

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

Abstract

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

Keywords: battlefield analgesia; fentanyl; ketamine; morphine

Buy Now

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

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

Abstract

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

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

Buy Now

The 10 Commandments of Nutrition: 2014

Deuster PA, Lindsey AT, Butler FK. 14(3). 80 - 89. (Journal Article)

Abstract

The US Special Operations Command requires sound recommendations on nutrition to ensure optimal performance of Special Operations personnel. New information continues to emerge, and previous recommendations need to be modified as the evidence base continues to grow. The first 10 Commandments of Nutrition were published in the SEAL professional journal Full Mission Profile in 1992, published for the second time in this journal in 2005, and now revised a second time to reflect the newest science. Whether you are part of the Special Operations Forces (SOF) community or an athlete seeking to improve your performance, these are simple and helpful nutrition guidelines to follow.

Keywords: dietary supplements; omega-3 fatty acids; protein; carbohydrate; grains; fresh fruits and vegetables

Buy Now

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

Butler FK, Holcomb JB, Schreiber MA, Kotwal RS, Jenkins DA, Champion HR, Bowling F, Cap AP, DuBose JJ, Dorlac WC, Dorlac GR, McSwain NE, Timby JW, Blackbourne LH, Stockinger Z, Strandenes G, Weiskopf RB, Gross K, Bailey JA. 14(3). 13 - 38. (Journal Article)

Abstract

This report reviews the recent literature on fluid resuscitation from hemorrhagic shock and considers the applicability of this evidence for use in resuscitation of combat casualties in the prehospital Tactical Combat Casualty Care (TCCC) environment. A number of changes to the TCCC Guidelines are incorporated: (1) dried plasma (DP) is added as an option when other blood components or whole blood are not available; (2) the wording is clarified to emphasize that Hextend is a less desirable option than whole blood, blood components, or DP and should be used only when these preferred options are not available; (3) the use of blood products in certain Tactical Field Care (TFC) settings where this option might be feasible (ships, mounted patrols) is discussed; (4) 1:1:1 damage control resuscitation (DCR) is preferred to 1:1 DCR when platelets are available as well as plasma and red cells; and (5) the 30-minute wait between increments of resuscitation fluid administered to achieve clinical improvement or target blood pressure (BP) has been eliminated. Also included is an order of precedence for resuscitation fluid options. Maintained as recommendations are an emphasis on hypotensive resuscitation in order to minimize (1) interference with the body's hemostatic response and (2) the risk of complications of overresuscitation. Hextend is retained as the preferred option over crystalloids when blood products are not available because of its smaller volume and the potential for long evacuations in the military setting.

Keywords: hemorrhage; fluid resuscitation; shock; plasma; blood products; damage control resuscitation

Buy Now

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

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

Abstract

Selected Meeting Highlights

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

Shackelford S, Butler FK, Kragh JF, Stevens RA, Seery JM, Parsons DL, Montgomery HR, Kotwal RS, Mabry RL, Bailey JA. 15(1). 17 - 31. (Journal Article)

Abstract

Keywords: tourniquet; Tactical Combat Casualty Care guidelines; external hemorrhage control; shock; resuscitation; emergency medical services

Buy Now

Saving Lives on the Battlefield (Part II) - One Year Later: A Joint Theater Trauma System and Joint Trauma System Review of Prehospital Trauma Care in Combined Joint Operations Area-Afghanistan (CJOA-A)

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.

Buy Now

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

Onifer DJ, Butler FK, Gross K, Otten EJ, Patton R, Russell RJ, Stockinger Z, Burrell E. 15(2). 17 - 24. (Journal Article)

Abstract

The current Tactical Combat Casualty Care (TCCC) Guidelines recommend parenteral promethazine as the single agent for the treatment of opioid-induced nausea and/or vomiting and give a secondary indication of "synergistic analgesic effect." Promethazine, however, has a well-documented history of undesired side effects relating to impairment and dysregulation of the central and autonomic nervous systems, such as sedation, extrapyramidal symptoms, dystonia, impairment of psychomotor function, neuroleptic malignant syndrome, and hypotension. These may be particularly worrisome in the combat casualty. Additionally, since 16 September 2009, there has been a US Food and Drug Administration (FDA) black box warning for the injectable form of promethazine, due to "the risk of serious tissue injury when this drug is administered incorrectly." Conversely, ondansetron, which is now available in generic form, has a well-established favorable safety profile and demonstrated efficacy in undifferentiated nausea and vomiting in the emergency department and prehospital settings. It has none of the central and autonomic nervous system side effects noted with promethazine and carries no FDA black box warning. Ondansetron is available in parenteral form and an orally disintegrating tablet, providing multiple safe and effective routes of administration. Despite the fact that it is an off-label use, ondansetron is being increasingly given for acute, undifferentiated nausea and vomiting and is presently being used in the field on combat casualties by some US and Allied Forces. Considering the risks involved with promethazine use, and the efficacy and safety of ondansetron and ondansetron's availability in a generic form, we recommend removing promethazine from the TCCC Guidelines and replacing it with ondansetron.

Buy Now

Emergency Cricothyroidotomy in Tactical Combat Casualty Care

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

Abstract

Buy Now

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

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

Abstract

Hemorrhage Control Devices: Tourniquets and Hemostatic Dressings

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

Abstract

Buy Now

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

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

Abstract

Buy Now

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

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

Abstract

Buy Now

TCCC Updates

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

Abstract

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

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

Abstract

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

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

Buy Now

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

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

Abstract

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

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

Abstract

The Use of Pelvic Binders in Tactical Combat Casualty Care: TCCC Guidelines Change 1602 7 November 2016

Shackelford S, Hammesfahr R, Morissette D, Montgomery HR, Kerr W, Broussard M, Bennett BL, Dorlac WC, Bree S, Butler FK. 17(1). 135 - 147. (Classical Conference)

Abstract

Keywords: pelvic binder; prehospital guidelines; TCCC Guideline

Author: Butler J

Top

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

Hoedebecke KL, Rerucha C, Maxwell K, Butler J. 13(4). 1 - 5. (Journal Article)

Abstract

Dietary supplementation has become progressively more prevalent, with over half of the American population reporting use of various products. An increased incidence of supplement use has been reported in the military especially within Special Operations Forces (SOF) where training regimens rival those of elite athletes. Federal regulations regarding dietary supplements are minimal, allowing for general advertisement to the public without emphasis on the potentially harmful sideeffects. Subsequent medical care for these negative effects causes financial burden on the military in addition to the unit's loss of an Operator and potential mission compromise. This report reviews a case of an Operator diagnosed with drug-induced liver injury secondary to a testosterone prohormone supplement called Post Cycle II™. Clinical situations like this emphasize the necessity that SOF Operators and clinicians be aware of the risks and benefits of these minimally studied substances. Providers should also be aware of the Human Performance Resource Center for Health Information and Natural Medicines Comprehensive Database supplement safety ratings as well as the Food and Drug Administration's MedWatch and Natural Medicines WATCH, to which adverse reactions should be reported.

Keywords: liver injury; prohormone; testosterone; supplement

Buy Now

Author: Cabrera J

Top

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

Hing M, Cabrera J, Barstow C, Forsten RD. 12(3). 23 - 35. (Journal Article)

Abstract

To determine the rates of Post-traumatic Stress Disorder (PTSD) positive symptom scores in Special Operations Forces (SOF) personnel, an anonymous survey of SOF was employed, incorporating the PTSD Checklist (PCLM) with both demographic and deployment data. Results indicate that all SOF units studied scored above the accepted cut-offs for PTSD positive screening.1 When total symptom severity score exceeded established cutoff points and were combined with criteria for Diagnostic and Statistical Manual of Mental Disorders, Edition 4 (DSM-IV) diagnosis of PTSD,2 approximately 16-20% of respondents met scoring threshold for positive screening, almost double those of conventional Army units. Collectively, Special Forces (SF) Soldiers and SOF combat- arms Soldiers had significantly higher PLC-M scores than their non-combat-arms SOF counterparts. SOF Soldiers with three or more deployments to Afghanistan had significantly higher PCL-M scores. Considering the evidence suggesting that SOF Soldiers are hyper-resilient to stress, these results should drive further research schemata and challenge clinical assumptions of PTSD within Special Operations.

Buy Now

Author: Caci JB

Top

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

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

Abstract

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

Caci JB, Blaylock JM, De La Barrera R, Thomas SJ, Lyons AG. 14(3). 111 - 115. (Journal Article)

Abstract

The endemicity of dengue fever (DF) and, consequently, sequelae of DF are increasing worldwide. The increases are largely a result of widespread international travel and the increased range of the mosquito vectors. US Army Special Operations Command (USASOC) personnel are at an increased risk of exposure to dengue based on their frequent deployments to and presence in dengue endemic areas worldwide. Repeated deployments to different endemic areas can increase the risk for developing the more serious sequelae of dengue: dengue hemorrhagic fever (DHF) and dengue shock syndrome (DSS). Information about the seroprevalence rate of dengue in USASOC personnel, in particular, is lacking and is critical to assessing the risk, tailoring preventive medicine countermeasures, leveraging field diagnostics, and maintaining mission capability. In the first part of a two-part project to assess baseline seroprevalence in USASOC units, a random, unit-stratified sample of 500 anonymous serum specimens from personnel assigned to the highest-risk units in USASOC were screened for dengue using a microneutralization assay. Of the 500 specimens screened, 56 (11.2%) of 500 had neutralizing titers (NT) (MN(50) ≥ 10) against at least one DENV serotype. Subsequent sample titration resulted in 48 (85.7%) of 56 of the samples with NT (MN(50) ≥ 10) against at least one dengue serotype for an overall dengue exposure rate of 9.6% (48 of 500). The second part of the ongoing project, started in 2012, was a multicenter, serosurveillance project using predeployment and postdeployment sera collected from USASOC personnel deployed to South and Central America, Africa, and Southeast Asia. Preliminary results show a 13.2% (55 of 414) seropositivity rate. The significance of these findings as they relate to personal risk and operational impact is discussed.

Keywords: dengue fever; USASOC; dengue hemorrhagic fever; dengue shock syndrome

Buy Now

POW and Detainee Operations: Lessons Unlearned

Caci JB. 15(2). 139 - 143. (Journal Article)

Abstract

Throughout the history of modern warfare, tales of atrocities have repeatedly surfaced that depict active and passive aggression toward prisoners of war (POWs). Yet, with each conflict, new tales are born and an undeniable reality of warfare inflicts fresh scars for aggressors to bear. It is understandable, based on human nature and the goals of war, that a government (or its representatives) will feel malice toward enemy prisoners captured during a conflict. It is unquestionably a challenge to overcome that human nature, despite the statutes that outline lawful treatment of POWs. While most aspects of warfare have been revolutionized throughout history, the means by which a military deals with its POWs remains somewhat mired in the reticence of leaders to acknowledge that it will factor into every conflict-that it will, in fact, become a source of controversy as long as it is handled as an afterthought. As shown in accounts dating back to the Revolutionary War, the law can only influence human nature to a point, especially when resources are limited, ignorance is a reality, and no one is watching.

Keywords: prisoners of war; history of warfare; POW camps

Buy Now

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

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

Abstract

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

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

Buy Now

Author: Cahill KV

Top

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

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

Abstract

Objective: We sought to characterize the risk of a heart attack in a 48-year-old asymptomatic US Special Operations Command (SOCOM) Soldier without known coronary artery disease (CAD). Background: CAD continues to be a leading cause of morbidity and mortality among most age groups in the United States. Much research is dedicated to establishing new techniques to predict myocardial infarction (MI). Methods: Coronary computed tomography (CT) angiography, also known as CCTA, along with 7-protein serum biomarker risk assessment was performed for risk evaluation. Results: A 48-year-old SOCOM Soldier with a family history of heart disease had skeletal chest pain from war injuries and a 5-fold higher risk of heart attack over the next 5 years on the basis of protein markers. A nonobstructive left anterior descending coronary artery (LAD) plaque with a lipid-rich core and a thin fibrous cap (i.e., vulnerable plaque) was detected by CCTA. The patient was warned about his risk and prescribed four cardiac medications and scheduled for angioplasty even though he fell outside the guidelines by not having a severe obstructive blockage. Four days later, unfortunately, he had a heart attack before starting his medications and before angioplasty. Conclusion: CCTA with biomarker testing may have an important role in predicating acute coronary syndrome (ACS) in Special Operations Forces (SOF) Soldiers with at least one risk factor. Conventional stress testing and nuclear scanning would not detect non-flow-limiting vulnerable plaques in vulnerable patients. In order to collect more data, the PROTECT Registry has been started to evaluate asymptomatic Soldiers with at least one risk factor referred to the clinic by military physicians.

Keywords: cardiac risk; heart attack; CCTA; risk assessment

Buy Now

Author: Cain JS

Top

Survey Of The Indications For Use Of Emergency Tourniquets

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

Abstract

Indications and evidence are limited, multiple and complex for emergency tourniquet use. Good recent outcomes challenge historically poor outcomes. Optimal tourniquet use in trauma care appears to depend on adequate devices, modern doctrine, refined training, speedy evacuation, and performance improvement. Challenges remain in estimation of blood loss volumes, lesion lethality, and casualty propensity to survive hemorrhage. Summary Background Data: Evidence gaps persist regarding emergency tourniquet use indications in prehospital and emergency department settings as indication data are rarely reported. Methods: Data on emergency tourniquet use was analyzed from a large clinical study (NCT00517166 at ClinicalTrials.gov). The study included 728 casualties with 953 limbs with tourniquets. The median casualty age was 26 years (range, 4-70). We compared all other known datasets to this clinical study. Results: Tourniquet use was prehospital in 671 limbs (70%), hospital only in 104 limbs (11%), and both prehospital and hospital in 169 limbs (18%).Major hemorrhage was observed at or before the hospital in 487 (51%) limbs and minor hemorrhage was observed at the hospital in 463 limbs (49%). Anatomic lesions indicating tourniquets included open fractures (27%), amputations (26%), soft tissue wounds (20%), and vascular wounds (17%). Situations, as opposed to anatomic lesions, indicating tourniquets included bleeding from multiple sites other than limbs (24%), hospital mass casualty situations (1%), one multiple injury casualty needed an airway procedure, and one casualty had an impaled object. Conclusions: The current indication for emergency tourniquet use is any compressible limb wound that the applier assesses as having possibly lethal hemorrhage. This indication has demonstrated good outcomes only when devices, training, doctrine, evacuation, and research have been optimal. Analysis of emergency tourniquet indications is complex and inadequately evidenced, and further study is prudent. Prehospital data reporting may fill knowledge gaps. Objective: The purpose of this study is to report and analyze emergency tourniquet use indications to stop limb bleeding.

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

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

Abstract

Buy Now

Tragedy Into Drama: An American History of Tourniquet Use in the Current War

Kragh JF, Walters TJ, Westmoreland T, Miller RM, Mabry RL, Kotwal RS, Ritter BA, Hodge DC, Greydanus DJ, Cain JS, Parsons DL, Edgar EP, Harcke HT, Baer DG, Dubick MA, Blackbourne LH, Montgomery HR, Holcomb JB, Butler FK. 13(3). 5 - 25. (Journal Article)

Abstract

Background: Although the scientific results of recent tourniquet advances in first aid are well recorded, the process by which tourniquet use advances were made is not. The purpose of the present report is to distill historical aspects of this tourniquet story during the current wars in Afghanistan and Iraq to aid scientists, leaders, and clinicians in the process of development of future improvements in first aid. Methods: The process of how developments of this tourniquet story happened recently is detailed chronologically and thematically in a "who did what, when, where, why, and how" way. Results: Initially in these wars, tourniquets were used rarely or were used as a means of last resort. Such delay in tourniquet use was often lethal; subsequently, use was improved incrementally over time by many people at several organizations. Three sequential keys to success were (1) unlocking the impasse of enacting doctrinal ideas already approved, (2) reaching a critical density of both tourniquets and trained users on the battlefield, and (3) capturing their experience with tourniquets. Other keys included translating needs among stakeholders (such as casualties, combat medics, providers, trainers, and decision-makers) and problem-solving logistic snags and other issues. Eventually, refined care was shown to improve survival rates. From all medical interventions evidenced in the current wars, the tourniquet broke rank and moved to the forefront as the prehospital medical breakthrough of the war. Conclusion: The recorded process of how tourniquet developments in prehospital care occurred may be used as a reference for parallel efforts in first aid such as attempts to improve care for airway and breathing problems.

