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Featured Articles

Fall 2012

Omega-3 Fatty Acid Ingestion as a TBI Prophylactic

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

Abstract

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

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

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Campbell BH, Alderman SM. 12(3). 8 - 13. (Journal Article)

Abstract

Background: Selection criteria for Special Operations Forces (SOF) physicians are often unclear to potential candidates without prior SOF experience. To date, no published career resource exists to guide the careers of physicians interested in becoming a SOF surgeon. Using a survey tool, desirable characteristics and personal attributes were identified that can be used to inform candidate career decisions and better prepare them for a future position in Special Operations. Methods: A descriptive, cross-sectional survey instrument was developed and distributed to current Army SOF Command Surgeons for further distribution to subordinate surgeons. Results were analyzed as a cohort and by subordinate command. Results: Respondents consisted of current SOF Surgeons. Uniformly, the individual characteristics most strongly desired are professionalism, being a team player, and leadership. Possessing or obtaining Airborne and Flight Surgeon qualifications prior to consideration for a surgeon position was highly desired. Residency training within Family Medicine or Emergency Medicine constituted the vast majority of specialty preference. Conclusions: Understanding which characteristics and attributes are desirable to current surgeons and commanders can aid physicians interested in SOF surgeon positions. Using this study and future studies can guide career planning and foster the selection of ideally trained physicians who will operate at the tip of the spear. The views expressed are those of the author(s) and do not reflect the official policy of the Department of the Army, the Department of Defense or the U.S. Government.

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

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Faudree LK. 12(3). 14 - 18. (Journal Article)

Abstract

On 3 October 2001, the first chalk of Night Stalkers left Campbell Army Airfield enroute to Uzbekistan in support of what would become our nation's longest war. The vast majority of Soldiers were untested in war and would quickly have the opportunity to meet with the enemies of our nation in close combat. The two Special Operations Task Forces (TF), TF Dagger to the north in Uzbekistan and TF Sword in the south (aboard the USS Kitty Hawk) were our nation's first strike options against Al Qaeda and Taliban forces in Afghanistan. Due to the inherent nature of forced entry operations (restrictive terrain, lack of medical infrastructure, etc.) TF Dagger and TF Sword utilized 160th Special Operations Aviation Regiment (Airborne) [SOAR (A)] rotary wing aircraft solely for the Casualty Evacuation (CASEVAC) operations during the first months of Operation ENDURING FREEDOM.

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Detection of Increased Intracranial Pressure by Ultrasound

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Hightower S, Chin EJ, Heiner JD. 12(3). 19 - 22. (Journal Article)

Abstract

Increases in intracranial pressure (ICP) may damage the brain by compression of its structures or restriction of its blood flow, and medical providers my encounter elevated ICP in conventional and non-conventional medical settings. Early identification of elevated ICP is critical to ensuring timely and appropriate management. However, few diagnostic methods are available for detecting increased ICP in an acutely ill patient, which can be performed quickly and noninvasively at the bedside. The optic nerve sheath is a continuation of the dura mater of the central nervous system and can be viewed by ocular ultrasound. Pressure changes within the intracranial cavity affect the diameter of the optic nerve sheath. Data acquired from multiple clinical settings suggest that millimetric increases in the optic nerve sheath diameter detected via ocular ultrasound correlate with increasing levels of ICP. In this review, we discuss the use of ocular ultrasound to evaluate for the presence of elevated ICP via assessment of optic nerve sheath diameter, and describe critical aspects of this valuable diagnostic procedure. Ultrasound is increasingly becoming a medical fixture in the modern battlefield where other diagnostic modalities can be unavailable or impractical to employ. As Special Forces and other austere medical providers become increasingly familiar with ultrasound, ocular ultrasound for the assessment of increased intracranial pressure may help optimize their ability to provide the most effective medical management for their patients.

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

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

Abstract

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

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Unforeseen Risk: Leptospirosis and the U.S. Special Operations Community

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Grambusch DM, Hoedebecke KL. 12(3). 36 - 42. (Journal Article)

Abstract

Leptospirosis is a bacterial zoonosis with worldwide distribution and is potentially lethal to those infected if left untreated. Due to the global posture of the U.S. Special Operations community, there is a seemingly perfect overlap of the regions in which they deploy and areas with concurrent endemic leptospirosis infection. Furthermore, Special Operations Forces (SOF) personel are known for working by, with, and through the host nation defense force, who tend to be commonly affected and often serve as a reservoir for this infection. Other risk factors including the usage of infected military working dogs, contaminated training sites, and certain recreational activities associated with water increase the danger of exposure for this cohort. Due to this increased risk of leptospirosis by U.S. Special Operations service members, medical providers within this community must understand and utilize proper preventive medicine, prophylaxis, early detection, diagnosis, and treatment for this potentially lethal infection.

