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Featured Articles

Summer 2016

A Herpes Zoster Outbreak on the Sinai Peninsula

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Acierto D, Savioli S, Studer NM. 16(2). 1 - 4. (Case Reports)

Abstract

Background: Infection with the varicella zoster virus, a type of herpesvirus, causes chickenpox in children and herpes zoster (commonly known as shingles) in adults. Case Presentation: Two 20-year-old male Soldiers returned from an outpost with a rash consistent with herpes zoster. Two other Soldiers with whom they were in close had had a similar rash 2 weeks earlier, which had since resolved at the time of initial presentation. Management and Outcome: Both Soldiers were started on an antiviral regimen and released to duty. They reported progressive relief, but both Soldiers redeployed to the United States before complete resolution. Conclusion: Herpes zoster cannot be transmitted from person to person. It is rare for young healthy people to become afflicted with it, let alone for two people to get it at the same time, which initially raised concern for infections mimicking herpes zoster. However, herpes zoster may be triggered by acute stress. Providers in deployed areas should consider the diagnosis in personnel who have had childhood varicella zoster infection (chickenpox).

Keywords: shingles; herpes zoster; operational medicine; Sinai

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Early, Prehospital Activation of the Walking Blood Bank Based on Mechanism of Injury Improves Time to Fresh Whole Blood Transfusion

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Bassett AK, Auten JD, Zieber TJ, Lunceford NL. 16(2). 5 - 8. (Journal Article)

Abstract

Balanced component therapy (BCT) remains the mainstay in trauma resuscitation of the critically battle injured. In austere medical environments, access to packed red blood cells, apheresis platelets, and fresh frozen plasma is often limited. Transfusion of warm, fresh whole blood (FWB) has been used to augment limited access to full BCT in these settings. The main limitation of FWB is that it is not readily available for transfusion on casualty arrival. This small case series evaluates the impact early, mechanism-of-injury (MOI)-based, preactivation of the walking blood bank has on time to transfusion. We report an average time of 18 minutes to FWB transfusion from patient arrival. Early activation of the walking blood bank based on prehospital MOI may further reduce the time to FWB transfusion.

Keywords: blood bank, walking; blood, fresh whole; therapy, blood component

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Case Report of an Anthrax Presentation Relevant to Special Operations Medicine

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Winkler S, Enzenauer RW, Karesh JW, Pasteur N, Eisnor DL, Painter RB, Calvano CJ. 16(2). 9 - 12. (Journal Article)

Abstract

Special Operations Forces (SOF) medical personnel function worldwide in environments where endemic anthrax (caused by Bacillus anthracis infection) may present in one of three forms: cutaneous, pulmonary, or gastrointestinal. This report presents a rare periocular anthrax case from Haiti to emphasize the need for heightened diagnostic suspicion of unusual lesions likely to be encountered in SOF theaters.

Keywords: periocular anthrax; Bacillus anthracis; ophthalmology; diagnostics

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Preliminary Measures of Instructor Learning in Teaching Junctional Tourniquet Users

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Kragh JF, Aden JK, Shackelford S, Dubick MA. 16(2). 13 - 15. (Journal Article)

Abstract

Background: The objective of the present study was to assess the effect of instructor learning on student performance in use of junctional tourniquets. Methods: From a convenience sample of data available after another study, we used a manikin for assessment of control of bleeding from a right groin gunshot wound. Blood loss was measured by the instructor while training users. The data set represented a group of 30 persons taught one at a time. The first measure was a plot of mean blood loss volumes for the sequential users. The second measure was a plot of the cumulative sum (CUSUM) of mean blood loss (BL) volumes for users. Results: Mean blood loss trended down as the instructor gained experience with each newly instructed user. User performance continually improved as the instructor gained more experience with teaching. No plateau effect was observed within the 30 users. The CUSUM plot illustrated a turning point or cusp at the seventh user. The prior portion of the plot (users 1-7) had the greatest improvement; performance did not improve as much thereafter. The improvement after the seventh user was the only change detected in the instructor's trend of performance. Conclusions: The instructor's teaching experience appeared to directly affect user performance; in a model of junctional hemorrhage, the volume of blood loss from the manikin during junctional tourniquet placement was a useful metric of instructor learning. The CUSUM technique detected a small but meaningful change in trend where the instructor learning curve was greatest while working with the first seven users.