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

Buy Now

Author: Cairns BA

Top

Interest Survey And Guide To Medical Schooladmissions For SOF Medics

True NA, Conway AC, Landis TM, Cairns CB, Cairns BA. 11(2). 30 - 34. (Journal Article)

Abstract

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

Buy Now

Author: Cairns CB

Top

Interest Survey And Guide To Medical Schooladmissions For SOF Medics

True NA, Conway AC, Landis TM, Cairns CB, Cairns BA. 11(2). 30 - 34. (Journal Article)

Abstract

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

Buy Now

Author: Caldwell L

Top

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

O'Hara R, Vojta C, Henry A, Caldwell L, Wade M, Swanton S, Linderman JK, Ordway J. 16(2). 57 - 61. (Journal Article)

Abstract

Introduction: Heat-related illness is a critical factor for military personnel operating in hyperthermic environments. Heat illness can alter cognitive and physical performance during sustained operations missions. Therefore, the primary purpose of this investigation was to determine the effects of a novel cooling shirt on core body temperature in highly trained US Air Force personnel. Methods: Twelve trained (at least 80th percentile for aerobic fitness according to the American College of Sports Medicine, at least 90% on the US Air Force fitness test), male Air Force participants (mean values: age, 25 ± 2.8 years; height, 178 ± 7.9cm; body weight 78 ± 9.6kg; maximal oxygen uptake, 57 ± 1.9mL/kg/ min; and body fat, 10% ± 0.03%) completed this study. Subjects performed a 70-minute weighted treadmill walking test and 10-minute, 22.7kg sandbag shuttle test under two conditions: (1) "loaded" (shirt with cooling inserts) and (2) "unloaded" (shirt with no cooling inserts). Results: Core body temperature, exercise heart rate, capillary blood lactate, and ratings of perceived exertion were recorded. Core body temperature was lower (ρ = .001) during the 70-minute treadmill walking test in the loaded condition. Peak core temperature during the 70-minute walking test was also significantly lower (ρ = .038) in the loaded condition. Conclusion: This lightweight (471g), passive cooling technology offers multiple hours of sustained cooling and reduced core and peak body temperature during a 70-minute, 22.7kg weighted-vest walking test.

Keywords: cooling; Special Forces; physical activity; hyperthermia; fatigue, volitional

Buy Now

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

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

Abstract

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

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

Buy Now

Author: Callahan CL

Top

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

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

Abstract

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

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

Buy Now

Author: Callaway DW

Top

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

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

Abstract

Buy Now

Redefining Technical Rescue and Casualty Care for SOF: Part 1

McKay SD, Johnston J, Callaway DW. 12(4). 86 - 93. (Journal Article)

Abstract

Trauma care in the tactical environment is complex; it requires a unique blend of situational awareness, foresight, medical skill, multitasking, and physical strength. Rescue is a critical, but often over-looked, component of nearly all tactical trauma casualty management. Successful fullspectrum casualty management requires proficiency in four areas: casualty access, assessment, stabilization, and extraction. When complex rescue situations arise (casualty removal from roof tops, mountain terrain, collapsed structures, wells, or a karez), casualty care often becomes further complicated. Special Operations units have historically looked to civilian technical rescue techniques and equipment to fill this "rescue gap." Similar to the evolution of pre-hospital military medicine from civilian guidelines (e.g. Advanced Trauma Life Support) (ATLS)) to an evidence-based, tactical-specific guideline (Tactical Combat Casualty Care (TCCC)), an evolution is required within the rescue paradigm. This shift from civilian-based technical rescue guidelines towards an Operational Rescue™ capability allows tactical variables such as minimal equipment, low light/night vision goggles (NVG) considerations, enemy threats, and variable evacuation times to permeate through the individual rescue skill set. Just as with TCCC, in which the principles of casualty care remain consistent, the practices must be adapted to end-users environment, so it is with rescue.

Buy Now

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

Bobko JP, Lai TT, Smith R, Shapiro G, Baldridge T, Callaway DW. 13(4). 94 - 107. (Journal Article)

Abstract

Background: Active shooter events and active violent incidents are increasingly targeting civilians, placing children at heightened risk for complex and devastating trauma. The U.S. Department of Homeland Security has identified as a priority preparing domestic first responders to manage complex mass casualty incidents as a primary step in strengthening our medical system. Existing literature suggests that many prehospital providers are uncomfortable treating critically ill or injured pediatric patients and that there is a gap in the consistent provision of high-quality trauma care to these patients. The success of threat-based care developed by the military has led to an exponential rise in the familiarity and utilization of these concepts within certain specialized elements of civilian care. Evolution of these concepts is accelerating to meet the demands of the nonmilitary civilian environment through the formation and subsequent work of the Committee for Tactical Emergency Casualty Care (C-TECC). However, a gap remains in the available literature describing the application of these principles to specialized populations. Methods: In the absence of an evidence-based set of guidelines for prehospital care of the pediatric casualty, the C-TECC sought to establish a set of peer-reviewed guidelines to serve as a foundation describing current best practices. The Pediatric Working Group (PWG) utilized the adult TECC guidelines as a starting point and identified a series of key questions regarding trauma interventions. The PWG conducted a standard PubMed search to identify key relevant or potentially relevant literature. The literature review was presented to the C-TECC Guidelines Committee for review and approval of recommended principles. Recommendations: Given the dearth of supporting literature on the subject, the TECC committee was purposefully conservative in the adaptation of the adult TECC guidelines to a pediatric standard. The guidelines highlight information tailored to the pediatric population and were designed to be a resource for individual agencies seeking guidance for high-threat operations. To our knowledge, the TECC Pediatric Appendix is the first published recommendation for the widespread use of tourniquets in pediatric hemorrhage. In addition, the Guidelines are meant to highlight gaps in trauma literature and stimulate discussion regarding future research in the area of prehospital care of the pediatric casualty.

Keywords: TCCC; pediatric hemorrhage; pediatrics; C-TCCC

Buy Now

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

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

Abstract

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

Schwartz RB, Lerner B, Llewellyn C, Pennardt A, Wedmore I, Callaway DW, Wightman JM, Casillas R, Eastman A, Gerold KB, Giebner S, Davidson R, Kamin R, Piazza G, Bollard GA, Carmona PA, Sonstrom B, Seifarth W, Nicely B, Croushorn J, Carmona PA. 14(2). 122 - 138. (Classical Conference)

Abstract

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

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

Abstract

Another Civilian Life Saved by Law Enforcement-Applied Tourniquets

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

Abstract

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

Keywords: tourniquet; law enforcement; tactical medicine

Buy Now

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

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

Abstract

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

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

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

Abstract

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

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

Abstract

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

Buy Now

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

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

Abstract

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

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

Abstract

The Ranger First Responder Program and Tactical Emergency Casualty Care Implementation: A Whole-Community Approach to Reducing Mortality From Active Violent Incidents

Fisher AD, Callaway DW, Robertson JN, Hardwick SA, Bobko JP, Kotwal RS. 15(3). 46 - 53. (Journal Article)

Abstract

Active violent incidents are dynamic and challenging situations that can produce a significant amount of preventable deaths. Lessons learned from the military's experience in Afghanistan and Iraq through the Committee on Tactical Combat Casualty Care and the 75th Ranger Regiment's Ranger First Responder Program have helped create the Committee for Tactical Emergency Casualty Care (C-TECC) to address the uniqueness of similar wounding patterns and to end preventable deaths. We propose a whole-community approach to active violent incidents, using the C-TECC Trauma Chain of Survival and a tiered approach for training and responsibilities: the first care provider, nonmedical professional first responders, medical first responders, and physicians and trauma surgeons. The different tiers are critical early links in the Chain of Survival and this approach will have a significant impact on active violent incidents.

Keywords: Committee on Tactical Combat Casualty Care; Ranger First Responder Program; Committee on Emergency Casualty Care; wounding patterns; Chain of Survival; preventable death

Buy Now

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

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

Abstract

TacMed Updates: Committee for Tactical Emergency Casualty Care Spring Update

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

Abstract

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

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

Abstract

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

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

Abstract

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

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

Buy Now

Don't Let the Word "Myopic" Blind You

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

Abstract

Medical Provider Ballistic Protection at Active Shooter Events

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

Abstract

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

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

Buy Now

Author: Calvano CJ

Top

Field Diagnosis and Treatment of Ophthalmic Trauma

Calvano CJ, Enzenauer RW. 12(2). 58 - 64. (Journal Article)

Abstract

Identification and management of injuries to the eyes and ocular adnexa is commonly encountered by frontline medical personnel. This brief review is intended for the Special Forces Medic of all branches and describes the clinical presentation of common ophthalmic and periocular trauma with appropriate management strategies. Prompt recognition of these wounds facilitates early treatment and optimized visual outcomes for affected Soldiers and civilians alike.

Keywords: trauma; eye; ophthalmology; vision; open globe

Buy Now

Tactical Lighting in Special Operations Medicine: Survey of Current Preferences

Calvano CJ, Enzenauer RW, Eisnor DL, LaPorta AJ. 13(1). 15 - 21. (Journal Article)

Abstract

Success in Special Operations Forces medicine (SOFMED) is dependent on maximizing visual capability without compromising the provider or casualty position when under fire. There is no single ideal light source suitable for varied SOFMED environments. We present the results of an online survey of Special Operations Medical Operators in an attempt to determine strengths and weaknesses of current systems. There was no consensus ideal hue for tactical illumination. Most Operators own three or more lights, and most lights were not night vision compatible. Most importantly, nearly 25% of respondents reported that lighting issues contributed to a poor casualty outcome; conversely, a majority (50 of 74) stated their system helped prevent a poor outcome. Based on the results of this initial survey, we can affirm that the design and choice of lighting is critical to SOFMED success. We are conducting ongoing studies to further define ideal systems for tactical applications including field, aviation, and marine settings.

Keywords: lighting; tactical; dark adaptation; contrast sensitivity; illumination

Buy Now

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

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

Abstract

Buy Now

Tactical Lighting in Special Operations Medicine: Survey of Current Preferences

Calvano CJ, Enzenauer RW, Eisnor DL, LaPorta AJ. 13(4). 15 - 21. (Journal Article)

Abstract

Success in Special Operations Forces medicine (SOFMED) is dependent on maximizing visual capability without compromising the provider or casualty position when under fire. There is no single ideal light source suitable for varied SOFMED environments. We present the results of an online survey of Special Operations Medical Operators in an attempt to determine strengths and weaknesses of current systems. There was no consensus ideal hue for tactical illumination. Most Operators own three or more lights, and most lights were not night vision compatible. Most importantly, nearly 25% of respondents reported that lighting issues contributed to a poor casualty outcome; conversely, a majority (50 of 74) stated their system helped prevent a poor outcome. Based on the results of this initial survey, we can affirm that the design and choice of lighting is critical to SOFMED success. We are conducting ongoing studies to further define ideal systems for tactical applications including field, aviation, and marine settings.

Keywords: lighting; tactical; dark adaptation; contrast sensitivity; illumination

Buy Now

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

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

Abstract

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

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

Buy Now

USASOC Division Of Science & Technology: What It Means For Special Operations Medicine

Calvano CJ, Forman S, Osborn T, Gothard W. 16(1). 65 - 66. (Editorial)

Abstract

Buy Now

Case Report of an Anthrax Presentation Relevant to Special Operations Medicine

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

Abstract

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

Keywords: periocular anthrax; Bacillus anthracis; ophthalmology; diagnostics

Buy Now

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

Pedler M, Ruiz F, Lamari M, Hutchinson C, Noyes B, Petrash M, Calvano CJ, La Porta A, Enzenauer RW. 16(4). 54 - 58. (Journal Article)

Abstract

Background: Success in Special Operations Forces medicine (SOFMED) depends on maximizing visual capability without compromising the provider or casualty when under fire. There is no single light that has been deemed "ideal" for all SOFMED environments. Methods: We used the Farnsworth-Munsell (FM) hue test to determine color vision of normal subjects under white, red-green, and blue flashlights to determine color discrimination. Then we used a timed color-determination visual test to determine how quickly normal subjects can identify color correctly. We had subjects perform a simulated surgery illuminated by a normal white-light source, then by red-green or blue light-emitting diode (LED) tactical light. Results: The total error score for white light was 49.714, 272.923 for red/green light, and 531.4 for blue light. The subjective perception of simulated trauma wounds was not substantially different with red-green LED tactical light when compared with white LED light. However, simulated surgery under the blue LED was more difficult compared with simulated surgery under the red-green LED light. Conclusion: Red-green was a superior light source for SOFMED and military first responders in this study, especially, where light was required to allow accurate and efficient application of Tactical Combat Casualty Care to injured personnel.

Buy Now

Author: Calvillo A

Top

Traumatic Amputation Of A Finger- A Stark Reminder

Calvillo A, Spivey JL. 07(2). 1 - 4. (Journal Article)

Abstract

Because service members wear rings while on military duty, the potential for undue injury to the hands and fingers of service members is increased. Therefore, it is important to be informed about how and when they occur. Soldiers wear rings while on duty because they forget to take them off, don't want to lose them, or, for marital and other varying reasons. This article will show the consequences of ring related injuries.

Author: Cameron O

Top

Field Electronic Medical Records

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

Abstract

Buy Now

Author: Campbell BH

Top

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

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.

Buy Now

Author: Cancio LC

Top

Management of Burn Wounds Under Prolonged Field Care

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

Author: Cap AP

Top

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

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

Abstract

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

Keywords: pneumothorax; chest seal; TCCC Guideline

Buy Now

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

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

Abstract

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

Buy Now

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

Butler FK, Holcomb JB, Schreiber MA, Kotwal RS, Jenkins DA, Champion HR, Bowling F, Cap AP, DuBose JJ, Dorlac WC, Dorlac GR, McSwain NE, Timby JW, Blackbourne LH, Stockinger Z, Strandenes G, Weiskopf RB, Gross K, Bailey JA. 14(3). 13 - 38. (Journal Article)

Abstract

This report reviews the recent literature on fluid resuscitation from hemorrhagic shock and considers the applicability of this evidence for use in resuscitation of combat casualties in the prehospital Tactical Combat Casualty Care (TCCC) environment. A number of changes to the TCCC Guidelines are incorporated: (1) dried plasma (DP) is added as an option when other blood components or whole blood are not available; (2) the wording is clarified to emphasize that Hextend is a less desirable option than whole blood, blood components, or DP and should be used only when these preferred options are not available; (3) the use of blood products in certain Tactical Field Care (TFC) settings where this option might be feasible (ships, mounted patrols) is discussed; (4) 1:1:1 damage control resuscitation (DCR) is preferred to 1:1 DCR when platelets are available as well as plasma and red cells; and (5) the 30-minute wait between increments of resuscitation fluid administered to achieve clinical improvement or target blood pressure (BP) has been eliminated. Also included is an order of precedence for resuscitation fluid options. Maintained as recommendations are an emphasis on hypotensive resuscitation in order to minimize (1) interference with the body's hemostatic response and (2) the risk of complications of overresuscitation. Hextend is retained as the preferred option over crystalloids when blood products are not available because of its smaller volume and the potential for long evacuations in the military setting.

Keywords: hemorrhage; fluid resuscitation; shock; plasma; blood products; damage control resuscitation

Buy Now

Author: Cardin S

Top

Warrior Model For Human Performacne And Injury Prevention: Eagle Tactical Athlete Program (ETAP) Part I

Sell TC, Abt JP, Crawford K, Lovalekar M, Nagai T, Deluzio J, Smalley BW, McGrail MA, Rowe RS, Cardin S, Lephart SM. 10(3). 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.

Warrior Model For Human Performance And Injury Prevention: Eagle Tactical Athlete Program (ETAP) Part II

Abt JP, Sell TC, Crawford K, Lovalekar M, Nagai T, Deluzio J, Smalley BW, McGrail MA, Rowe RS, Cardin S, Lephart SM. 10(3). 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.

