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Featured Articles

Winter 2012

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

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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

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

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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.

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Global Health Language and Culture Competency

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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.

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

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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

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

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Jenkins CM. 12(4). 24 - 27. (Journal Article)

Abstract

Biofeedback assisted self-regulation training can be an effective treatment for post-concussion headaches. The following is an example of using biofeedback assisted self-regulation training as an intervention to treat posttrauma headaches in a Special Operations Forces (SOF) support soldier. This Soldier was a 23-year-old male who had suffered a concussion while off duty four months earlier and continued to experience headache. Threemodality biofeedback (temperature, surface electromyogram and skin conduction) was used to help the patient learn to self-regulate and control his headaches. This was accomplished over four visits over two weeks. This was a compressed timeline to allow him to deploy with his unit. This form of treatment can be a viable nonmedication based option for addressing post concussion headaches for deploying Soldiers.

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Biometrics in Support of Special Forces Medical Operations

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Kershner MR. 12(4). 29 - 32. (Journal Article)

Abstract

Recommendations on ways in which the ODA can leverage biometrics in medical operations to improve their security, improve relations with indigenous personnel, and contribute to the larger theater biometrics program.

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

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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

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Addressing Maternal Healthcare Needs in the Counterinsurgency Environment

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Lang G, Lang C. 12(4). 39 - 44. (Journal Article)

Abstract

All pregnant women are at risk of obstetric complications, most of which occur during labor and delivery among women with no previously identified risk factors. More than 95 percent of these deaths occur in developing countries. In sub-Saharan Africa, a region of the world currently experiencing significant humanitarian crises, the lifetime risk of maternal death is one in 30 whereas the lifetime risk in developed countries is one in 2,800.1 The majority of maternal deaths from obstetric complications are due to hemorrhage, eclampsia, sepsis, or obstructed labor, each of which is treatable. Emergency obstetric care is critical to reducing maternal death and disability. SOF medical personnel supporting counterinsurgency (COIN) operations may find themselves in situations where no legitimate agencies are available to provide maternal healthcare. Similarly, SOF medical personnel should be prepared to assist in rebuilding infrastructure and basic services to include the provision for maternal health. This article provides an overview of maternal health in underdeveloped countries; the importance of addressing the unique healthcare needs of women during COIN operations; and how the employment of Female Treatment Teams (FTT) can assist in meeting these needs. A subsequent article will review the basics of prenatal care and life-saving emergency obstetric care, and discusses the essential information and skills that should be taught in a MEDSEM covering maternal healthcare.

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

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Mueller G, Hunt B, Wall V, Rush R, Moloff A, Schoeff J, Wedmore I, Schmid J, LaPorta AJ. 12(4). 45 - 53. (Journal Article)

Abstract

The effects of stress induced cortisol on learning and memory is well documented in the literature.1-3 Memory and learning are enhanced at low levels while high levels are detrimental. Repetitive training in stressful situations enables management of the stress response4 as demonstrated by the high intensity training military members undergo to prepare for tactical situations. Appropriate management of one's stress response is critical in the medical field, as the negative effects of stress can potentially hinder life-saving procedures and treatments. This also applies to physicians-in-training as they learn and practice triage, emergency medicine, and surgical skills prior to graduation. Rocky Vista University's Military Medicine Honor's Track (MMHT) held a week long high-intensity emergency medicine and surgical Intensive Skills Week (ISW), facilitated by military and university physicians, to advance students' skills and maximize training using the Human Worn Partial Surgical Task Simulator (Cut Suit). The short-term goal of the ISW was to overcome negative stress responses to increase confidence, technical and non-technical knowledge, and skill in surgery and emergency medicine in an effort to improve performance as third-year medical students. The long-term goal was to enhance performance and proficiency in residency and future medical practice. The metrics for the short-term goals were the focus of this pilot study. Results show an increase in confidence and decrease in perceived stress as well as statistically significant improvements in technical and non-technical skills and surgical instrumentation knowledge throughout the week. There is a correlative benefit to physician and non-physician military personnel, especially Special Operations Forces (SOF) medical personnel, from developing and implementing similar training programs when live tissue or cadaver models are unavailable or unfeasible.

Keywords: stress control; medical student; enhanced learning scenario; high intensisty; military medicine

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Resourcing Interventions Enhance Psychology Support Capabilities in Special Operations Forces

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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)

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War Time Medicine on a Peace Time Mission

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Reynolds S, Mclemore AN, Squires A. 12(4). 60 - 71. (Journal Article)

Abstract

As we realized the MEDEVAC from JTF-B was not going to happen, the words of instructors from the Joint Special Operations Medical Training Center (JSOMTC) echoed through my head, "Men, pay attention to this. There will be a day when you, as Deltas, will have to sustain a patient for hours, possibly days; this is what separates you from any other medical professional in the military, so shut up and stay awake." We had heard those words every time we started a new section of Special Forces Medical Sergeants (SFMS) course. Now those words were staring right back at us in the form of the patient's friends and family. We looked at our patient in the back of that beat up truck and knew we could keep our patient alive. We had the knowledge and the equipment; we just didn't know how much longer we would have to sustain him.

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Combat Ready Clamp Medic Technique

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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

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USSOCOM TCCC CASEVAC Set Program A Retrospective and Overview

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Gilpin J. 12(4). 79 - 85. (Journal Article)

Abstract

The United States Special Operations Command (USSOCOM) Tactical Combat Casualty Care (TCCC) Casualty Evacuation (CASEVAC) Set Program was initiated in 2006 as a three-step effort. The initial effort was to develop an improved Individual First Aid Kit (IFAK); this was followed by the development of a Medic bag and culminated with the CASEVAC Set. The intent of the Program is both standardizing the medical load out across SOF components and expanding the skill set of Special Operations Forces (SOF) medical practitioners by providing equipment and training outside the normal parameters of many units. Even though the Set is currently being fielded to a variety of units, there are still personnel unaware of the Set and its capabilities. The goal of this article is to increase awareness of the existence of the program and to promote thought/discussion regarding the expansion of the capabilities of the Advanced Tactical Practitioner (ATP) beyond traditional medical skills. This program is best understood by first looking back to where it originated, and then examining where it is at present.

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Redefining Technical Rescue and Casualty Care for SOF: Part 1

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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.

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