Keywords: leptospirosis; operational medicine; adventure racing; zoonosis; zoonotic disease; spirochetes; working dogs; Special Operations

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

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Kechijian D, Rush SC. 12(3). 43 - 49. (Journal Article)

Abstract

Progressive injury prevention and physical preparation programs are needed in military special operations to optimize mission success and Operator quality of life and longevity. While physical risk is inherent in Special Operations, non-traumatic injuries resulting from overuse, poor biomechanics, and arbitrary exercise selection can be alleviated with proper medical care and patient education. An integrated approach to physical readiness that recognizes the continuity between rehabilitation and performance training is advocated to ensure that physiological adaptations do not come at the expense of orthopedic health or movement proficiency. Movement quality should be regularly evaluated and enforced throughout the training process to minimize preventable injuries and avoid undermining previous rehabilitative care. While fitness and proper movement are not substitutes for Operator specific tasks, they are foundational to many tactically-relevant skills. In light of how much is at stake, sports medicine care in the military, especially special operations, should parallel that which is practiced in professional and collegiate athletics.

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

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

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

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Reese JM, Fisher SD, Robbins DP. 12(3). 52 - 56. (Journal Article)

Abstract

Rhabdomyolysis is a common syndrome that can range from asymptomatic to a severe life-threatening condition. It is the result of acute muscle fiber necrosis leading to cell lysis and subsequent transfer of those byproducts into the circulatory system. The most significant constituent of these byproducts is myoglobin, which has been known to cause renal failure in 10-50% of patients that develop rhabdomyolysis. In addition, the electrolytes contained within these cells are leached into the blood stream, which can lead to significant electrolyte abnormalities. The etiology of rhabdomyolysis is broad and includes inherited diseases, drugs, toxins, muscle compression or overexertion, infections, and more. This syndrome may carry a mortality rate ranging from 7-80%. We describe five patients assigned to various companies within 160th Special Operations Aviation Regiment (Airborne) that developed exertional rhabdomyolysis of the bilateral upper extremities between June 2011 and January 2012. In this case series we will describe the events leading up to the diagnosis, lack of risk factors or family history, diagnostic criteria, treatment, and future concerns related to the condition.

Keywords: rhabdomyolysis; acute renal failure; myoglobinuria; creatinine kinase; overexertion exercise

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Effect of Hetastarch Bolus in Trauma Patients Requiring Emergency Surgery

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Ryan ML, Ogilvie MP, Pereira BM, Gomez-Rodriguez JC, Livingstone AS, Proctor KG. 12(3). 57 - 67. (Journal Article)

Abstract

If blood products are not available, current military guidelines recommend a hetastarch bolus (HEX, Hextend ™ 6% hetastarch in lactated electrolyte buffer, www. hospira.com) for initial treatment of hypovolemic shock in the field. We previously reported that a HEX bolus plus standard of care (SOC = crystalloid plus blood products) was safe during initial resuscitation in 1714 trauma patients. This study tests the hypothesis that HEX+SOC is more effective than SOC alone for volume expansion in trauma patients requiring urgent operation. Methods: From July 2009 to August 2010, the records from all adults who required emergency surgery within 4 hours of admission were screened for a retrospective cohort observational study. Burns, and those with primary neurosurgical or orthopedic indications, were excluded. The study population was comprised of 281 patients with blunt (n = 72) or penetrating (n = 209) trauma; 141 received SOC and 140 received SOC+HEX in the emergency room only (ER, n = 81) or the ER and operating room (OR, n = 59). Each case was reviewed with waiver of consent. Results: After penetrating injury, with SOC, the injury severity score was 17 and mortality was 12%; the corresponding values in the HEX(ER) and HEX(OR) groups were 19-21 and 8%, but these apparent differences did not reach significance. However, in patients receiving HEX, initial heart rate was higher, base deficit was lower, and hematocrit was lower (consistent with relative hypovolemia), even though blood product requirements were reduced, and urine output was greater (all ρ < 0.05). These effects were absent in patients with blunt trauma. Platelet consumption was higher with HEX after either penetrating (ρ = 0.004) or blunt trauma (ρ = 0.045), but coagulation tests were unchanged. Conclusion: HEX is safe for initial resuscitation in young patients who required urgent operation after penetrating trauma, but there was no apparent effect after blunt trauma. A bolus of HEX reduced transfusion requirements without inducing coagulopathy or causing renal dysfunction, but a randomized controlled trial is necessary to eliminate the possibility of selection bias.

Keywords: hydroxyethyl starch; Hextend®; trauma resuscitation; colloid; Tactical Combat Casualty Care; first responder; field medic

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

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

Abstract

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

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

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

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

Abstract

Timothy Floyd, MD
Artbook Press, 2010.

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

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

Abstract

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