Author: Cardona W

Top

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

McCown ME, Monterroso VH, Cardona W. 14(1). 86 - 90. (Journal Article)

Abstract

Objective: Emerging infectious and zoonotic diseases are made up in large proportion by vector-borne diseases (VBD). Dogs are parasitized by disease vectors such as ticks and mosquitoes, making dogs adequate reservoirs for zoonoses. Risk of exposure to VBD exists for the U.S. military personnel and Military Working Dogs (MWD) when deployed globally. The importance of canine VBD surveillance relates to veterinary and public health significance for the host nations as well as for the U.S. troops and MWDs. The objective of this work was to survey dogs from the cities of Medellin, Barranquilla, and Cartagena in Colombia to determine the prevalence of heartworm disease (Dirofilaria immitis), ehrlichiosis (Ehrlichia canis), Lyme disease (Borrelia burgdorferi), and anaplasmosis (Anaplasma phagocytophilum). Methods: Canine (n = 498) blood samples (1-3mL) were collected during July 2011 from Medellin (n = 175), Barranquilla (n = 223), and Cartagena (n = 100) and were tested on-site using IDEXX SNAP® 4Dx® Test Kits. Results: The overall combined sample prevalence of E. canis, A. phagocytophilum, D. immitis, and B. burgdorferi was 62%, 33%, 1.6%, and 0%, respectively. In Medellin, 26% of the samples were positive for E. canis, 12% for A. phagocytophilum, and 0% for D. immitis. In Barranquilla, sample prevalence for E. canis, A. phagocytophilum, and D. immitis was 83%, 40%, and 2%, respectively. In Cartagena, E. canis, A. phagocytophilum, and D. immitis prevalence was 80%, 51%, and 3%, respectively. Conclusion: E. canis and A. phagocytophilum are present in all three surveyed cities. There is a higher sample prevalence for E. canis and A. phagocytophilum than for D. immitis. In addition, the prevalence for these organisms is higher in Barranquilla and Cartagena than in Medellin. Overall, this study emphasizes the value of surveillance for VBDs in order to determine disease prevalence, develop risk assessments, and implement control measures.

Keywords: zoonotic disease; parasites; vector-borne disease; dogs; public health; surveillance; Colombia

Buy Now

Author: Caremil F

Top

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

Meusnier J, Dewar C, Mavrovi E, Caremil F, Wey P, Martinez J. 16(3). 41 - 46. (Journal Article)

Abstract

Background: Junctional hemorrhage (i.e., between the trunk and limbs) are too proximal for a tourniquet and difficult to compress. These hemorrhages are responsible for 20% of preventable deaths by bleeding on the battlefield. The majority of these involve the groin area. Devices allowing a proximal compression for arterial axes have been recently developed. Objective: The purpose of this study was to compare the use of two junctional- tourniquet models, the Combat Ready Clamp (CRoC®) and the SAM® Junctional Tourniquet (SJT), in simulated out-of-hospital trauma care when tourniquets were ineffective to stop the arterial flow. Methods: During our clinical study, 84 healthy volunteers wearing battle dress performed a physical exercise to come approximate the operational context. The volunteers were randomly divided into two groups according to the device (the CRoC or SJT) used as supplement to a tourniquet self-applied to the root of the thigh. The primary study end point was the complete interruption of popliteal arterial flow, measured with Doppler auscultation. Time to effectiveness and subjective questionnaire data to evaluate the devices' application were also collected. Results: Junctional device effectiveness was almost 90% for both the CRoC and the SJT, and did not differ between them, either used with a tourniquet (ρ = .36) or alone (ρ = .71). The time to effectiveness of the SJT was significantly shorter than that of the CRoC (ρ = .029). Conclusion: The SJT and the CRoC were equally effective. The SJT was faster to apply and preferred by the users. Our study provides objective evidence to the French Tactical Casualty Care Committee for improving junctional hemorrhage treatment.

Keywords: junctional tourniquet; hemorrhage; groin; medical device; Combat Ready Clamp; SAM® Junctional Tourniquet

Buy Now

Author: Carlton D

Top

Hiv Postexposure Prophylaxis For Special Forces Soldiers

Lutz RH, Carlton D, Taylor SF. 09(4). 10 - 15. (Journal Article)

Abstract

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

Author: Carmona PA

Top

TacMed Updates: TEMS v. 2014

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

Abstract

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

Schwartz RB, Lerner B, Llewellyn C, Pennardt A, Wedmore I, Callaway DW, Wightman JM, Casillas R, Eastman A, Gerold KB, Giebner S, Davidson R, Kamin R, Piazza G, Bollard GA, Carmona PA, Sonstrom B, Seifarth W, Nicely B, Croushorn J, Carmona PA. 14(2). 122 - 138. (Classical Conference)

Abstract

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

Schwartz RB, Lerner B, Llewellyn C, Pennardt A, Wedmore I, Callaway DW, Wightman JM, Casillas R, Eastman A, Gerold KB, Giebner S, Davidson R, Kamin R, Piazza G, Bollard GA, Carmona PA, Sonstrom B, Seifarth W, Nicely B, Croushorn J, Carmona PA. 14(2). 122 - 138. (Classical Conference)

Abstract

The Ongoing Evolution (Revolution) of TEMS

Carmona PA. 14(3). 139 - 141. (Journal Article)

Abstract

Buy Now

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

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

Abstract

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

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

Buy Now

Author: Carpenter J

Top

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

Boedecker BH, Nicholas TA, Carpenter J, Leighton S, Bernhagen MA, Murray WB, Wadman MC. 11(2). 21 - 29. (Journal Article)

Abstract

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

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

Buy Now

Author: Carter T

Top

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

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

Abstract

Buy Now

Author: Cashwell MJ

Top

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

Cashwell MJ, Wilcoxen AC, Meghoo CA. 13(3). 42 - 44. (Journal Article)

Abstract

Digital intubation is a useful technique that is rarely taught in conventional airway management courses. With limited equipment and minimal training, a Special Operations Forces (SOF) medic can use this technique to intubate an unconscious patient with a high degree of success. The objectives of this report are to (1) learn the sequence of events for successful digital intubation, (2) recognize and appreciate the advantages and limitations of this technique, and (3) appreciate the requirements for establishing a unit-level training program.

Keywords: digital intubation; airway

Buy Now

Author: Casillas R

Top

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

Schwartz RB, Lerner B, Llewellyn C, Pennardt A, Wedmore I, Callaway DW, Wightman JM, Casillas R, Eastman A, Gerold KB, Giebner S, Davidson R, Kamin R, Piazza G, Bollard GA, Carmona PA, Sonstrom B, Seifarth W, Nicely B, Croushorn J, Carmona PA. 14(2). 122 - 138. (Classical Conference)

Abstract

Author: Cauchi T

Top

Field Electronic Medical Records

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

Abstract

Buy Now

Author: Cavett T

Top

Trigger-Point Dry Needling for the SOF Medic

Cavett T, Solarczyk J. 16(4). 33 - 39. (Journal Article)

Abstract

We propose that trigger-point dry needle (TrP-DN) therapy is an effective low-risk treatment for pain associated with myofascial trigger points (MTrP), and should be incorporated into the Special Operations Forces (SOF) Medic's scope of practice. Furthermore, TrP-DN therapy can be used as a treatment adjunct on the SOF continuum of care, providing analgesia and increased tolerance for rehabilitative therapy, thereby facilitating improved patient outcomes and faster return to operational readiness. The incidence of musculoskeletal injuries in the SOF community is discussed, as are available treatment options TrP-DN methods, a case study of a Soldier deployed to Afghanistan, the science behind the subject of MTrP and TrP-DN, and the risks associated with TrP-DN and how we can mitigate them effectively. Caution should be used in the interpretation of a body of literature based largely on case studies. Although the amount of published evidence in support of the potential benefits of TrP-DN is growing, larger, randomized, placebo-controlled trials and studies that evaluate the effects of TrP-DN in a methodologically rigorous and statistically significant way are needed. Based on anecdotal evidence of and personal experience with the success of the therapy, as well as its growing use within both civilian and military medicine, the possible therapeutic benefit of TrP-DN is relevant for the SOF community.

Buy Now

Author: Cestero R

Top

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

Gerhardt RT, Berry J, Mabry RL, Flournoy L, Arnold RG, Hults C, Robinson JB, Thaxton RA, Cestero R, Heiner JD, Koller AR, Cox KM, Patterson JN, Dalton WR, McKeague AL, Gilbert G, Manemeit C, Adams BD. 14(1). 50 - 57. (Journal Article)

Abstract

Objective: We sought to determine whether Contingency Telemedical Support (CTS) improves the success rate and efficiency of primary care providers performing critical actions during simulated combat trauma resuscitation. Critical actions included advanced airway, chest decompression, extremity hemorrhage control, hypothermia prevention, antibiotics and analgesics, and hypotensive resuscitation, among others. Background: Recent studies report improved survival associated with skilled triage and treatment in the out-of-hospital/preoperative phase of combat casualty care. Historically, ground combat units are assigned primary care physicians and physician assistants as medical staff, due to resource limitations. Although they are recognized as optimal resuscitators, demand for military trauma surgeons and emergency physicians exceeds supply and is unlikely to improve in the near term. Methods: A prospective trial of telemedical mentoring during a casualty resuscitation encounter was studied using a high-fidelity patient simulator (HFPS). Subjects were randomized and formed into experimental (CTS) or control teams. CTS team leaders were equipped with a headset/microphone interface and telementored by a combat-experienced emergency physician or trauma surgeon. A standardized, scripted clinical scenario and HFPS were used with 14 critical actions. At completion, subjects were surveyed. Statistical approach included contingency table analysis, two-tailed t-test, and correlation coefficient. This study was reviewed and approved by our institutional review board (IRB). Results: Eighteen CTS teams and 16 control teams were studied. By intention-to-treat ITT analysis, 89% of CTS teams versus 56% of controls completed all life-threatening inventions (LSIs) (p < .01); 78% versus 19% completed all critical actions (p < .01); and 89% versus 56% established advanced airways within 8 minutes (p < .06). Average time to completion in minutes (95% confidence interval [CI] 95) was 12 minutes (10-14) for CTS versus 18 (16-20) for controls, with 75% of control teams not completing all critical actions. Conclusion: In this model, real-time telementoring of simulated trauma resuscitation was feasible and improved accuracy and efficiency of non-emergency-trained resuscitators. Clinical validation and replicated study of these findings for guiding remote damage control resuscitation are warranted.

Keywords: military medicine; war; emergency medical services; resuscitation; telemedicine; wounds and injuries

Buy Now

Author: Chagaris MJ

Top

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

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

Abstract

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

Buy Now

Author: Chalut C

Top

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

Hoang TN, Kang J, LaPorta AJ, Makler VI, Chalut C. 13(4). 22 - 33. (Journal Article)

Abstract

Background: Teamwork and successful communication are essential parts of any medical specialty, especially in the trauma setting. U.S. Navy physicians developed a course for deploying fleet surgical teams to reinforce teamwork, communication, and baseline knowledge of trauma management. Method: The course combines 22 hours of classroom didactics along with 28 hours of hands-on simulation and cadaver-based laboratories to reinforce classroom concepts. It culminates in a 6-hour, multiwave exercise of multiple, critically injured victims of a mass casualty and uses the "Cut Suit" (Human Worn Partial Task Surgical Simulator; Strategic Operations), which enables performance of multiple realistic surgical procedures as encountered on real casualties. Participants are graded on time taken from initial patient encounter to disposition and the number of errors made. Pre- and post-training written examinations are also given. The course is graded based on participants' evaluation of the course. Results: The majority of the participants indicated that the course promoted teamwork, enhanced knowledge, and gave confidence. Only 51.72% of participants felt confident in dealing with trauma patients before the course, while 82.76% felt confident afterward (ρ = .01). Both the time spent on each patient and the number of errors made also decreased after course completion. Conclusion: The course was successful in improving teamwork, communication and base knowledge of all the team members.

Keywords: fleet surgincal team predeployment training course; fleet surgical team; Cut Suit; human worn partial task surgical simulator; trauma team training; educational gap in teamwork and communication; teamwork-centered training; military trauma training

Buy Now

Author: Chambers MJ

Top

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

Klotz JK, Leo M, Andersen BL, Nkodo AA, Garcia G, Wichern AM, Chambers MJ, Gonzalez ON, Pahle MU, Wagner JA, Robinson JB, Kragh JF. 14(2). 1 - 5. (Journal Article)

Abstract

Junctional hemorrhage, bleeding that occurs at the junction of the trunk and its appendages, is the most common preventable cause of death from compressible hemorrhage on the battlefield. As of January 2014, four types of junctional tourniquets have been developed and cleared by the U.S. Food and Drug Administration (FDA). Successful use of the Abdominal Aortic Tourniquet (AAT™) and Combat Ready Clamp (CRoC™) has already been reported. We report here the first known prehospital use of the SAM® Junctional Tourniquet (SJT) for a battlefield casualty with inguinal junctional hemorrhage.

Keywords: SAM® Junctional Tourniquet; junctional hemorrhage; prehospital care; hemorrhage control; wounds and injuries

Buy Now

Author: Champion HR

Top

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

Butler FK, Holcomb JB, Schreiber MA, Kotwal RS, Jenkins DA, Champion HR, Bowling F, Cap AP, DuBose JJ, Dorlac WC, Dorlac GR, McSwain NE, Timby JW, Blackbourne LH, Stockinger Z, Strandenes G, Weiskopf RB, Gross K, Bailey JA. 14(3). 13 - 38. (Journal Article)

Abstract

This report reviews the recent literature on fluid resuscitation from hemorrhagic shock and considers the applicability of this evidence for use in resuscitation of combat casualties in the prehospital Tactical Combat Casualty Care (TCCC) environment. A number of changes to the TCCC Guidelines are incorporated: (1) dried plasma (DP) is added as an option when other blood components or whole blood are not available; (2) the wording is clarified to emphasize that Hextend is a less desirable option than whole blood, blood components, or DP and should be used only when these preferred options are not available; (3) the use of blood products in certain Tactical Field Care (TFC) settings where this option might be feasible (ships, mounted patrols) is discussed; (4) 1:1:1 damage control resuscitation (DCR) is preferred to 1:1 DCR when platelets are available as well as plasma and red cells; and (5) the 30-minute wait between increments of resuscitation fluid administered to achieve clinical improvement or target blood pressure (BP) has been eliminated. Also included is an order of precedence for resuscitation fluid options. Maintained as recommendations are an emphasis on hypotensive resuscitation in order to minimize (1) interference with the body's hemostatic response and (2) the risk of complications of overresuscitation. Hextend is retained as the preferred option over crystalloids when blood products are not available because of its smaller volume and the potential for long evacuations in the military setting.

Keywords: hemorrhage; fluid resuscitation; shock; plasma; blood products; damage control resuscitation

Buy Now

Author: Chandrashekar R

Top

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

McCown ME, Alleman A, Sayler KA, Chandrashekar R, Thatcher B, Tyrrell P, Stillman B, Beall M, Barbet AF. 14(4). 81 - 85. (Journal Article)

Abstract

Background: Based on the high tick-borne pathogen results from a 2011 surveillance study in three Colombian cities, an in-depth point prevalence survey was conducted to determine the seroprevalence of tick-borne pathogens at a specific point in time in 70 working dogs, 101 shelter dogs, and 47 client-owned dogs in Barranquilla, Colombia. Results: Of the 218 serum samples, 163 (74%) were positive for Ehrlichia canis and 116 (53%) for Anaplasma platys. Exposure to tick-borne pathogens was highest in shelter and working dogs where more than 90% of the samples were seropositive or positive on polymerase chain reaction for one or more organisms as compared to 51% in client-owned animals. Conclusion: Surveillance for exposure to tickborne pathogens provides vital information necessary to protect and conserve the health of local humans and animals, deployed military service members, and working dogs in various parts of the world. This study and resultant data demonstrate the value of following a broadbased surveillance study with a more specific, focused analysis in an area of concern. This area's high levels of exposure warrant emphasis by medical planners and advisors on precautionary measures for military dogs, Special Operations Forces personnel, and the local public.

