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Featured Articles

Summer 2009

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

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Hammesfahr R. 09(3). 1 - 6. (Journal Article)

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

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Wallace GR. 09(3). 7 - 13. (Journal Article)

Abstract

The North Atlantic Treaty Organization (NATO) Special Operations Forces (SOF) Coordination Center (NSCC) is a new NATO memorandum of understanding (MOU) organization that is effecting rapid advancement in NATO's ability to efficiently utilize SOF at the strategic/operational level. The NSCC's lines of development in communications information systems (CIS), education, training, and real life support to the International Security Assistance Force (ISAF) SOF and the development of pivotal documents to develop and mature NATO SOF doctrine and policy are all occurring at lightning speed. Within this process of establishing a SOF community in NATO, the author's focus is the development of previously non-existent NATO SOF medical doctrine and policy. Many barriers to change lie ahead, but through unity of effort, we will ensure certainty of our actions.

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

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Risk G, Hetzler MR. 09(3). 14 - 21. (Journal Article)

Abstract

Current operational theaters have developed to where medical evacuation and surgical assets are accessible in times comparable to the United States. While this has been an essential tool in achieving the best survivability on a battlefield in our history, the by-product of this experience is a recognized shortcoming in current protocols and capabilities of Special Forces medics for prolonged care. The purpose of this article is to provide a theory of care, identify training and support requirements, and to capitalize on current successful resuscitation theories in developing a more efficient and realistic capability under the worst conditions.

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

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

Abstract

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

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

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Ballard SR, Enzenauer RW, O'Donnell T, Fleming JC, Risk G, Waite AN. 09(3). 26 - 32. (Journal Article)

Abstract

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

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

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Baldwin TM. 09(3). 33 - 43. (Journal Article)

Abstract

Tinnitus is the phantom perception of sound in the absence of overt acoustic stimulation. Its impact on the military population is alarming. Annually, tinnitus is the most prevalent disability among new cases added to the Veterans Affairs numbers. Also, it is currently the most common disability from the War on Terror. Conventional medical treatments for tinnitus are well documented, but prove to be unsatisfying. Hyperbaric oxygen (HBO2) therapy may improve tinnitus, but the significance of the level of improvement is not clear. There is a case for large randomized trials of high methodological rigor in order to define the true extent of the benefit with the administration of HBO2 therapy for tinnitus.

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

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

Abstract

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

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

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

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

Abstract

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

Should We Teach Every Soldier How To Start An Iv?

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Mabry RL, Cuenca PJ. 09(3). 64 - 66. (Previously Published)

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

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

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Pietrzak RH, Johnson DC, Goldstein MB, Malley JC, Southwick SM. 09(3). 67 - 73. (Previously Published)

Previously Published in Depression and Anxiety 0 : 17 (2009). Permission granted to republish in the JSOM.

Abstract

Background: A number of studies have examined the prevalence and correlates of posttraumatic stress disorder (PTSD), depression, and related psychiatric conditions in Soldiers returning from Operations Enduring Freedom and Iraqi Freedom (OEF/OIF), but none have examined whether factors such as psychological resilience and social support may protect against these conditions in this population. Methods:Atotal of 272 predominantly older reserve/National Guard OEF/OIF veterans completed a mail survey assessing traumatic stress and depressive symptoms, resilience, and social support. Results: Resilience scores in the full sample were comparable to those observed in civilian outpatient primary-care patients. Respondents with PTSD, however, scored significantly lower on this measure and on measures of unit support and postdeployment social support. Ahierarchical regression analysis in the full sample suggested that resilience (specifically, increased personal control and positive acceptance of change) and postdeployment social support were negatively associated with traumatic stress and depressive symptoms, even after adjusting for demographic characteristics and combat exposure. Conclusions: These results suggest that interventions to bolster psychological resilience and postdeployment social support may help reduce the severity of traumatic stress and depressive symptoms in OEF/OIF veterans.

Psychosocial Buffers Of Traumatic Stress, Depressive Symptoms, And Psychosocial Difficulties In Veterans Of Operations Enduring Freedom And Iraqi Freedom: The Role Of Resilience, Unit Support, And Postdeployment Social Support

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Pietrzak RH, Johnson DC, Goldstein MB, Malley JC, Rivers AJ, Morgan CA, Southwick SM. 09(3). 74 - 78. (Previously Published)

Previously published in the Journal ofAffective Disorders, (2009), doi:10.1016/j.jad.2009.04.015. Permission granted to republish in the JSOM.

Abstract

Background: Little research has examined the role of protective factors such as psychological resilience, unit support, and postdeployment social support in buffering against PTSD and depressive symptoms, and psychosocial difficulties in veterans of Operations Enduring Freedom (OEF) and Iraqi Freedom (OIF). Materials and Methods:Atotal of 272 OEF/OIF veterans completed a survey containing PTSD and depression screening measures, and questionnaires assessing resilience, social support, and psychosocial functioning. Results: Lower unit support and postdeployment social support were associated with increased PTSD and depressive symptoms, and decreased resilience and psychosocial functioning. Path analyses suggested that resilience fully mediated the association between unit support and PTSD and depressive symptoms, and that postdeployment social support partially mediated the association between PTSD and depressive symptoms and psychosocial functioning. Limitations: Generalizability of results is limited by the relatively low response rate and predominantly older and reserve/National Guard sample. Conclusions: These results suggest that interventions designed to bolster unit support, resilience, and postdeployment support may help protect against traumatic stress and depressive symptoms, and improve psychosocial functioning in veterans.

Editorial Comment on "Psychological Resilience and Postdeployment Social Support Protect Against Traumatic Stress and Depressive Symptoms in Soldiers Returning from Operations Enduring Freedom and Iraqi Freedom"

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Myatt CA, Johnson DC. 09(3). 79 - 79. (Editorial)

Editorial Comment On "psychsocial Buffers Of Traumatic Stress, Depressive Symptoms, And Psychosocial Difficulties In Veterans Of Operations Enduring Freedom And Iraqi Freedom: The Role Of Resilience, Unit Support, And Post-Deployment Social Support"

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Myatt CA, Johnson DC. 09(3). 80 - 80. (Editorial)