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Featured Articles

Fall 2013

Abdominal Aortic Tourniquet Controls Junctional Hemorrhage From a Gunshot Wound of the Axilla

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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

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

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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

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

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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

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

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Calvano CJ. 13(3). 29 - 30. (Journal Article)

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Design and Demonstration of a Battery-Less Fluid Warmer for Combat

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Ndao S, Jensen KF, Velmahos GC, King DR. 13(3). 31 - 36. (Journal Article)

Abstract

Background: Prehospital battlefield hypothermia remains an issue, with cold fluid resuscitation likely being a significant contributor. Currently, no prehospital battlefield technology exists to warm intravenous resuscitation fluids. Existing commercial fluid-warming technologies are either inadequate or unreliable or have an unacceptable weight and size, making them inappropriate for the austere combat environment. We propose the creation of a battery-less, flameless, portable, low- weight, small, chemically powered fluid warmer for the battlefield. Methods: A magnesium-based exothermic chemical reaction was used as the sole heating source. A low-weight, small insulated container was created to contain the reaction. The chemical reaction was manipulated to sustain fluid heating as long as required. Results: The exothermic reaction was used to boil a Fluorinert ™ liquid within an insulated container that heats resuscitation fluid passing through the heat exchanger. A working prototype device, 9 inches in length and 4 inches in diameter, was engineered and tested. Warming was maintained over a variety of clinically relevant flow rates. Conclusion: A chemically based, safe, battery-less, flameless, lightweight fluid warmer was created. This technology could represent a significant remote capability currently unavailable on the battlefield.

Keywords: trauma; bleeding; prehospital; resuscitation; warming; thermal

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MEDEVAC Use of Ketamine for Postintubation Transport

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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

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Digital Intubation: The Two-Fingered Solution to Securing an Airway

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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

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Blast Traumatic Brain Injury - What Do We Know?

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Rolan T. 13(3). 45 - 50. (Journal Article)

Abstract

Traumatic brain injury (TBI) is a significant problem in both the civilian and military worlds. Although much is understood about the effects of TBI, relatively few diagnostic or therapeutic modalities are available. Currently, TBI treatment is in a primitive phase and other than acute lifesaving interventions, is largely relegated to rehabilitation efforts. This article discusses known aspects of neuronal injury related to blast TBI, as well as a review of the current state of diagnostic and therapeutic interventions.

Keywords: blast traumatic brain injury; neuronal dysfunction

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Deployed Assessment and Management of mTBI Casualties

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Garfin B. 13(3). 51 - 55. (Journal Article)

Abstract

The wars in Afghanistan and Iraq have placed a spotlight on screening, evaluation, and treatment of mild traumatic brain injury, otherwise known as concussion. The author presents a mass casualty case in which a Ranger company medical section assessed and managed 30 Servicemembers (SM) diagnosed with concussion. Through the process of treating these Servicemembers, a consolidated checklist was created based on existing Department of Defense, United States Special Operations Command (USSOCOM), and United States Army Special Operations Command (USASOC) guidelines. During this and subsequent clinical encounters, utilization of this checklist resulted in efficient identification of concussed personnel, appropriate treatment, and documentation.

Keywords: traumatic brain injury; concussion

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Traumatic Brain Injury: Analysis of Functional Deficits and Posthospital Rehabilitation Outcomes

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Lewis FD, Horn GJ. 13(3). 56 - 61. (Journal Article)

Abstract

Background: Advances in emergency medicine, both in the field and in trauma centers, have dramatically increased survival rates of persons sustaining traumatic brain injury (TBI). However, these advances have come with the realization that many survivors are living with significant residual deficits in multiple areas of functioning, which make the resumption of a quality lifestyle extremely difficult. To this point, TBI has recently been characterized as a chronic disease. As with other chronic diseases, TBI is often causative of persistent disabling symptoms in multiple organ systems. Therefore, posthospital residential rehabilitation programs have emerged to treat these symptoms with the goal of helping these individuals regain function and live more productive and independent lives. Purpose: This study examined the nature and severity of residual deficits experienced by a group of 285 brain-injured individuals and evaluate the efficacy of posthospital residential rehabilitation programs in treating those deficits. Method: Participants consisted of 285 individuals who had sustained a TBI and, due to multiple residual deficits, were unable to care for themselves, necessitating admission to residential posthospital rehabilitation programs. All participants were evaluated at admission and discharge on the Mayo-Portland Adaptability Inventory-Version 4 (MPAI-4). The MPAI-4, developed specifically for persons with acquired brain injury, measures 29 areas of function often affected by TBI. Results: From the 29 skills evaluated, the 12 most often rated as causing the greatest interference with function were identified. Of these skills, the cognitive deficits including memory, attention/concentration, novel problem solving, and awareness of deficits were highly correlated with disruption in performing everyday societal roles. The impact of treatment for reducing the level of disability in these areas was statistically significant, t(284) = 17.43, p < .0001. Improvement was significant even for participants admitted more than 1 year postinjury, t(78) = 8.05, p < .0001. Conclusions: Skill deficits interfering with reintegration into home and community are highly interrelated and should be treated with the understanding that progress in one area may be dependent on change in another area. Cognitive skills including memory, attention/ concentration, novel problem solving, and awareness of deficits were highly correlated with measures of overall functional outcome. Posthospital programs using a multidisciplinary treatment approach achieved significant reduction in disability from program admission to discharge. The benefits of these programs were realized even for the most chronically-impaired participants.