Keywords: first aid; damage control; hemorrhage, prevention and control; shock; tourniquet; resuscitation; emergency medical services

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Tourniquet Effectiveness When Placed Over the Joint Service Lightweight Integrated Suit Technology

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Peponis T, Ramly E, Roth KA, King DR. 16(2). 17 - 19. (Journal Article)

Abstract

Background: Chemical, biological, radiological, and nuclear threats (CBRNs) are uncommon; however, Special Operations Forces (SOF) are likely at the highest risk for tactical exposure. In the event of exposure, SOF will rely on the Joint Service Lightweight Integrated Suit Technology (JSLIST) for survival. Doctrine dictates that a tourniquet should be applied over the JSLIST after a severe limb injury with hemorrhage. There is no evidence in the literature that the Combat Application Tourniquet (C-A-T), which is currently the most widely available tourniquet on the battlefield, can effectively occlude arterial blood flow when applied over the JSLIST. We hypothesized that C-A-T application over the JSLIST would be ineffective at occluding arterial blood flow in the lower extremity. Materials and Methods: Following institutional review board approval, 20 healthy volunteers were recruited to participate. All volunteers wore the G3 Combat Pant and they donned the JSLIST. First, an operating room pneumatic tourniquet (gold standard) was applied in the proximal thigh and inflated to 300mmHg. Distal arterial interrogation was performed by examination of distal pulses and noninvasive arterial plethysmography wave-form analysis. After a 1-hour recovery period, the C-A-T was applied and tightened. A double routing technique was used, with three 180° turns of the windlass. The same distal interrogation followed. Half of the volunteers had the pneumatic tourniquet applied first, and the other half had the C-A-T applied first. Results: All volunteers had palpable pulses at baseline despite a wide range in volunteer body mass index. Distal pulses were absent in all volunteers following inflation of the pneumatic tourniquet as well as tightening of the C-A-T. The observed difference between the mean amplitude of plethysmographic waveforms was not different. Conclusion: The C-A-T effectively occludes arterial flow in the lower extremity, even when applied over the JSLIST. This finding supports existing military doctrine for tourniquet application over the JSLIST in the nonpermissive CBRN environment to control extremity exsanguination.

Keywords: tourniquet; hemorrhage; Combat Application Tourniquet; Joint Service Lightweight Integrated Suit Technology

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Preliminary Comparison of Pneumatic Models of Tourniquet for Prehospital Control of Limb Bleeding in a Manikin Model

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Gibson R, Aden JK, Dubick MA, Kragh JF. 16(2). 21 - 27. (Journal Article)

Abstract

Background: Emergency tourniquet use has been associated with hemorrhage control and improved survival during the wars since 2001, but little is known of the differential performance of pneumatic tourniquet models. The purpose of this study was to compare the performance of three models of pneumatic tourniquets in a laboratory setting to aid a possible decision to field test suitable models for medic preference. Methods: A laboratory experiment was designed to test the effectiveness of tourniquets on a manikin thigh. Three models (one Emergency and Military Tourniquet [EMT] and two Tactical Pneumatic Tourniquets differing in width: 2 in. and 3 in. [TPT3]) were compared with the standard-issue Combat Application Tourniquet of a strap-and-windlass design. Two users conducted 40 tests each on a right-thigh manikin (HapMed Leg Tourniquet Trainer) with a simulated above-knee amputation injury. Measurements included effectiveness in hemorrhage control, pulse stoppage distal to the tourniquet, time to stop bleeding, blood loss, and pressure. Results: All four models were 100% effective in both hemorrhage control and pulse stoppage distal to the tourniquet. The TPT3 had the slowest mean time to stop bleeding and the highest mean blood loss. The EMT had the least mean pressure. An interuser difference was found only for mean pressure. Conclusions: All models of tourniquet performed equally well for both the critical outcome of effectiveness and the important outcome of pulse stoppage, whereas results for secondary outcomes (time, pressure, and blood loss) differed by model. The EMT had best performance for every type of measurement.