Keywords: tick-borne pathogens; point prevalence; surveillance; US Military SOF; military working dogs; Colombia

Buy Now

Author: Chang Y

Top

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

Mejaddam AY, van der Wilden GM, Chang Y, Cropano CM, Sideris AC, Hwbejire JO, Velmahos GC, Alam HB, de Moya MA, King DR. 13(1). 29 - 33. (Journal Article)

Abstract

Introduction: The usefulness of heart rate variability (HRV) and heart rate complexity (HRC) analysis as a potential triage tool has been limited by the inability to perform real-time analysis on a portable, handheld monitoring platform. Through a multidisciplinary effort of academia and industry, we report on the development of a rugged, handheld and noninvasive device that provides HRV and HRC analysis in real-time in critically ill patients. Methods: After extensive re-engineering, real-time HRV and HRC analyses were incorporated into an existing, rugged, handheld monitoring platform. Following IRB approval, the prototype device was used to monitor 20 critically ill patients and 20 healthy controls to demonstrate real-world discriminatory potential. Patients were compared to healthy controls using a Student's t test as well as repeated measures analysis. Receiver operator characteristic (ROC) curves were generated for HRV and HRC. Results: Critically ill patients had a mean APACHE-2 score of 15, and over 50% were mechanically ventilated and requiring vasopressor support. HRV and HRC were both lower in the critically ill patients compared to healthy controls (ρ < 0.0001) and remained so after repeated measures analysis. The area under the ROC for HRV and HRC was 0.95 and 0.93, respectively. Conclusions: This is the first demonstration of real-time, handheld HRV and HRC analysis. This prototype device successfully discriminates critically ill patients from healthy controls. This may open up possibilities for real-world use as a trauma triage tool, particularly on the battlefield.

Keywords: heart rate complexity; heart rate variability; entropy; triage; combat

Buy Now

Author: Chauvin V

Top

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

Cotte J, d'Aranda E, Chauvin V, Kaiser E, Meaudre E. 13(4). 59 - 62. (Journal Article)

Abstract

Background and Objective: Almost 50% of military trauma patients who need transfusions develop a coagulopathy. Immediately treating this coagulopathy improves the patient's prognosis. Field military hospitals often lack laboratory devices needed to diagnose a clinically significant coagulopathy and have limited blood product resources such as plasma. Point-of-care (POC) devices for the measurement of prothrombin time (PT) are available and have been tested in a variety of situations, including hemorrhagic surgery. The authors compared a POC device, the Coaguchek XS Pro (F. Hoffmann-La Roche Ltd., Basel, Switzerland), with laboratory measures for determining the PT in military trauma patients in a field hospital. Methods: This single-center prospective study was designed to compare POC coagulation monitoring with traditional laboratory testing. It was conducted at the French military hospital located at Kabul International Airport. All patients with trauma injuries resulting from war operations were included. A blood sample was drawn immediately on admission. PT was determined both in the laboratory and with use of the Coaguchek XS pro. Results: Forty patients with war trauma were enrolled during a 3-month period. The authors recorded 69 measurements. The two methods were correlated with a correlation coefficient of 0.78 (ρ < .001). The Bland- Altman plot showed a mean difference of 5.8% (95% confidence interval -14.9% to 26.6%). Using a PT cutoff of 60%, POC had a sensitivity of 77.1% and a specificity of 94.1%. Results from POC PT measurement were available within a mean of 25.8 minutes before laboratory measures. Conclusions: The Coaguchek XS Pro device can be used successfully in an austere environment without compromising its performance.

Keywords: point-of-care; coagulation; prothrombin time; military trauma

Buy Now

Author: Chen J

Top

Special Forces Medicine in Israel

Ostfeld I, Paran H, Chen J, Barneis Y, Dreyfuss U, Kedem H, Glassberg E. 14(3). 116 - 120. (Journal Article)

Abstract

The Special Forces (SF) of the Israel Defense Force (IDF) have a long and pioneering history in tactical and medical aspects. Moreover, the importance of medical assistance is highly regarded in the Israeli SF community. Consequently, as current military challenges of Israel increase, the need for SF activity and for its medical support increases as well. Therefore, the authors anticipate that further development of SF medicine (SFM), as a specific branch of military medicine in Israel, will continue.

Keywords: Special Forces; Special Forces medicine; military medicine; Israel Defense Force; My Brother's Keeper

Buy Now

Junctional Tourniquet Training Experience

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

Abstract

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

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

Buy Now

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

Chen J, Benov A, Nadler R, Landau G, Sorkin A, Aden JK, Kragh JF, Glassberg E. 16(1). 36 - 42. (Journal Article)

Abstract

Background: Junctional hemorrhage is a common cause of battlefield death but little is known about testing of junctional tourniquet models by medics. The purpose of the testing described herein is to assess military experience in junctional tourniquet use in simulated prehospital care. Methods: Fourteen medics were to use the following four junctional tourniquets: Combat Ready Clamp (CRoC), Abdominal Aortic Junctional Tourniquet (AAJT), Junctional Emergency Treatment Tool (JETT), and SAM Junctional Tourniquet (SJT). The five assessment categories were safety, effectiveness, time to effectiveness, and two categories of user preference: (1) by all models assessed, and (2) by only the model most preferred. Users ranked preference by answering, "If you had to go to war today and you could only choose one, which tourniquet would you choose to bring?" Results: All tourniquet uses were safe. By the time the first five testers were done, all three AAJT models had been broken. CRoC and AAJT had the highest percentage effectiveness as their difference was not statistically significant. SJT and JETT had fastest mean times to effectiveness as their difference was not significant. For preference, using each user's ranking of all models assessed, SJT and AAJT were most preferred as their difference was not significant. For each user's most preferred model, SJT, AAJT, and JETT were most preferred as their difference was not significant. Conclusion: In the five assessment categories, multiple tourniquet models performed similarly well; SJT and AAJT performed best in four categories, JETT was best in three, and CRoC was best in two. Differences between the top-ranked models in each category were not statistically significant.

Keywords: tourniquets; hemorrhage; resuscitation; groin; inguinal; medical device; injuries; wounds

Buy Now

Author: Chen L

Top

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

Chen L, Reisner AT, Gribok A, Reifman J. 10(2). 55 - 62. (Previously Published)
Reproduced with permission from Prehospital Emergency Care 2009, Vol. 13, No. 3, Pages 286–294

Abstract

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

Author: Chew D

Top

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

Chew D, Hammesfahr R. 14(2). 60 - 65. (Journal Article)

Abstract

This is a report of the first riot in Singapore since 1969 and the subsequent emergency response from the police force and emergency medical services. Lessons learned are discussed, and recommendations for future medical response in incidents of civil unrest are made.

Keywords: Tactical Emergency Casualty Care; TECC; Singapore Riots; tactical medicine for law enforcement

Buy Now

Author: Chin EJ

Top

Detection of Increased Intracranial Pressure by Ultrasound

Hightower S, Chin EJ, Heiner JD. 12(3). 19 - 22. (Journal Article)

Abstract

Increases in intracranial pressure (ICP) may damage the brain by compression of its structures or restriction of its blood flow, and medical providers my encounter elevated ICP in conventional and non-conventional medical settings. Early identification of elevated ICP is critical to ensuring timely and appropriate management. However, few diagnostic methods are available for detecting increased ICP in an acutely ill patient, which can be performed quickly and noninvasively at the bedside. The optic nerve sheath is a continuation of the dura mater of the central nervous system and can be viewed by ocular ultrasound. Pressure changes within the intracranial cavity affect the diameter of the optic nerve sheath. Data acquired from multiple clinical settings suggest that millimetric increases in the optic nerve sheath diameter detected via ocular ultrasound correlate with increasing levels of ICP. In this review, we discuss the use of ocular ultrasound to evaluate for the presence of elevated ICP via assessment of optic nerve sheath diameter, and describe critical aspects of this valuable diagnostic procedure. Ultrasound is increasingly becoming a medical fixture in the modern battlefield where other diagnostic modalities can be unavailable or impractical to employ. As Special Forces and other austere medical providers become increasingly familiar with ultrasound, ocular ultrasound for the assessment of increased intracranial pressure may help optimize their ability to provide the most effective medical management for their patients.

Buy Now

Author: Chipman J

Top

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

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

Abstract

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

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

Buy Now

Author: Cho TH

Top

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

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

Abstract

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

Buy Now

Author: Chorba R

Top

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

Guthrie RM, Chorba R. 16(1). 1 - 5. (Case Reports)

Abstract

Purpose: Chronic mechanical neck pain can have a complex clinical presentation and is often difficult to treat. This case study illustrates a successful physical therapy treatment approach using dry needling and auricular acupuncture techniques. Case Report: A 51-year-old active-duty, male US Marine was treated by a physical therapist in a direct-access military clinic for chronic neck pain poorly responsive to previous physical therapy, pharmacologic, and surgical interventions. Needling techniques were combined with standard physical therapy interventions to address the comprehensive needs of the patient. Within five treatments, the patient reported reduced pain levels from 8-9/10 to 0-2/10, improved sleep quality, and increased function with daily activities. Over several months, the patient reduced multiple medication use by greater than 85%. The effects of treatment were lasting, and the patient accomplished a successful transition to an independent maintenance program. Conclusion: Needling techniques have the potential to expedite favorable physical therapy outcomes for active-duty service members suffering from chronic mechanical and degenerative neck pain. The dramatic improvements observed in this case warrant additional exploration of treatment efficacy and delineation of best practices in the delivery of these techniques.

Keywords: pain, neck; physical therapy; dry needling; acupuncture; acupuncture, battlefield; pain management

Buy Now

Author: Christensen J

Top

Medical Seminars: A New Paradigm For SOF Counterinsurgency Medical Programs

Alderman SM, Christensen J, Crawford I. 10(4). 16 - 22. (Journal Article)

Abstract

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

Author: Christopher GE

Top

Functional Training Program Bridges Rehabilitation And Return To Duty

Gross DL, Christopher GE, Faulk RT. 09(1). 29 - 48. (Journal Article)

Abstract

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

Author: Chung K

Top

Management of Crush Syndrome Under Prolonged Field Care

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

Abstract

Buy Now

Author: Clark JR

Top

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

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

Abstract

Author: Clarke J

Top

Oral Steroids for Dermatitis

Fisher AD, Clarke J, Williams TK. 15(2). 8 - 11. (Journal Article)

Abstract

Contact/allergic dermatitis is frequently treated inappropriately with lower-than-recommended doses or inadequate duration of treatment with oral and intramuscular glucocorticoids. This article highlights a case of dermatitis in a Ranger Assessment and Selection Program student who was improperly treated over 2 weeks with oral steroids after being bit by Cimex lectularius, commonly known as bed bugs. The article also highlights the pitfalls of improper oral steroid dosing and provides reasoning for longer-duration oral steroid treatment.

Keywords: dermatitis; steroids; bed bugs; military; Cimex lectularis

Buy Now

Author: Clay J

Top

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

Delmonaco BL, Baker A, Clay J, Kilbourn J. 16(1). 103 - 108. (Journal Article)

Abstract

An eight-person team of conventional US Air Force (USAF) medical providers deployed to support US Special Operations Forces (SOF) in North and West Africa for the first time in November 2014. The predeployment training, operations while deployed, and lessons learned from the challenges of performing surgery and medical evacuations in the remote desert environment of Chad and Niger on the continent of Africa are described. The vast area of operations and far-forward posture of these teams requires cooperation between partner African nations, the French military, and SOF to make these medical teams effective providers of surgical and critical care in Africa. The continuous deployment of conventional USAF medical providers since 2014 in support of US Special Operations Command Africa is challenging and will benefit from more medical teams and effective air assets to provide casualty evacuation across the vast area of operations.

Keywords: US Special Operations Command North and West Africa; far-forward surgery; conventional US Air Force; Mobile Field Surgical Team; Niamey, Niger; N'Dhamena, Chad; CASEVAC; Boko Haram; al-Qaeda I the Islamic Maghreb; French Military

Buy Now

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

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

Abstract

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

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

Buy Now

Author: Clinton J

Top

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

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

Abstract

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

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

Buy Now

Author: Clumpner BR

Top

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

Clumpner BR, Polston RW, Kragh JF, Westmoreland T, Harcke HT, Jones JA, Dubick MA, Baer DG, Blackbourne LH. 13(1). 34 - 41. (Journal Article)

Abstract

Background: Common first aid tourniquets, like the Combat Application Tourniquet (CAT) of a windlass and band design, can have the band routed through the buckle in three different ways, and recent evidence indicates users may be confused with complex doctrine. Objective: The purpose of the present study is to measure the differential performance of the three possible routings in order to better understand good tourniquet practice. Methods: A training manikin was used by two investigators to measure tourniquet effectiveness, time to stop bleeding, and blood loss. Results: The effectiveness rate was 99.6% (239/240) overall. Results were similar for both single-slit routings (inside vs. outside, p > 0.05). Effectiveness rates (yes-no results for hemorrhage control expressed as a proportion of iterations) were not statistically different between single and double routing. However, the time to stop bleeding and blood loss were statistically different (ρ < 0.05). Conclusions: CAT band routing, through the buckle either singly or doubly, affects two key performance criteria: time to stop bleeding and volume of blood lost. Single routing proved to be faster, thereby saving more blood. Learning curves required to optimize user performance varied over 30-fold depending on which variable was selected (e.g., effectiveness vs. blood loss).

Keywords: hemorrhage; first aid; trauma; damage control; emergency medical services

Buy Now

No Slackers in Tourniquet Use to Stop Bleeding

Polston RW, Clumpner BR, Kragh JF, Jones JA, Dubick MA, Baer DG. 13(2). 12 - 19. (Journal Article)

Abstract

Background: Tourniquets on casualties in war have been loose in 4%-9% of uses, and such slack risks death from uncontrolled bleeding. A tourniquet evidence gap persists if there is a mechanical slack-performance association. Objective: The purpose of the present study was to determine the results of tourniquet use with slack in the strap versus no slack before windlass turning, in order to develop best practices. Methods: The authors used a tourniquet manikin 254 times to measure tourniquet effectiveness, windlass turns, time to stop bleeding, and blood volume lost at 5 degrees of strap slack (0mm, 25mm, 50mm, 100mm, and 200mm maximum). Results: When comparing no slack (0mm) to slack (any positive amount), there were increases with slack in windlass turns (ρ < .0001, 3-fold), time to stop bleeding (ρ < .0001, 2-fold), and blood volume lost (ρ < .0001, 2-fold). When comparing no slack to 200mm slack, the median results showed an increase in slack for windlass turns (ρ < .0001), time to stop bleeding (ρ < .0001), and blood volume lost (ρ < .0001). Conclusions: Any slack presence in the strap impaired tourniquet performance. More slack had worse results. Trainers can now instruct tourniquet users with concrete guidance.

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

Buy Now

Author: Coburn M

Top

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

Smith CP, Sorrells A, Coburn M. 10(2). 36 - 40. (Journal Article)

Abstract

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

Author: Conklin C

Top

Prehospital Analgesia With Ketamine for Combat Wounds: A Case Series

Fisher AD, Rippee B, Shehan H, Conklin C, Mabry RL. 14(4). 11 - 17. (Journal Article)

Abstract

Background: No data have been published on the use of ketamine at the point of injury in combat. Objective: To provide adequate pain management for severely injured Rangers, ketamine was chosen for its analgesic and dissociative properties. Ketamine was first used in the 75th Ranger Regiment in 2005 but fell out of favor because medical providers had limited experience with its use. In 2009, with new providers and change in medic training at the battalion level, the Regiment implemented a protocol using doses of ketamine that exceed the current Tactical Combat Casualty Care recommendations. Methods: Medical after-action reports were reviewed for all Ranger casualties who received ketamine at the point of injury for combat wounds from January 2009 to October 2014. Patients and medics were also interviewed. Results: Unit medical protocols authorize ketamine for tourniquet pain, amputations, long-bone fractures, and pain refractory to other agents. Nine of the 11 patients were US Forces; two were local nationals (one female, one male). The average initial dose given intramuscularly was 183mg, about 2 to 3mg/kg and intravenously 65mg, about 1mg/kg. The patients also received an opioid, a benzodiazepine, or both. There was one episode of apnea that was corrected quickly with stimulus. Eight of the 11 patients required the application of at least one tourniquet; four patients needed between two and four tourniquets to control hemorrhage. Pain was assessed with a subjective 1-10 scale. Before ketamine, the pain was rated as 9-10, with one patient claiming a pain level of 8. Of the US Forces, seven of the nine had no pain after receiving ketamine and two had a pain level of four. Two of the eight had posttraumatic stress disorder. Conclusions: In this small, retrospective sample of combat casualties, ketamine appeared to be a safe and effective battlefield analgesic.

