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Featured Articles

Winter 2015

Hypolipidemia in a Special Operations Candidate: Case Report and Review of the Literature

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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

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

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

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Testing Tourniquet Use in a Manikin Model: Two Improvised Techniques

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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

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

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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

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Comprehensive Performance Nutrition for Special Operations Forces

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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

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Evaluating Alternatives to Traditional Cotton Laparotomy Sponges for Blood Absorption in the Austere and Mobile Surgical Environment

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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

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OK, Doc . . . What Do I Really Have? Posttraumatic Stress Disorder Versus Traumatic Brain Injury

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Figueroa XA, Wright JK. 15(4). 59 - 66. (Journal Article)

Abstract

The authors review the diagnostic overlap that exists between posttraumatic stress disorder (PTSD) and traumatic brain injury (TBI). Achieving the correct diagnosis is much more difficult and the potential to inappropriately treat patients is greater than most physicians realize. The need to properly diagnose and select appropriate treatment strategies is essential, especially with TBI cases. A number of new and experimental therapies are being used to treat PTSD effectively and reverse the neurological sequelae of TBI, potentially returning to active duty Servicemembers who are undergoing a medical review board.

Keywords: posttraumatic stress disorder; traumatic brain injury

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Garrison Clinical Setting Inadequate for Maintenance of Procedural Skills for Emergency Medicine Physicians: A Cross-Sectional Study

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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

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

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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

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Fever and Thrombocytopenia in a Returning Soldier

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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

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Providers Face Challenges Maintaining Deployment-Ready Skills at Garrison Hospitals

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Schauer SG, Varney SM. 15(4). 79 - 80. (Editorial)

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

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

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

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Vokoun ES. 15(4). 82 - 82. (Letter)

Taser and Conducted Energy Weapons

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LeClair TG, Meriano T. 15(4). 83 - 88. (Journal Article)

Keywords: taser; conducted energy weapons

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US Military Dietary Protein Recommendations: A Simple But Often Confused Topic

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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

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Crimean-Congo Hemorrhagic Fever

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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

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Middle East Respiratory Syndrome

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Shishido AA, Letizia A. 15(4). 99 - 101. (Journal Article)

Abstract

Middle East respiratory syndrome (MERS) emerged in the Arabian Peninsula in 2012, and subsequently spread to other countries in Europe and Asia, and to the United States. As of August 2015, the disease has infected 1,400 patients, of whom 500 have died, yielding a 36% mortality rate. The exact mode of transmission is unknown and there are no proven treatments. While the overall case rate for MERS has been low, its presence in countries that house US troops, unknown mode of transmission, and high mortality rate make it a significant health concern among US military personnel.

Keywords: Middle East Respiratory Syndrome; Coronavirus; epidemiology; clinical presentation

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Injuries and Footwear (Part 1): Athletic Shoe History and Injuries in Relation to Foot Arch Height and Training in Boots

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Knapik JJ, Pope R, Orr R, Grier T. 15(4). 102 - 108. (Journal Article)

Abstract

This article traces the history of the athletic shoe, examines whether selecting running shoes based on foot arch height influences injuries, and examines historical data on injury rates when physical training (PT) is performed in boots versus running shoes. In the 1980s and into the 2000s, running shoe companies were advertising specialized shoes with "motion control," "stability," and "cushioning," designed for individuals with low, normal, and high arches, respectively. Despite marketing claims that these shoes would reduce injury rates, coordinated studies in Army, Air Force, and Marine Corps basic training showed that assigning or selecting shoes on this basis had no effect on injury rates. Consistent with this finding, biomechanical studies have shown that the relationships between arch height, foot joint mobility, and rear-foot motion are complex, variable, and frequently not as strong as often assumed. In 1982, the US Army switched from PT in boots to PT in running shoes because of the belief that boots were causing injuries and that running shoes would reduce injury rates. However, a historical comparison of injury rates before and after the switch to running shoes showed virtually no difference in injury risk between the two periods. It is not clear at this point if the type of footwear effects injury incidence.

Keywords: injury, foot; shoe, athletic; physical training

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Real-World Experience With Three Point-of-Care Blood Analyzers in Deployed Environments

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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

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Recovery of Bacteria and Fungi From a Leg Wound

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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

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Application of Medical Intelligence Prep of the Environment: A Review of Operational Vignettes

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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

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Deconstructing the Definition of Prolonged Field Care

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Keenan S. 15(4). 125 - 125. (Journal Article)

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Vietnam 1968-1969: A Battalion Surgeon's Journal

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Farr WD. 15(4). 126 - 126. (Book Review)

Abstract

Holley, Byron E. Vietnam 1968-1969. A Battalion Surgeon's Journal.
New York: Ivy Books, 1993. 211 pages. ISBN-10: 0804109346/ISBN-13: 978-0804109345.

"Follow Admiral William Halsey's advice: Look around and see what needs to be done. Then do it."

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Kragh JF. 15(4). 130 - 132. (Interview)

Abstract

-Frank Butler on serving the operational medicine community

The Continuing Threat of Intentional Mass Casualty Events in the U.S.

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Fabbri WP. 15(4). 142 - 145. (Journal Article)

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Military History of Increasing Survival: The U.S. Military Experience with Tourniquets and Hemostatic Dressings in the Afghanistan and Iraq Conflicts

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Butler FK. 15(4). 149 - 152. (Journal Article)

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Hemorrhage Control Devices: Tourniquets and Hemostatic Dressings

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Holcomb JB, Butler FK, Rhee P. 15(4). 153 - 156. (Journal Article)

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Intentional Mass Casualty Events: Implications for Prehospital Emergency Medical Services Systems

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Levy MJ. 15(4). 157 - 159. (Journal Article)

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Integrated Education of All Responders

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McSwain NE. 15(4). 160 - 162. (Journal Article)

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TCCC Updates: Translating Military Advances in Exdternal Hemorrhage Control to Law Enforcement

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Butler FK. 15(4). 167 - 174. (Classical Conference)

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

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