Keywords: traumatic brain injury; Mayo-Portland Adaptability Inventory - Version 4; prehospital residential rehabilitation programs; acquired brain injury

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Cultural Self-Awareness as a Crucial Component of Military Cross-Cultural Competence

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Pappamihiel CJ. 13(3). 62 - 69. (Journal Article)

Abstract

The military forces in the United States represent a unique culture that includes many subcultures within their own military society. Acculturation into the military often deemphasizes the influence of personal narrative and thereby establishes the primacy of military culture over personal cultural influences. The authors make the argument that military personnel need to further develop an understanding and appreciation of personal cultural narrative as well as organizational culture. The increased integration of military personnel with interagency partners, along with cooperative efforts between relief organizations, and nongovernmental organizations in politically/economically unstable areas around the globe serves to make cross-cultural interaction unavoidable in the future. Military medical personnel are especially likely to interact with others who have culturally different values. These interactions can occur between organizations as easily as they can during patient care. They must be able to step outside of their military culture and develop cross-cultural competence that is grounded in cultural self-awareness. Without an appropriate level of cultural self-awareness, military and medical personnel run the risk of being unable to communicate across dissimilar cultures or worse, alienating key stakeholders in collaborative operations between military services, coalition partners, and nonmilitary organizations. It is the authors' contention that unless military personnel, especially those in the medical arena, are able to appropriately self-assess situations that are impacted by culture, both their own and the other personnel involved, the resulting cultural dissonance is more likely to derail any significant positive effect of such collaborations.

Keywords: military cultural sensitivity; cultural awareness in the Armed Forces; cultural self-awareness

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Cultural Competency and Patient-Centered Communication: A Study of an Isolated Outbreak of Urinary Tract Infections in Afghanistan

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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

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Preparing for Operations in a Resource-Depleted and/or Extended Evacuation Environment

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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

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

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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

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The Agitated Patient

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Goldstein S. 13(3). 87 - 91. (Journal Article)

Abstract

Caring for an agitated patient can be a daunting task for the tactical emergency medical support (TEMS) or Special Operations Forces (SOF) medic. The cause, degree, and duration of agitation can vary among such individuals. These patients create a high-stress and disruptive environment, needing numerous people involved to control. One agitated patient can disrupt an entire tactical team or casualty evacuation. The patient's history and physical examination can give important clues to the cause, thereby directing treatment and leading to a quick and safe resolution. The variety of treatments for the agitated patient are just as numerous as the causes and range from verbal deescalation to medications and physical restraint, all of which have a risk-benefit profile to consider.

Keywords: agitated patients; brain; TBI; hypoxia; hypoglycemia; hypothermia; delirium; ketamine; dissociative; combative; sedation

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Operator Training and TEMS Support: A Survey of Unit Leaders in Northern and Central California

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Young JB, Galante JM, Sena MJ. 13(3). 92 - 97. (Journal Article)

Abstract

Background: Members of Special Weapons and Tactics (SWAT) teams routinely work in high-risk tactical situations. Awareness of the benefit of Tactical Emergency Medical Support (TEMS) is increasing but not uniformly emphasized. Objectives: To characterize the current regional state of tactical medicine and identify potential barriers to more widespread implementation. Methods: A multiple-choice survey was administered to SWAT team leaders of 22 regional agencies in northern and central California. Questions focused on individual officer self-aid and buddy care training, the use and content of individual first aid kits (IFAKs), and the operational inclusion of a dedicated TEMS provider. Results: Respondents included city police (54%), local county sheriff (36%), state law enforcement (5%), and federal law enforcement (5%). Results showed that 100% of respondents thought it was "Very Important" for SWAT officers to understand the basics of self-aid and buddy care and to carry an IFAK, while only 71% of respondents indicated that team members actually carried an IFAK. In addition, 67% indicated that tourniquets were part of the IFAK, and 91% of surveyed team leaders thought it was "Very Important" for teams to have a trained medic available onsite at callouts or high-risk warrant searches. Also, 59% of teams used an organic TEMS element. Conclusion: The majority of SWAT team leaders recognize the benefit of basic Operator medical training and the importance of a TEMS program. Despite near 100% endorsement by unit-level leadership, a significant proportion of teams are lacking one of the key components including Operator IFAKs and/or tourniquets. Tactical team leaders, administrators, and providers should continue to promote adequate Operator training and equipment as well as formal TEMS support

Keywords: TEMS; tactical emergency medical support; SWAT; law enforcement; tactical medics

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Certified Tactical Paramedic: A Benchmark for Competency in Austere and Hostile Environments

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Clark JR. 13(3). 99 - 100. (Editorial)

Endovascular Resuscitation Techniques for Severe Hemorrhagic Shock and Traumatic Arrest in the Presurgical Setting

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Glassberg E, Nadler R, Dagan D. 13(3). 101 - 101. (Letter)

Rabies

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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."

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Sarcoidosis

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Sola CA, Trickett CV, Lehman KA. 13(3). 105 - 108. (Journal Article)

Abstract

An active duty male presents to your clinic with concerns of an increasing number of enlarging papules on his neck. How would you describe the morphology of these lesions? What questions should be included in your history? What would you include in your examination? What would you include in your differential diagnosis? What labs and/or tests would you order? This report discusses cutaneous sarcoidosis and its diagnosis and treatment.

Keywords: cutaneous sarcoidosis; sarcoidosis; papules; pseudofolliculitis barbae; erythema nodosum; lupus pernio

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I Remember Nothing More: A Doctor's Powerfully Moving Memoir of Her Struggle to Save the Children of the Warsaw Ghetto

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Farr W. 13(3). 109 - 109. (Book Review)

Abstract

Adina Blady Szwajger. I Remember Nothing More. New York, NY: Simon and Schuster; 1988.
205 pages. ISBN 0-671-76038-6.

Who Owns Battlefield Medicine?

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Kragh JF. 13(3). 112 - 112. (Interview)

Abstract

Bob Mabry on Being SOMA President and Being at Black Hawk Down