Keywords: ketamine; midazolam; pain management; TCCC; tourniquet; PTSD

Buy Now

Author: Conkright W

Top

Omega-3 Fatty Acid Ingestion as a TBI Prophylactic

Barringer N, Conkright W. 12(3). 5 - 7. (Journal Article)

Abstract

Given the hazardous nature of combat operations and training exercises (e.g. airborne operations) conducted by the United States military, servicemembers are at high risk for sustaining a traumatic brain injury (TBI). Since the beginning of the Iraq and Afghanistan wars, almost a quarter of a million servicemembers have sustained a TBI.1 A large number of TBIs are a result of the concussive forces generated by improvised explosive devices (IED). A smaller number are a result of penetrating head wounds. Others may be caused by activities resulting in powerful acceleration, deceleration, or rotational forces. Therapies for treating TBI thus far have been limited. Much of the research conducted to date has focused on post-injury pharmacological interventions.2 Additionally, better protective equipment could help in preventing TBIs; however, these issues are outside the scope of this paper. A relatively new area of research is investigating prophylactic measures taken to lessen the effects of TBI. One such measure involves nutritional interventions and their effects on TBI severity. Therefore, the purpose of this paper is to elucidate the potential benefits of omega-3 fatty acid intake as it relates to TBI severity.

Buy Now

Author: Convertino VA

Top

The Impedance Threshold Device (ITD-7) A New Device For Combat Casualty Care To Augment Circulation And Blood Pressure In Hypotensive Spontaneously Breathing Warfighters

Parsons DL, Convertino VA, Idris A, Smith S, Lindstrom D, Parquette B, Aufderheide T. 09(1). 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

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

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

Abstract

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

Buy Now

Author: Conway AC

Top

Interest Survey And Guide To Medical Schooladmissions For SOF Medics

True NA, Conway AC, Landis TM, Cairns CB, Cairns BA. 11(2). 30 - 34. (Journal Article)

Abstract

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

Buy Now

Author: Cook MR

Top

This Is Africa

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

Buy Now

Author: Cook P

Top

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

Sirkin MR, Cook P, Davis KG. 15(4). 54 - 58. (Journal Article)

Abstract

Background: The operative control of noncompressible hemorrhage is the single largest impact that could be addressed in reducing the mortality on the battlefield. Laprotomy pads, traditionally used for hemorrhage evacuation, are made of woven cotton, and, while effective, their use requires a substantial amount of space and adds weight. This poses no concern in traditional operating rooms but is a hindrance for mobile providers and providers in austere environments. We sought to compare different absorptive compunds to ascertain their utility as alternatives for traditional laparotomy pads. Methods: Samples of cotton laparotomy pads, pure rayon sheets, rayon-polypropylene composite sheets, and non-polyester composite "microfiber" sheets were weighed and submerged in heparinized whole bovine blood. After saturation, the favrics were weighed, wrung dry, reweighed, and resubmerged. This process was performed for a total of three sequential submersions. The saturated weights and dry weights of each fabric were used to calculate how much blood each fabric could absorb initially and after multiple repeated uses. The initial densities of the four fabrics was calculated and compared. Results: The initial submersions demonstrated that 1g each of cotton, rayon, rayon-polypropylene, and nylon-polyester were able to absorb 7.58g, 12.98g, 10.16g, and 9.73g of blood respectively. The second and third sequential trials, which were statistically similar, demonstrated that 1g of cotton, rayon, rayon-polypropolyene, and nylon-polyester were able to absorb 1.73g, 2.83g, 2.3g, and 2.3g of blood, respectively. The calculated densities of cotton, rayon, rayon-polypropylene, and nylon-polyester were 0.087g/cm³, .012g/cm³, 0.098g/cm³, and 0.093g/cm³, respectively. Conclusion: Per gram, rayon absorbed approximately 1.7 times more blood thancotton and three-quarters the amount of the storage space. Rayon also retained its superior absorption abilites on repeated uses, demonstrating the potential for re-use in remote and austere environments. Thus, rayon could serve as a viable alternative to traditional cotton laparotomy pads in the austere environments.

Keywords: hemorrhage; laparotomy; cotton; rayon; sponge; austere; surgery; packing; combat casualty care; absorption; density

Buy Now

Author: Cordoni L

Top

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

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

Abstract

Selected Meeting Highlights

Author: Cordova CB

Top

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

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

Abstract

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

Buy Now

Author: Corey G

Top

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

Corey G, Lafayette T. 13(3). 74 - 80. (Journal Article)

Abstract

The wars in Afghanistan and Iraq are the only conflicts to which many medics have ever been exposed. These mature theaters have robust medical systems that ensure rapid access to full-spectrum medical care for all combat-wounded and medically injured personnel. As current conflicts draw to a close, U.S. medics may be deployed to environments that will require the ability to stabilize casualties for longer than 1 hour. Historical mission analysis reveals the need to review skills that have not been emphasized during upgrade and predeployment training. This unit's preparation for the extended care environment can be accomplished using a 4-point approach: (1) review of specific long-term skills training, (2) an extended care lab that reviews extended care skills and then lets the medic practice in a real-time scenario, (3) introduction to the HITMAN mnemonic tool, which helps identify and address patient needs, and (4) teleconsultation.

Keywords: extended care; austere environments; long-term skills training; teleconsultation

Buy Now

Author: Cotte J

Top

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

Cotte J, d'Aranda E, Chauvin V, Kaiser E, Meaudre E. 13(4). 59 - 62. (Journal Article)

Abstract

Background and Objective: Almost 50% of military trauma patients who need transfusions develop a coagulopathy. Immediately treating this coagulopathy improves the patient's prognosis. Field military hospitals often lack laboratory devices needed to diagnose a clinically significant coagulopathy and have limited blood product resources such as plasma. Point-of-care (POC) devices for the measurement of prothrombin time (PT) are available and have been tested in a variety of situations, including hemorrhagic surgery. The authors compared a POC device, the Coaguchek XS Pro (F. Hoffmann-La Roche Ltd., Basel, Switzerland), with laboratory measures for determining the PT in military trauma patients in a field hospital. Methods: This single-center prospective study was designed to compare POC coagulation monitoring with traditional laboratory testing. It was conducted at the French military hospital located at Kabul International Airport. All patients with trauma injuries resulting from war operations were included. A blood sample was drawn immediately on admission. PT was determined both in the laboratory and with use of the Coaguchek XS pro. Results: Forty patients with war trauma were enrolled during a 3-month period. The authors recorded 69 measurements. The two methods were correlated with a correlation coefficient of 0.78 (ρ < .001). The Bland- Altman plot showed a mean difference of 5.8% (95% confidence interval -14.9% to 26.6%). Using a PT cutoff of 60%, POC had a sensitivity of 77.1% and a specificity of 94.1%. Results from POC PT measurement were available within a mean of 25.8 minutes before laboratory measures. Conclusions: The Coaguchek XS Pro device can be used successfully in an austere environment without compromising its performance.

Keywords: point-of-care; coagulation; prothrombin time; military trauma

Buy Now

Author: Coughlin O

Top

Tourniquet Pressures: Strap Width and Tensioning System Widths

Wall PL, Coughlin O, Rometti MR, Birkholz S, Gildemaster Y, Grulke L, Sahr SM, Buising CM. 14(4). 19 - 29. (Journal Article)

Abstract

Background: Pressure distribution over tourniquet width is a determinant of pressure needed for arterial occlusion. Different width tensioning systems could result in arterial occlusion pressure differences among nonelastic strap designs of equal width. Methods: Ratcheting Medical Tourniquets™ (RMTs; m2® inc., http://www.ratcheting buckles.com) with a 1.9cm-wide (Tactical RMT) or 2.3cmwide (Mass Casualty RMT) ladder were directly compared (16 recipients, 16 thighs and 16 upper arms for each tourniquet ® 2). Then, RMTs were retrospectively compared with the windlass Combat Application Tourniquet (C-A-T ["CAT"], http://combattourniquet.com) with a 2.5cm-wide internal tensioning strap. Pressure was measured with an air-filled No. 1 neonatal blood pressure cuff under each 3.8cm-wide tourniquet. Results: RMT circumferential pressure distribution was not uniform. Tactical RMT pressures were not higher, and there were no differences between the RMTs in the effectiveness, ease of use ("97% easy"), or discomfort. However, a difference did occur regarding tooth skipping of the pawl during ratchet advancement: it occurred in 1 of 64 Tactical RMT applications versus 27 of 64 Mass Casualty RMT applications. CAT and RMT occlusion pressures were frequently over 300mmHg. RMT arm occlusion pressures (175-397mmHg), however, were lower than RMT thigh occlusion pressures (197-562mmHg). RMT effectiveness was better with 99% reached occlusion and 1% lost occlusion over 1 minute versus the CAT with 95% reached occlusion and 28% lost occlusion over 1 minute. RMT muscle tension changes (up to 232mmHg) and pressure losses over 1 minute (24 ± 11mmHg arm under strap to 40 ± 12mmHg thigh under ladder) suggest more occlusion losses may have occurred if tourniquet duration was extended. Conclusions: The narrower tensioning system Tactical RMT has better performance characteristics than the Mass Casualty RMT. The 3.8cmwide RMTs have some pressure and effectiveness similarities and differences compared with the CAT. Clinically significant pressure changes occur under nonelastic strap tourniquets with muscle tension changes and over time periods as short as 1 minute. An examination of pressure and occlusion changes beyond 1 minute would be of interest.

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

Buy Now

Author: Cox KL

Top

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

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

Abstract

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

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

Buy Now

Author: Cox KM

Top

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

Gerhardt RT, Berry J, Mabry RL, Flournoy L, Arnold RG, Hults C, Robinson JB, Thaxton RA, Cestero R, Heiner JD, Koller AR, Cox KM, Patterson JN, Dalton WR, McKeague AL, Gilbert G, Manemeit C, Adams BD. 14(1). 50 - 57. (Journal Article)

Abstract

Objective: We sought to determine whether Contingency Telemedical Support (CTS) improves the success rate and efficiency of primary care providers performing critical actions during simulated combat trauma resuscitation. Critical actions included advanced airway, chest decompression, extremity hemorrhage control, hypothermia prevention, antibiotics and analgesics, and hypotensive resuscitation, among others. Background: Recent studies report improved survival associated with skilled triage and treatment in the out-of-hospital/preoperative phase of combat casualty care. Historically, ground combat units are assigned primary care physicians and physician assistants as medical staff, due to resource limitations. Although they are recognized as optimal resuscitators, demand for military trauma surgeons and emergency physicians exceeds supply and is unlikely to improve in the near term. Methods: A prospective trial of telemedical mentoring during a casualty resuscitation encounter was studied using a high-fidelity patient simulator (HFPS). Subjects were randomized and formed into experimental (CTS) or control teams. CTS team leaders were equipped with a headset/microphone interface and telementored by a combat-experienced emergency physician or trauma surgeon. A standardized, scripted clinical scenario and HFPS were used with 14 critical actions. At completion, subjects were surveyed. Statistical approach included contingency table analysis, two-tailed t-test, and correlation coefficient. This study was reviewed and approved by our institutional review board (IRB). Results: Eighteen CTS teams and 16 control teams were studied. By intention-to-treat ITT analysis, 89% of CTS teams versus 56% of controls completed all life-threatening inventions (LSIs) (p < .01); 78% versus 19% completed all critical actions (p < .01); and 89% versus 56% established advanced airways within 8 minutes (p < .06). Average time to completion in minutes (95% confidence interval [CI] 95) was 12 minutes (10-14) for CTS versus 18 (16-20) for controls, with 75% of control teams not completing all critical actions. Conclusion: In this model, real-time telementoring of simulated trauma resuscitation was feasible and improved accuracy and efficiency of non-emergency-trained resuscitators. Clinical validation and replicated study of these findings for guiding remote damage control resuscitation are warranted.

Keywords: military medicine; war; emergency medical services; resuscitation; telemedicine; wounds and injuries

Buy Now

Junctional Tourniquet Training Experience

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

Abstract

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

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

Buy Now

Author: Cozzarelli TA

Top

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

Cozzarelli TA. 10(4). 39 - 42. (Journal Article)

Abstract

The Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury (DCoE) and the Defense and Veterans Brain Injury Center (DVBIC) hosted a consensus conference to address persistent cognitive impairments following mild traumatic brain injury (mTBI) and the role of cognitive rehabilitation in this population. Fifty military and civilian subject matter experts developed clinical guidance for cognitive rehabilitation of Service members with cognitive symptoms persisting three or more months following injury. This article highlights the initial evaluation, comprehensive assessment and treatment recommendations contained within the guidance "Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury and Defense and Veterans Brain Injury Center Consensus Conference on Cognitive Rehabilitation for Mild Traumatic Brain Injury." The full clinical guidance is available at: (http://www.dcoe.health.mil/Resources.aspx).

Author: Crandall ML

Top

Giant Basal Cell Carcinoma

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

Abstract

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

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

Buy Now

Author: Crawford I

Top

Medical Seminars: A New Paradigm For SOF Counterinsurgency Medical Programs

Alderman SM, Christensen J, Crawford I. 10(4). 16 - 22. (Journal Article)

Abstract

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

Author: Crawford K

Top

Warrior Model For Human Performacne And Injury Prevention: Eagle Tactical Athlete Program (ETAP) Part I

Sell TC, Abt JP, Crawford K, Lovalekar M, Nagai T, Deluzio J, Smalley BW, McGrail MA, Rowe RS, Cardin S, Lephart SM. 10(3). 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.

Warrior Model For Human Performance And Injury Prevention: Eagle Tactical Athlete Program (ETAP) Part II

Abt JP, Sell TC, Crawford K, Lovalekar M, Nagai T, Deluzio J, Smalley BW, McGrail MA, Rowe RS, Cardin S, Lephart SM. 10(3). 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.

Author: Crawley G

Top

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

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

Abstract

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

Author: Crisp JD

Top

Portable Ultrasound Empowers Special Forces Medics

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

Abstract

Author: Croom D

Top

Thrombotic Microangiopathy Syndrome in a Basic Underwater Demolition/SEAL Student

Croom D, Tracy H. 16(3). 16 - 19. (Journal Article)

Abstract

Thrombotic microangiopathy (TMA) syndromes represent a spectrum of illnesses that share common clinical and pathologic features of microangiopathic hemolytic anemia, thrombocytopenia, and organ injury from pathologic small-vessel thrombosis. At least nine primary TMA syndromes have been described and classified based on common probable etiologies, diagnostic criteria, and treatments. The most recognized of the TMA syndromes include thrombotic thrombocytopenic purpura (TTP) and hemolytic-uremic syndrome (HUS). Advanced laboratory techniques are required to distinguish between these syndromes; however, all patients should initially be treated with plasma exchange for presumed ADAMTS13 deficiency-mediated TMA. The authors present a case of a TMA syndrome in a Navy SEAL (Sea, Air, Land) candidate.

Keywords: syndrome, hemolytic-uremic; thrombotic thrombocytopenic purpura; microangiopathies, thrombotic; disseminated intravascular coagulation

Buy Now

Author: Cropano CM

Top

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

Mejaddam AY, van der Wilden GM, Chang Y, Cropano CM, Sideris AC, Hwbejire JO, Velmahos GC, Alam HB, de Moya MA, King DR. 13(1). 29 - 33. (Journal Article)

Abstract

Introduction: The usefulness of heart rate variability (HRV) and heart rate complexity (HRC) analysis as a potential triage tool has been limited by the inability to perform real-time analysis on a portable, handheld monitoring platform. Through a multidisciplinary effort of academia and industry, we report on the development of a rugged, handheld and noninvasive device that provides HRV and HRC analysis in real-time in critically ill patients. Methods: After extensive re-engineering, real-time HRV and HRC analyses were incorporated into an existing, rugged, handheld monitoring platform. Following IRB approval, the prototype device was used to monitor 20 critically ill patients and 20 healthy controls to demonstrate real-world discriminatory potential. Patients were compared to healthy controls using a Student's t test as well as repeated measures analysis. Receiver operator characteristic (ROC) curves were generated for HRV and HRC. Results: Critically ill patients had a mean APACHE-2 score of 15, and over 50% were mechanically ventilated and requiring vasopressor support. HRV and HRC were both lower in the critically ill patients compared to healthy controls (ρ < 0.0001) and remained so after repeated measures analysis. The area under the ROC for HRV and HRC was 0.95 and 0.93, respectively. Conclusions: This is the first demonstration of real-time, handheld HRV and HRC analysis. This prototype device successfully discriminates critically ill patients from healthy controls. This may open up possibilities for real-world use as a trauma triage tool, particularly on the battlefield.

Keywords: heart rate complexity; heart rate variability; entropy; triage; combat

Buy Now

Author: Crossland BW

Top

Return to Duty After Severe Bilateral Lower Extremity Trauma

Sheean AJ, Owens J, Suttles ST, Crossland BW, Stinner DJ. 15(1). 1 - 6. (Case Reports)

Abstract

Despite the preponderance of evidence demonstrating poor outcomes as a result of combat-related orthopaedic trauma, teams of medical professionals have remained undaunted in their pursuit of innovative techniques to maximize the functional capacity of Servicemembers with devastating extremity injuries. We present the case of an Active Duty Special Forces (SF) qualified senior noncommissioned officer (NCO) with severely injured extremities successfully salvaged with a multidisciplinary program involving cutting-edge prosthetic technology and a novel approach to physical rehabilitation.

Keywords: ankle fusion; outcomes; limb salvage; rehabilitation

Buy Now

Author: Croushorn J

Top

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

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

Abstract

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

Keywords: AAT; hemorrhage; amputations

Buy Now

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

Schwartz RB, Lerner B, Llewellyn C, Pennardt A, Wedmore I, Callaway DW, Wightman JM, Casillas R, Eastman A, Gerold KB, Giebner S, Davidson R, Kamin R, Piazza G, Bollard GA, Carmona PA, Sonstrom B, Seifarth W, Nicely B, Croushorn J, Carmona PA. 14(2). 122 - 138. (Classical Conference)

Abstract

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

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

Abstract

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

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

Buy Now

Author: Cuenca PJ

Top

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

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

Abstract

Should We Teach Every Soldier How To Start An Iv?

Mabry RL, Cuenca PJ. 09(2). 64 - 66. (Previously Published)
Previously published in Military Medicine,. 2009 Jun;174(6):iii-v. Permission granted to republish in the JSOM.

Abstract

Intra-articular Morphine versus Lidocaine for Acute Knee Pain

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

Abstract

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

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

Buy Now

Author: Culbertson NT

Top

What Can Be Done With Expired Pharmaceuticals? A Review Of Literature As It Pertains To Special Operations Force's Medics

Culbertson NT. 11(2). 1 - 6. (Journal Article)

Abstract

Over the past decade, increasing evidence suggests that pharmaceuticals may continue to be potent beyond their date of expiration. Despite this evidence, we have not yet experienced a change in United States federal policy that would recommend usage of expired pharmaceuticals. While the scientific community and federal regulators continue to study the matter, the medical community is often guilty of misunderstanding the nuances of the issue. As a result, many healthcare professionals misinform their peers and their patients on either the appropriateness or inappropriateness of taking expired medications. Even though both the American Medical Association (AMA) and the Food and Drug Administration (FDA) do not recommend the dosing of expired pharmaceuticals at this time, discussion of the issue is warranted in order to understand the potential behind some expired drugs and to encourage further research. This discussion is particularly relevant to the Special Operations medical community, since Special Operations Force's (SOF) medic s frequently encounter expired medication overseas. Given thei r unique sk ill set and working environ ment, the SOF medic should be familiar with the potential applications of expired medications, including their drawbacks.

Keywords: date of expiration; expired pharmaceuticals; shelf-life extension

Buy Now

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

Culbertson NT, Scholl BJ. 13(3). 70 - 73. (Journal Article)

Abstract

Background: Personal hygiene is strongly associated with disease prevention and is especially important during prolonged patrol or combat operations. Understanding cultural variances associated with personal hygiene is critical for Special Operation Forces (SOF) medics to prevent, monitor, and treat acquired and transmitted infections while working with host nation personnel. Case Presentation: During a multiday, long-range patrol, approximately 40 male Afghan National Army troops between the ages of 22 and 49 presented for treatment of burning or pain while urinating. All patients were empirically diagnosed with urinary tract infections. Methods and Discussion: The high attack rate and isolated nature of the outbreak suggested that personal hygiene or sexual intercourse was the most likely cause of the isolated outbreak. However, the cultural sensitivity of both topics made social history gathering a difficult task. After participating in a detailed medical interview, one patient revealed that he and his comrades were blocking their urethras with clay plugs after voiding to prevent residual urine from dripping onto their clothes. Conclusions: This case study presents what might be an undocumented practice carried throughout many ethnic cultures endogenous to Afghanistan and discusses how cultural barriers can impact effective health care delivery.

Keywords: urinary tract infections; hygiene; primary prevention; patient-centered care; cultural competency

Buy Now

Author: Cullinan W

Top

Prolonged Field Care of a Casualty With Penetrating Chest Trauma

Barnhart G, Cullinan W, Pickett JR. 16(4). 99 - 101. (Case Reports)

Abstract

As Special Operations mission sets shift to regions with less coalition medical infrastructure, the need for quality long-term field care has increased. More and more, Special Operations Medics will be expected to maintain casualties in the field well past the "golden hour" with limited resources and other tactical limitations. This case report describes an extended-care scenario (>12 hours) of a casualty with a chest wound, from point of injury to eventual casualty evacuation and hand off at a Role II facility. This case demonstrates the importance of long-term tactical medical considerations and the effectiveness of minimal fluid resuscitation in treating penetrating thoracic trauma.

Keywords: prolonged field care; chest trauma, penetrating; resuscitation, fluid

Buy Now

Author: Cungi P

Top

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

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

Abstract

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

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

Buy Now

Author: Cuniowski P

Top

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

Mabry RL, Cuniowski P, Frankfurt A, Adams BD. 11(2). 16 - 19. (Journal Article)

Abstract

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

Buy Now

Author: Cunningham CW

Top

Delayed Diagnosis of Pelvic hematoma without Fracture Due to Military Parachuting

Cunningham CW, Kotwal RS, Kragh JF. 13(2). 4 - 7. (Case Reports)

Abstract

The U.S. military has been conducting static-line parachute jumps for nearly a century. Beginning with World War II, military forces have also employed full-scale airborne operations as a method for insertion into combat. Through the years, injuries from blunt trauma as a result of static-line parachute jumps have evolved little with the refinement of equipment, training, and tactics. Parachute jumps continue to invoke primarily musculoskeletal injuries, especially to the lower extremities, back, neck, and head. These injuries are usually straightforward in their presentation and diagnosis. We describe the delayed diagnosis of a pelvic hematoma due to an uncommon blunt trauma jump injury. The purpose of this case report is to increase awareness of injury patterns during paratrooper operations, as well as to review the diagnosis and management of occult hemorrhage. Specific objectives for the readers are to (1) know the common injury types and patterns for airborne operations, (2) know the descent rate of T-10C/D parachutes and factors influencing the rate, (3) recognize signs and symptoms associated with a pelvic hematoma, and (4) recognize common complications resulting from a pelvic hematoma.

Keywords: airborne; paratrooper; parachute (T-10, T-11, SF-10); pelvic trauma; hemorrhage; hematoma; ultrasound; combat-load

Buy Now

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

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

Abstract

Power To The People

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

Abstract

Buy Now

Author: Curlee JB

Top

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

Theodoridis CA, Kafka KE, Perez AM, Curlee JB, Yperman PC, Oppermann N, Holmstroem E, Niegsch DD, Mannino A, Ramundo N. 16(1). 44 - 50. (Journal Article)

Abstract

Background: Previous research has shown that external hemorrhage from proximal leg amputations and junctional sites represents 19.2% of potentially survivable lethal hemorrhage. A recent effort to address this problem has resulted in the development of various junctional tourniquets. This study assessed and compared two Tactical Combat Casualty Care Committee-approved junctional tourniquets, the Combat Ready Clamp (CRoC) and the Junctional Emergency Treatment Tool (JETT), to contribute to their future development and to better inform on the decisions for device selection by military units. Aims of the study also were to provide concrete feedback and suggestions on how to effectively apply the devices. Methods: Via a specific questionnaire, 75 international attendees of the International Special Training Centre Medical Branch Special Operations Forces Advanced Medical First Responder course evaluated the CRoC and the JETT on different parameters. Both devices were tested objectively through timed applications aimed at stopping unilateral lower-extremity distal pulse on 33 of these 75 students, verified by palpation by Medical Branch instructors. Subjective and objective data were examined for mutual correlation. Results: Users ranked the JETT higher than the CRoC on all parameters, including effectiveness on the battlefield (ρ < .001), ease of use (ρ < .039), speed of application (ρ < .001), and not slipping in use (ρ < .001), although the difference on other parameters such as effectiveness in hemorrhage control was not statistically significant. Considering all parameters together, the JETT was evaluated as a better device than the CRoC (ρ < .001). The application time measurement suggested that the JETT was applied faster (by approximately 15 seconds on average; p < .001). The fastest CRoC and JETT applications were 37 and 29 seconds, respectively. The JETT was not easier to use or more effective than the CRoC; there was a 9% failure rate of the JETT occluding a unilateral common femoral artery. The JETT's efficacy in occluding a unilateral common femoral artery can be compromised if the device's pelvic binder is not sufficiently tightened prior to threading the T-handled pad. The CRoC's application time can be drastically reduced if the device is kept assembled and firm pressure is immediately asserted upon placement on the intended location through the vertical arm, then threading the device. Both devices were applied safely; no adverse effects were reported during or after application. Conclusion: Even though the JETT might be preferred by military medical providers, the CRoC still has merits. As both devices proved to occlude the arterial flow in no less than 54 seconds on average, they could be used to supplement direct pressure and wound packing, the latter two still being considered the immediate actions for inguinal bleeding control. Considering that the CRoC and the JETT can be applied in as little as 37 and 29 seconds, respectively, users should be effectively trained and entirely proficient on either device to justify their election as the primary countermeasure to hemorrhage not amenable to regular tourniquets.

Keywords: hemorrhage, junctional; tourniquet, junctional; Combat Ready Clamp; Junctional Emergency Treatment Tool; Tactical Combat Casualty Care Committee; hemorrhage control

Buy Now

Author: Dagan D

Top

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

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

Abstract

Author: Daigle KA

Top

Comprehensive Performance Nutrition for Special Operations Forces

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

Abstract

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

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

Buy Now

Author: Dalton WR

Top

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

Gerhardt RT, Berry J, Mabry RL, Flournoy L, Arnold RG, Hults C, Robinson JB, Thaxton RA, Cestero R, Heiner JD, Koller AR, Cox KM, Patterson JN, Dalton WR, McKeague AL, Gilbert G, Manemeit C, Adams BD. 14(1). 50 - 57. (Journal Article)

Abstract

Objective: We sought to determine whether Contingency Telemedical Support (CTS) improves the success rate and efficiency of primary care providers performing critical actions during simulated combat trauma resuscitation. Critical actions included advanced airway, chest decompression, extremity hemorrhage control, hypothermia prevention, antibiotics and analgesics, and hypotensive resuscitation, among others. Background: Recent studies report improved survival associated with skilled triage and treatment in the out-of-hospital/preoperative phase of combat casualty care. Historically, ground combat units are assigned primary care physicians and physician assistants as medical staff, due to resource limitations. Although they are recognized as optimal resuscitators, demand for military trauma surgeons and emergency physicians exceeds supply and is unlikely to improve in the near term. Methods: A prospective trial of telemedical mentoring during a casualty resuscitation encounter was studied using a high-fidelity patient simulator (HFPS). Subjects were randomized and formed into experimental (CTS) or control teams. CTS team leaders were equipped with a headset/microphone interface and telementored by a combat-experienced emergency physician or trauma surgeon. A standardized, scripted clinical scenario and HFPS were used with 14 critical actions. At completion, subjects were surveyed. Statistical approach included contingency table analysis, two-tailed t-test, and correlation coefficient. This study was reviewed and approved by our institutional review board (IRB). Results: Eighteen CTS teams and 16 control teams were studied. By intention-to-treat ITT analysis, 89% of CTS teams versus 56% of controls completed all life-threatening inventions (LSIs) (p < .01); 78% versus 19% completed all critical actions (p < .01); and 89% versus 56% established advanced airways within 8 minutes (p < .06). Average time to completion in minutes (95% confidence interval [CI] 95) was 12 minutes (10-14) for CTS versus 18 (16-20) for controls, with 75% of control teams not completing all critical actions. Conclusion: In this model, real-time telementoring of simulated trauma resuscitation was feasible and improved accuracy and efficiency of non-emergency-trained resuscitators. Clinical validation and replicated study of these findings for guiding remote damage control resuscitation are warranted.

Keywords: military medicine; war; emergency medical services; resuscitation; telemedicine; wounds and injuries

Buy Now

Author: Daly IM

Top

Care of the Burn Casualty in the Prolonged Field Care Environment

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

Abstract

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

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

Buy Now

Author: d'Andrea P

Top

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

Peffer J, Ley N, Wuelher J, d'Andrea P, Rittberg C, Losch J, Lynch JH. 15(4). 109 - 112. (Journal Article)

Abstract

Austere environments such as Africa pose clinical challenges, which are multiplied for Special Operations Forces (SOF) providers who must face these challenges with limited resources against the tyranny of distance. These limited resources apply not only to treatment tools but to diagnostic tools as well. Laboratory diagnostics may provide critical information in diagnosis, initial triage, and/or evacuation decisions, all of which may enhance a patient's survival. However, unlike in climatecontrolled, fixed-facility hospitals, the deployed SOF provider must have access to a simple, reliable device for point-of-care testing (POCT) to obtain clinically meaningful data in a practical manner given the surroundings.

Keywords: Africa; medicine, tactical; testing, laboratory; analyzers, blood, point-of-care; malaria; HIV; medicine, wilderness

Buy Now

Author: Danielson PD

Top

Evaluation of Commercially Available Traction Splints for Battlefield Use

Studer NM, Grubb SM, Horn GT, Danielson PD. 14(2). 46 - 55. (Journal Article)

Abstract

Background: Femoral fracture is a common battlefield injury with grave complications if not properly treated. Traction splinting has been proved to decrease morbidity and mortality in battlefield femur fractures. However, little standardization of equipment and training exists within the United States Armed Forces. Currently, four traction splints that have been awarded NATO Stock Numbers are in use: the CT-6 Leg Splint, the Kendrick Traction Device (KTD), the REEL Splint (RS), and the Slishman Traction Splint (STS). Objective: The purpose of this study was to determine the differences between the four commercially available traction devices sold to the U.S. Government. Methods: After standardized instruction, subjects were timed and evaluated in the application of each of the four listed splints. Participant confidence and preferences were assessed by using Likert-scaled surveys. Free response remarks were collected before and after timed application. Results: Subjects had significantly different application times on the four devices tested (analysis of variance [ANOVA], ρ < .01). Application time for the STS was faster than that for both the CT-6 (t-test, ρ < .0028) and the RS (ρ < .0001). Subjects also rated the STS highest in all post-testing subjective survey categories and reported significantly higher confidence that the STS would best treat a femoral fracture (ρ < .00229). Conclusions: The STS had the best objective performance during testing and the highest subjective evaluation by participants. Along with its ability to be used in the setting of associated lower extremity amputation or trauma, this splint is the most suitable for battlefield use of the three devices tested.

Keywords: combat medic; medical training; traction splinting; Tactical Combat Casualty Care; femoral

Buy Now

Evaluation of Commercially Available Traction Splints for Battlefield Use: Response

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

Abstract

Author: Dannenbaum J

Top

A Review of Reduction Techniques for Anterior Glenohumeral Joint Dislocations

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

Abstract

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

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

Buy Now

Author: d'Aranda E

Top

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

Cotte J, d'Aranda E, Chauvin V, Kaiser E, Meaudre E. 13(4). 59 - 62. (Journal Article)

Abstract

Background and Objective: Almost 50% of military trauma patients who need transfusions develop a coagulopathy. Immediately treating this coagulopathy improves the patient's prognosis. Field military hospitals often lack laboratory devices needed to diagnose a clinically significant coagulopathy and have limited blood product resources such as plasma. Point-of-care (POC) devices for the measurement of prothrombin time (PT) are available and have been tested in a variety of situations, including hemorrhagic surgery. The authors compared a POC device, the Coaguchek XS Pro (F. Hoffmann-La Roche Ltd., Basel, Switzerland), with laboratory measures for determining the PT in military trauma patients in a field hospital. Methods: This single-center prospective study was designed to compare POC coagulation monitoring with traditional laboratory testing. It was conducted at the French military hospital located at Kabul International Airport. All patients with trauma injuries resulting from war operations were included. A blood sample was drawn immediately on admission. PT was determined both in the laboratory and with use of the Coaguchek XS pro. Results: Forty patients with war trauma were enrolled during a 3-month period. The authors recorded 69 measurements. The two methods were correlated with a correlation coefficient of 0.78 (ρ < .001). The Bland- Altman plot showed a mean difference of 5.8% (95% confidence interval -14.9% to 26.6%). Using a PT cutoff of 60%, POC had a sensitivity of 77.1% and a specificity of 94.1%. Results from POC PT measurement were available within a mean of 25.8 minutes before laboratory measures. Conclusions: The Coaguchek XS Pro device can be used successfully in an austere environment without compromising its performance.

Keywords: point-of-care; coagulation; prothrombin time; military trauma

Buy Now

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

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

Abstract

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

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

Buy Now

Author: Dare C

Top

Ultrasound-Guided Triage

Dare C, Hampton K. 16(4). 117 - 117. (Journal Article)

Abstract

Keywords: ultrasound transfer; triage

Buy Now

Author: Davidson R

Top

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

Schwartz RB, Lerner B, Llewellyn C, Pennardt A, Wedmore I, Callaway DW, Wightman JM, Casillas R, Eastman A, Gerold KB, Giebner S, Davidson R, Kamin R, Piazza G, Bollard GA, Carmona PA, Sonstrom B, Seifarth W, Nicely B, Croushorn J, Carmona PA. 14(2). 122 - 138. (Classical Conference)

Abstract

Author: Davies BW

Top

Intraorbital Training Munition

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

Abstract

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

Keywords: orbit; trauma; training; munition

Buy Now

Author: Davies S

Top

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

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

Abstract

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

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

Buy Now

Author: Davinson JP

Top

Laboratory Testing of Emergency Tourniquets Exposed to Prolonged Heat

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

Abstract

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

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

Buy Now

Author: Davis KG

Top

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

Sirkin MR, Cook P, Davis KG. 15(4). 54 - 58. (Journal Article)

Abstract

Background: The operative control of noncompressible hemorrhage is the single largest impact that could be addressed in reducing the mortality on the battlefield. Laprotomy pads, traditionally used for hemorrhage evacuation, are made of woven cotton, and, while effective, their use requires a substantial amount of space and adds weight. This poses no concern in traditional operating rooms but is a hindrance for mobile providers and providers in austere environments. We sought to compare different absorptive compunds to ascertain their utility as alternatives for traditional laparotomy pads. Methods: Samples of cotton laparotomy pads, pure rayon sheets, rayon-polypropylene composite sheets, and non-polyester composite "microfiber" sheets were weighed and submerged in heparinized whole bovine blood. After saturation, the favrics were weighed, wrung dry, reweighed, and resubmerged. This process was performed for a total of three sequential submersions. The saturated weights and dry weights of each fabric were used to calculate how much blood each fabric could absorb initially and after multiple repeated uses. The initial densities of the four fabrics was calculated and compared. Results: The initial submersions demonstrated that 1g each of cotton, rayon, rayon-polypropylene, and nylon-polyester were able to absorb 7.58g, 12.98g, 10.16g, and 9.73g of blood respectively. The second and third sequential trials, which were statistically similar, demonstrated that 1g of cotton, rayon, rayon-polypropolyene, and nylon-polyester were able to absorb 1.73g, 2.83g, 2.3g, and 2.3g of blood, respectively. The calculated densities of cotton, rayon, rayon-polypropylene, and nylon-polyester were 0.087g/cm³, .012g/cm³, 0.098g/cm³, and 0.093g/cm³, respectively. Conclusion: Per gram, rayon absorbed approximately 1.7 times more blood thancotton and three-quarters the amount of the storage space. Rayon also retained its superior absorption abilites on repeated uses, demonstrating the potential for re-use in remote and austere environments. Thus, rayon could serve as a viable alternative to traditional cotton laparotomy pads in the austere environments.

Keywords: hemorrhage; laparotomy; cotton; rayon; sponge; austere; surgery; packing; combat casualty care; absorption; density

Buy Now

Author: De La Barrera R

Top

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

Caci JB, Blaylock JM, De La Barrera R, Thomas SJ, Lyons AG. 14(3). 111 - 115. (Journal Article)

Abstract

The endemicity of dengue fever (DF) and, consequently, sequelae of DF are increasing worldwide. The increases are largely a result of widespread international travel and the increased range of the mosquito vectors. US Army Special Operations Command (USASOC) personnel are at an increased risk of exposure to dengue based on their frequent deployments to and presence in dengue endemic areas worldwide. Repeated deployments to different endemic areas can increase the risk for developing the more serious sequelae of dengue: dengue hemorrhagic fever (DHF) and dengue shock syndrome (DSS). Information about the seroprevalence rate of dengue in USASOC personnel, in particular, is lacking and is critical to assessing the risk, tailoring preventive medicine countermeasures, leveraging field diagnostics, and maintaining mission capability. In the first part of a two-part project to assess baseline seroprevalence in USASOC units, a random, unit-stratified sample of 500 anonymous serum specimens from personnel assigned to the highest-risk units in USASOC were screened for dengue using a microneutralization assay. Of the 500 specimens screened, 56 (11.2%) of 500 had neutralizing titers (NT) (MN(50) ≥ 10) against at least one DENV serotype. Subsequent sample titration resulted in 48 (85.7%) of 56 of the samples with NT (MN(50) ≥ 10) against at least one dengue serotype for an overall dengue exposure rate of 9.6% (48 of 500). The second part of the ongoing project, started in 2012, was a multicenter, serosurveillance project using predeployment and postdeployment sera collected from USASOC personnel deployed to South and Central America, Africa, and Southeast Asia. Preliminary results show a 13.2% (55 of 414) seropositivity rate. The significance of these findings as they relate to personal risk and operational impact is discussed.

Keywords: dengue fever; USASOC; dengue hemorrhagic fever; dengue shock syndrome

Buy Now

Author: de Moya MA

Top

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

Mejaddam AY, van der Wilden GM, Chang Y, Cropano CM, Sideris AC, Hwbejire JO, Velmahos GC, Alam HB, de Moya MA, King DR. 13(1). 29 - 33. (Journal Article)

Abstract

Introduction: The usefulness of heart rate variability (HRV) and heart rate complexity (HRC) analysis as a potential triage tool has been limited by the inability to perform real-time analysis on a portable, handheld monitoring platform. Through a multidisciplinary effort of academia and industry, we report on the development of a rugged, handheld and noninvasive device that provides HRV and HRC analysis in real-time in critically ill patients. Methods: After extensive re-engineering, real-time HRV and HRC analyses were incorporated into an existing, rugged, handheld monitoring platform. Following IRB approval, the prototype device was used to monitor 20 critically ill patients and 20 healthy controls to demonstrate real-world discriminatory potential. Patients were compared to healthy controls using a Student's t test as well as repeated measures analysis. Receiver operator characteristic (ROC) curves were generated for HRV and HRC. Results: Critically ill patients had a mean APACHE-2 score of 15, and over 50% were mechanically ventilated and requiring vasopressor support. HRV and HRC were both lower in the critically ill patients compared to healthy controls (ρ < 0.0001) and remained so after repeated measures analysis. The area under the ROC for HRV and HRC was 0.95 and 0.93, respectively. Conclusions: This is the first demonstration of real-time, handheld HRV and HRC analysis. This prototype device successfully discriminates critically ill patients from healthy controls. This may open up possibilities for real-world use as a trauma triage tool, particularly on the battlefield.

Keywords: heart rate complexity; heart rate variability; entropy; triage; combat

Buy Now

Author: Deaton TG

Top

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

Deaton TG, Roby JL. 10(1). 22 - 25. (Journal Article)

Abstract

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

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

Ross EM, Deaton TG, Hurst N, Siefert J. 15(1). 71 - 78. (Journal Article)

Abstract

Prehospital ultrasound use is a relatively new skill set. The military noted the clear advantages of this skill set in the deployed setting and moved forward with teaching their advanced combat trauma medics skills to perform specific examinations. The training curriculum for Special Operations-level clinical ultrasound was created and adapted from training guidelines set forth by the American College of Emergency Physicians with a focus on the examinations relevant to the Special Operations community. Once providers leave the training environment, skill sustainment can be difficult. We discuss the relevant ultrasound exams for the prehospital setting. We address opportunities to improve point-of-care ultrasound skills through hands-on experience while in a fixed medical facility. Options for simulation-based training are discussed with descriptions for creating lowcost simulation models. Finally, a list of online resources is provided to review specific ultrasound examinations.

Keywords: point-of-care ultrasound; prehospital ultrasound; Special Operations-level clinical ultrasound; simulation

Buy Now

Author: DeLellis SM

Top

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

Burns GD, DeLellis SM. 08(4). 54 - 57. (Journal Article)

Abstract

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

The Neurometabolic Cascade And Implications Of mTBI: Mitigating Risk To The SOF Community

DeLellis SM, Kane S, Katz K. 09(3). 36 - 42. (Journal Article)

Abstract

Over the last decade, our understanding of biochemical changes that occur in the brain following an injury has increased dramatically. Although we have been able to discern and image severe injury and traumatic changes using techniques like computed tomography (CT) and magnetic resonance imaging (MRI) for decades, we have only recently begun to understand the physiologic changes that occur following a mild traumatic brain injury. Understanding the pathophysiology of a disease process enables healthcare providers to treat their patients better, but military healthcare providers shoulder the additional burden of conserving the fighting force. Neurocognitive testing in concert with clinical acumen and conservative profiling enables providers to protect their patients from further injury; while educating the patient and the chain of command will prevent additional injury and long-term cognitive sequelae, ultimately preserving the fighting force.

Author: Dellavolpe J

Top

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

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

Abstract

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

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

Buy Now

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

Powell D, McLeroy RD, Riesberg J, Vasios WN, Miles EA, Dellavolpe J, Keenan S, Pamplin JC. 16(4). 102 - 109. (Journal Article)

Abstract

One of the core capabilities of prolonged field care is telemedicine. We developed the Virtual Critical Care Consult (VC3) Service to provide Special Operations Forces (SOF) medics with on-demand, virtual consultation with experienced critical care physicians to optimize management and improve outcomes of complicated, critically injured or ill patients. Intensive-care doctors staff VC3 continuously. SOF medics access this service via phone or e-mail. A single phone call reaches an intensivist immediately. An e-mail distribution list is used to share information such as casualty images, vital signs flowsheet data, and short video clips, and helps maintain situational awareness among the VC3 critical care providers and other key SOF medical leaders. This real-time support enables direct communication between the remote provider and the clinical subject matter expert, thus facilitating expert management from near the point of injury until definitive care can be administered. The VC3 pilot program has been extensively tested in field training exercises and validated in several real-world encounters. It is an immediately available capability that can reduce medical risk and is scalable to all Special Operations Command forces.

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

Buy Now

Author: Delmonaco BL

Top

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

Delmonaco BL. 07(1). 48 - 50. (Journal Article)

Abstract

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

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

Delmonaco BL, Andrews J, May A. 08(2). 61 - 64. (Journal Article)

Abstract

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

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

Delmonaco BL, Baker A, Clay J, Kilbourn J. 16(1). 103 - 108. (Journal Article)

Abstract

An eight-person team of conventional US Air Force (USAF) medical providers deployed to support US Special Operations Forces (SOF) in North and West Africa for the first time in November 2014. The predeployment training, operations while deployed, and lessons learned from the challenges of performing surgery and medical evacuations in the remote desert environment of Chad and Niger on the continent of Africa are described. The vast area of operations and far-forward posture of these teams requires cooperation between partner African nations, the French military, and SOF to make these medical teams effective providers of surgical and critical care in Africa. The continuous deployment of conventional USAF medical providers since 2014 in support of US Special Operations Command Africa is challenging and will benefit from more medical teams and effective air assets to provide casualty evacuation across the vast area of operations.

Keywords: US Special Operations Command North and West Africa; far-forward surgery; conventional US Air Force; Mobile Field Surgical Team; Niamey, Niger; N'Dhamena, Chad; CASEVAC; Boko Haram; al-Qaeda I the Islamic Maghreb; French Military

Buy Now

Author: DeLorenzo RA

Top

Laboratory Testing of Emergency Tourniquets Exposed to Prolonged Heat

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

Abstract

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

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

Buy Now

Power To The People

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

Abstract

Buy Now

Author: Deluzio J

Top

Warrior Model For Human Performacne And Injury Prevention: Eagle Tactical Athlete Program (ETAP) Part I

Sell TC, Abt JP, Crawford K, Lovalekar M, Nagai T, Deluzio J, Smalley BW, McGrail MA, Rowe RS, Cardin S, Lephart SM. 10(3). 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.

Warrior Model For Human Performance And Injury Prevention: Eagle Tactical Athlete Program (ETAP) Part II

Abt JP, Sell TC, Crawford K, Lovalekar M, Nagai T, Deluzio J, Smalley BW, McGrail MA, Rowe RS, Cardin S, Lephart SM. 10(3). 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.

Author: Depenbrock P

Top

Tympanic Membrane Perforation In Ied Blasts

Depenbrock P. 08(1). 51 - 54. (Journal Article)

Abstract

Traumatic tympanic membrane (TM) perforation is a common finding in victims of IED blasts. Frequently it goes undiagnosed by medical providers on initial evaluation. Hearing loss, tinnitus, and vertigo are common complaints from Soldiers who have experienced acoustic trauma. Although symptoms are usually transient, their persistence is a cause for concern. Treatment of a ruptured TM is usually expectant. In certain instances specialty consultation is required. Since primary blast and neurologic injuries can accompany traumatic TM perforation, physicians should maintain a high index of suspicion for their presence. This article aims to address the pathophysiology, diagnosis, treatment, and associated complications of blast-induced tympanic membrane perforation. Objectives 1. Understand the biophysics of primary blast injury and how to prevent blast-induced acoustic trauma. 2. Understand the common presenting signs and symptoms of tympanic membrane rupture. 3. Understand the treatment of tympanic membrane rupture and the indications for specialty referral. 4. Understand the long-term complications associated with traumatic tympanic membrane rupture.

Author: DePold GD

Top

Adaptive Eyewear: Freeing The (visually) Oppressed

DePold GD. 08(3). 25 - 26. (Journal Article)

Abstract

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

Author: DeSoucy E

Top

Review of 54 Cases of Prolonged Field Care

DeSoucy E, Shackelford S, DuBose JJ, Zweben S, Rush SC, Kotwal RS, Montgomery HR, Keenan S. 17(1). 121 - 129. (Journal Article)

Abstract

Background: Prolonged field care (PFC) is field medical care applied beyond doctrinal planning time-lines. As current and future medical operations must include deliberate and contingency planning for such events, data are lacking to support efforts. A case review was conducted to define the epidemiology, environment, and operational factors that affect PFC outcomes. Methods: A survey distributed to US military medical providers solicited details of PFC encounters lasting more than 4 hours and included patient demographics, environmental descriptors, provider training, modes of transportation, injuries, mechanism of injury, vital signs, treatments, equipment and resources used, duration of PFC, and morbidity and mortality status on delivery to the next level of care. Descriptive statistics were used to analyze survey responses. Results: Surveys from 54 patients treated during 41 missions were analyzed. The PFC provider was on scene at time of injury or illness for 40.7% (22/54) of cases. The environment was described as remote or austere for 96.3% (52/54) of cases. Enemy activity or weather also contributed to need for PFC in 37.0% (20/54) of cases. Care was provided primarily outdoors (37.0%; 20/54) and in hardened nonmedical structures (37.0%; 20/54) with 42.6% (23/54) of cases managed in two or more locations or transport platforms. Teleconsultation was obtained in 14.8% (8/54) of cases. The prehospital time of care ranged from 4 to 120 hours (median 10 hours), and five (9.3%) patients died prior to transport to next level of care. Conclusion: PFC in the prehospital setting is a vital area of military medicine about which data are sparse. This review was a novel initial analysis of recent US military PFC experiences, with descriptive findings that should prove helpful for future efforts to include defining unique skillsets and capabilities needed to effectively respond to a variety of PFC contingencies.

Keywords: prolonged field care; after action review; military medicine; prehospital; medical evacuation

Buy Now

Author: Detro JF

Top

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

Hart RS, Detro JF. 09(1). 22 - 28. (Journal Article)

Abstract

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

Time For A Change: Recommended Mtoe Rank Adjustment For Army Special Operations Physician Assistants

Detro JF. 10(2). 10 - 13. (Journal Article)

Abstract

Author: Deuster PA

Top

An Integrated Approach for Special Operations

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

Abstract

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

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

Buy Now

The 10 Commandments of Nutrition: 2014

Deuster PA, Lindsey AT, Butler FK. 14(3). 80 - 89. (Journal Article)

Abstract

The US Special Operations Command requires sound recommendations on nutrition to ensure optimal performance of Special Operations personnel. New information continues to emerge, and previous recommendations need to be modified as the evidence base continues to grow. The first 10 Commandments of Nutrition were published in the SEAL professional journal Full Mission Profile in 1992, published for the second time in this journal in 2005, and now revised a second time to reflect the newest science. Whether you are part of the Special Operations Forces (SOF) community or an athlete seeking to improve your performance, these are simple and helpful nutrition guidelines to follow.

Keywords: dietary supplements; omega-3 fatty acids; protein; carbohydrate; grains; fresh fruits and vegetables

Buy Now

Performance Psychology as a Key Component of Human Performance Optimization

Herzog TP, Deuster PA. 14(4). 99 - 105. (Journal Article)

Abstract

The degree of psychological fitness will ultimately impact mission outcomes, so approaches to enhancing it are critical. Performance psychology is one important aspect of psychological fitness that fits into the holistic model of human performance optimization. This article delves into one component of performance psychology: how mental skill training can be applied to improve performance on mission-related tasks. Mental skills training provides added internal resources to help meet the extraordinary external demands that Special Operations Forces personnel can face. Relevance in terms of the demand-resource model and the positive psychology concept of flow are explained. The application of two specific mental skills-executing a goal-setting process and using mental imagery to rehearse technical, tactical, and strategic tasks-will be discussed by using the example of how to enhance performance when entering and clearing rooms.

Keywords: human performance optimization; psychological fitness; performance psychology

Buy Now

Mindfulness: A Fundamental Skill for Performance Sustainment and Enhancement

Deuster PA, Schoomaker E. 15(1). 93 - 99. (Journal Article)

Abstract

The term "mindfulness" has become very fashionable within the military and across multiple sectors of civilian and first responder populations. Overall, the key concept of mindfulness is intentionally being acutely aware of what is going on internally as well as externally, without reacting. Mindfulness and the awareness that underlies it are inherent capabilities that can be honed through training. As such, classes in mindfulness are being offered in many venues and medical clinics are using mindfulness-based interventions for patients for a wide range of medical issues. The evidence behind the benefits of mindfulness is extensive and instructive. Importantly, evidence suggests that mindfulness can be helpful for many operational, leadership, and personal activities and is likely beneficial for enhancing resilience and overall health. Many current military leaders are using mindfulness as a tool to better prepare for a dynamic and uncertain future.

Keywords: mindfulness; performance sustainment; performance enhancement

Buy Now

Monitoring Training for Human Performance Optimization

Austin KG, Deuster PA. 15(2). 102 - 108. (Journal Article)

Abstract

Physical fitness can significantly impact the mission success of Special Operations Forces (SOF). Much like athletes, Operators have multiple training components including technical, tactical, physical and mental conditioning, which must simultaneously be developed for mission success. Balancing multiple physical stressors to ensure positive results from training can be achieved through periodization-the intentional planning for success. Monitoring the training load can assist SOF in managing training stress and designing periodization that minimizes fatigue. The present article provides an overview of modern technology developed to quantify the stress of training. The training load maintained by SOF consists of external loads created through physical work and internal units of load determined by the rate of perceived effort during training that must be integrated in a manner that minimizes the accumulation of fatigue. Methods for determining training load are discussed in this article and examples are provided for determining training load, developing conditioning sessions and utilizing training load to maintain physical fitness, and improve return from injury.

Keywords: training, monitoring; load, training; load, external; load, internal; rate of perceived effort

Buy Now

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

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

Abstract

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

Keywords: androgen steroids; protein building

Buy Now

US Military Dietary Protein Recommendations: A Simple But Often Confused Topic

Pasiakos SM, Sepowitz JJ, Deuster PA. 15(4). 89 - 95. (Journal Article)

Abstract

Military recommendations for dietary protein are based on the recommended dietary allowance (RDA) of 0.8g of protein per kilogram of body mass (BM) established by the Food and Nutrition Board, Institute of Medicine (IOM) of the National Academies. The RDA is likely adequate for most military personnel, particularly when activity levels are low and energy intake is sufficient to maintain a healthy body weight. However, military recommendations account for periods of increased metabolic demand during training and real-world operations, especially those that produce an energy deficit. Under those conditions, protein requirements are higher (1.5-2.0g/kg BM) in an attempt to attenuate the unavoidable loss of muscle mass that occurs during prolonged or repeated exposure to energy deficits. Whole foods are recommended as the primary method to consume more protein, although there are likely operational scenarios where whole foods are not available and consuming supplemental protein at effective, not excessive, doses (20-25g or 0.25-0.3g/kg BM per meal) is recommended. Despite these evidence-based, condition-specific recommendations, the necessity of protein supplements and the requirements and rationale for consuming higher-protein diets are often misunderstood, resulting in an overconsumption of dietary protein and unsubstantiated health-related concerns. This review will provide the basis of the US military dietary protein requirements and highlight common misconceptions associated with the amount and safety of protein in military diets.

Keywords: military; US Army Special Operations Forces; sustained operations; whey protien; supplement; military dietary reference intakes

Buy Now

Sleep As A Strategy For Optimizing Performance

Yarnell AM, Deuster PA. 16(1). 81 - 85. (Journal Article)

Abstract

Recovery is an essential component of maintaining, sustaining, and optimizing cognitive and physical performance during and after demanding training and strenuous missions. Getting sufficient amounts of rest and sleep is key to recovery. This article focuses on sleep and discusses (1) why getting sufficient sleep is important, (2) how to optimize sleep, and (3) tools available to help maximize sleep-related performance. Insufficient sleep negatively impacts safety and readiness through reduced cognitive function, more accidents, and increased military friendly-fire incidents. Sufficient sleep is linked to better cognitive performance outcomes, increased vigor, and better physical and athletic performance as well as improved emotional and social functioning. Because Special Operations missions do not always allow for optimal rest or sleep, the impact of reduced rest and sleep on readiness and mission success should be minimized through appropriate preparation and planning. Preparation includes periods of "banking" or extending sleep opportunities before periods of loss, monitoring sleep by using tools like actigraphy to measure sleep and activity, assessing mental effectiveness, exploiting strategic sleep opportunities, and consuming caffeine at recommended doses to reduce fatigue during periods of loss. Together, these efforts may decrease the impact of sleep loss on mission and performance.

Keywords: actigraphy; caffeine; cognitive; napping; readiness; sleep

Buy Now

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

Buckenmaier CC, Galloway KT, Polomano RC, Deuster PA. 16(2). 82 - 87. (Journal Article)

Abstract

The intense physical demands and dangerous operational environments common to Special Operations Forces (SOF) result in a variety of painful conditions, including musculoskeletal pain, headaches, and acute and chronic pain from combat injuries. Pain is a wellaccepted barrier to human performance. The Pain Management Task Force and the development of the Defense Veterans Pain Rating Scale (DVPRS) are discussed to provide a framework for changing the culture of pain management away from intensity of pain to interference with function and performance. The emergence of complementary and integrative pain management (CIM) practices is briefly reviewed as viable alternatives to the traditional reliance on opioids and other prescription medications. The SOF community can be the change agent for the DVPRS and CIM approaches to pain management, which will in the end serve to accelerate recovery and return SOF operators to duty faster and with an enhanced ability to perform with less pain.

Buy Now

Caffeine and Performance

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

Abstract

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

Keywords: caffeine; performance enhancement

Buy Now

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

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

Abstract

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

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

Buy Now

Author: Dewar C

Top

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

Meusnier J, Dewar C, Mavrovi E, Caremil F, Wey P, Martinez J. 16(3). 41 - 46. (Journal Article)

Abstract

Background: Junctional hemorrhage (i.e., between the trunk and limbs) are too proximal for a tourniquet and difficult to compress. These hemorrhages are responsible for 20% of preventable deaths by bleeding on the battlefield. The majority of these involve the groin area. Devices allowing a proximal compression for arterial axes have been recently developed. Objective: The purpose of this study was to compare the use of two junctional- tourniquet models, the Combat Ready Clamp (CRoC®) and the SAM® Junctional Tourniquet (SJT), in simulated out-of-hospital trauma care when tourniquets were ineffective to stop the arterial flow. Methods: During our clinical study, 84 healthy volunteers wearing battle dress performed a physical exercise to come approximate the operational context. The volunteers were randomly divided into two groups according to the device (the CRoC or SJT) used as supplement to a tourniquet self-applied to the root of the thigh. The primary study end point was the complete interruption of popliteal arterial flow, measured with Doppler auscultation. Time to effectiveness and subjective questionnaire data to evaluate the devices' application were also collected. Results: Junctional device effectiveness was almost 90% for both the CRoC and the SJT, and did not differ between them, either used with a tourniquet (ρ = .36) or alone (ρ = .71). The time to effectiveness of the SJT was significantly shorter than that of the CRoC (ρ = .029). Conclusion: The SJT and the CRoC were equally effective. The SJT was faster to apply and preferred by the users. Our study provides objective evidence to the French Tactical Casualty Care Committee for improving junctional hemorrhage treatment.

Keywords: junctional tourniquet; hemorrhage; groin; medical device; Combat Ready Clamp; SAM® Junctional Tourniquet

Buy Now

Author: DeZee KJ

Top

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

Wilson RL, DeZee KJ. 14(4). 59 - 69. (Journal Article)

Abstract

Background: Special Forces Medical Sergeants (SFMS) are trained to provide trauma and medical care in support of military operations and diplomatic missions throughout the world with indirect physician oversight. This study assessed their perceptions of the current program designed to sustain their medical skills. Methods: An Internet-based survey was developed using the constructs of the Theory of Reasoned Action/Planned Behavior and validated through survey best practices. Results: Of the 334 respondents, 92.8% had deployed at least once as an SFMS. Respondents reported spending 4 hours per week sustaining their medical skills and were highly confident that they could perform their duties on a no-notice deployment. On a 5-point, Likerttype response scale, SFMS felt that only slight change is needed to the Special Operations Medical Skills Sustainment Course (mean: 2.17; standard deviation [SD]: 1.05), while moderate change is needed to the Medical Proficiency Training (mean: 2.82; SD: 1.21) and nontrauma modules (mean: 3.02; SD: 1.22). Respondents desire a medical sustainment program that is provided by subject matter experts, involves actual patient care, incorporates new technology, uses hands-on simulation, and is always available. Conclusions: SFMS are challenged to sustain their medical skills in the current operational environment, and barriers to medical training should be minimized to facilitate sustainment training. Changes to the current medical sustainment program should incorporate operator-level perspectives to ensure acceptability and utility but must be balanced with organizational realities. Improving the medical sustainment program will prepare SFMS for the challenges of future missions.

Keywords: Special Forces Medical Sergeants; medical sustainment program; medical training

Buy Now

Author: Dial J

Top

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

Johnson D, Dial J, Ard J, Yourk T, Burke E, Paine C, Gegel B, Burgert J. 14(1). 79 - 85. (Journal Article)

Abstract

Introduction: The military recommends that a 500mL bolus of Hextend® be administered via an intravenous (IV) 18-gauge needle or via an intraosseous (IO) needle for patients in hypovolemic shock. Purposes: The purposes of this study were to compare the time of administration of Hextend and the hemodynamics of IV and IO routes in a Class II hemorrhage swine model. Methods: This was an experimental study using 27 swine. After 30% of their blood volume was exsanguinated, 500mL of Hextend was administered IV or IO, but not to the control group. Hemodynamic data were collected every 2 minutes until administration was complete. Results: Time for administration was not significant (p = .78). No significant differences existed between the IO and IV groups relative to hemodynamics (p > .05), but both were significantly different than the control group (p < .05). Conclusions: The IO route is an effective method of administering Hextend.

Keywords: hemorrhage; shock; Hextend®; hetastarch; battlefield

Buy Now

Author: Dial-Ward M

Top

Baseline Dissociation And Prospective Success In Special Forces Assessment And Selection

Morgan CA, Hazlett G, Dial-Ward M, Southwick SM. 09(1). 87 - 92. (Previously Published)
Previously Published in Psychiatry (Edgemont) 2008;5(7):52-57. Permission granted by Psychiatry 2008 to reproduce in the JSOM.

Abstract

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

Author: Diaz GY

Top

The Tactical Combat Casualty Care Casualty CardTCCC Guidelines - Proposed Change 1301

Kotwal RS, Butler FK, Montgomery HR, Brunstetter T, Diaz GY, Kirkpatrick JW, Summers NL, Shackelford S, 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.

Buy Now

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

Brunstetter T, Diaz GY, Wasner C, Hart S, Burrows S. 13(3). 26 - 28. (Journal Article)

Abstract

From 5% to 22% of all U.S. Department of Defense combat casualties between 2001 and 2010 suffered some form of ocular trauma. Ocular injuries have an inordinately dramatic impact on return to duty, retention, and reintegration; only 25% of warfighters with severe ocular trauma return to duty. After a traumatic ocular event, the likelihood of saving an eye and preserving vision depends on several factors, especially the treatment quality at the point of injury. Every major organization associated with combat casualty care (e.g., the U.S. Army Institute of Surgical Research, the Committee on Tactical Combat Casualty Care, and the Department of Defense/VA Vision Center of Excellence) emphasizes the importance of placing a rigid eye shield on known/suspected eye injuries at point of injury. On the battlefield, there is no better way to protect an injured eye from further damage than with an eye shield, but shields are not readily available in individual first aid kits. Therefore, it is highly recommended that each Service rapidly integrate at least one rigid eye shield into every individual first aid kit, making them immediately available to every warfighter.

Keywords: rigid eye shield; ocular trauma; ballistic eye protection; eye injuries; open globe injuries; first aid kit

Buy Now

Author: DiGeorge NW

Top

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

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

Abstract

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

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

Buy Now

Author: Dimond FC

Top

Results Of Vietnamese Acupuncture Seen At The Second Surgical Hospital

Rich NM, Dimond FC. 09(1). 102 - 104. (Previously Published)
Previously published in Military Medicine-October, 1967

Abstract

One of the rewards in the medical service in a foreign land is the exposure to exotic diseases and methods of therapy which are virtually unknown to many physicians in the western world. With the treatment of Vietnamese patients by medical personnel from the United States and other countries with a similar system of medical education, new experiences and challenges are presented daily. The use of acupuncture as a form of therapy is undoubtedly as unfamiliar to many physicians as it was to us. In addition to our treatment of American casualties at the Second Surgical Hospital in the Republic of Vietnam, we had the opportunity of treating some interesting problems in Vietnamese patients who had previously been treated with acupuncture. The majority of our own staff questioned, "What is acupuncture?"

Author: Dituro P

Top

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

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

Abstract

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