Keywords: first aid; damage control; hemorrhage, prevention and control; shock; tourniquet; resuscitation; emergency medical services

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Pressures Under 3.8cm, 5.1cm, and Side-by-Side 3.8cm-Wide Tourniquets

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Wall PL, Weasel J, Rometti MR, Birkholz S, Gildemaster Y, Grulke L, Sahr SM, Buising CM. 16(2). 28 - 35. (Journal Article)

Abstract

Background: Applications of wider tourniquet are expected to occlude arterial flow at lower pressures. We examined pressures under 3.8cm-wide, 5.1cm-wide, and side-by-side-3.8cm-wide nonelastic strap-based tourniquets. Methods: Ratcheting Medical Tourniquets (RMT) were applied mid-thigh and mid-arm for 120 seconds with Doppler-indicated occlusion. The RMTs were a Single Tactical RMT (3.8cm-wide), a Wide RMT (5.1cm-wide), and Paired Tactical RMTs (7.6cm-total width). Tightening completion was measured at one-tooth advance past arterial occlusion, and paired applications involved alternating tourniquet tightening. Results: All 96 applications on the 16 recipients reached occlusion. Paired tourniquets had the lowest occlusion pressures (ρ < .05). All pressures are given as median mmHg, minimum-maximum mmHg. Thigh application occlusion pressures were Single 256, 219-299; Wide 259, 203-287; Distal of Pair 222, 183-256; and Proximal of Pair 184, 160-236. Arm application occlusion pressures were Single 230, 189-294; Wide 212, 161-258; Distal of Pair 204, 193-254, and Proximal of Pair 168, 148-227. Pressure increases with the final tooth advance were greater for the 2 teeth/cm Wide than for the 2.5 teeth/cm Tacticals (ρ < .05). Thigh final tooth advance pressure increases were Single 40, 33-49; Wide 51, 37-65; Distal of Pair 13, 1-35; and Proximal of Pair 15, 0-30. Arm final tooth advance pressure increases were Single 49, 41-71; Wide 63, 48-77; Distal of Pair 3, 0-14; and Proximal of Pair 23, 2-35. Pressure decreases occurred under all tourniquets over 120 seconds. Thigh pressure decreases were Single 41, 32-75; Wide 43, 28-62; Distal of Pair 25, 16-37; and Proximal of Pair 22, 15-37. Arm pressure decreases were Single 28, 21-43; Wide 26, 16-36; Distal of Pair 16, 12-35; and Proximal of Pair 12, 5-24. Occlusion losses before 120 seconds occurred predominantly on the thigh and with paired applications (ρ < .05). Occlusion losses occurred in six Paired thigh applications, two Single thigh applications, and one Paired arm application. Conclusions: Side-by-side tourniquets achieve occlusion at lower pressures than single tourniquets. Additionally, pressure decreases under tourniquets over time; so all tourniquet applications require reassessments for continued effectiveness.

Keywords: tourniquet; hemorrhage; first aid; emergency treatment

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Field Sterilization in the Austere and Operational Environment A Literature Review of Recommendations

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Will JS, Alderman SM, Sawyer RC. 16(2). 36 - 43. (Journal Article)

Abstract

Special Operations Forces medical providers are often deployed far beyond traditional military supply chains, forcing them to rely on alternative methods for field sterilization of medical equipment. This literature review proposes several alternative methods for both sterilization and disinfection of medical instruments after use and cleaning of skin and wounds before procedures. This article reviews recommendations from sources like the United Nations, the World Health Organization, the Special Operations Forces Medical Handbook, and the Centers for Disease Control and Prevention.

Keywords: prolonged field care; field sanitation; instrument sterilization; expedtionary medicine

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Literature Evidence on Live Animal Versus Synthetic Models for Training and Assessing Trauma Resuscitation Procedures

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Hart D, McNeil M, Hegarty C, Rush R, Chipman J, Clinton J, Reihsen T, Sweet R. 16(2). 44 - 51. (Journal Article)

Abstract

There are many models currently used for teaching and assessing performance of trauma-related airway, breathing, and hemorrhage procedures. Although many programs use live animal (live tissue [LT]) models, there is a congressional effort to transition to the use of nonanimal- based methods (i.e., simulators, cadavers) for military trainees. We examined the existing literature and compared the efficacy, acceptability, and validity of available models with a focus on comparing LT models with synthetic systems. Literature and Internet searches were conducted to examine current models for seven core trauma procedures. We identified 185 simulator systems. Evidence on acceptability and validity of models was sparse. We found only one underpowered study comparing the performance of learners after training on LT versus simulator models for tube thoracostomy and cricothyrotomy. There is insufficient data-driven evidence to distinguish superior validity of LT or any other model for training or assessment of critical trauma procedures.

Keywords: trauma; airway; hemorrhage; resuscitation; training; assessment; live tissue; simulation


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Inner Ear Barotrauma After Underwater Pool Competency Training Without the Use of Compressed Air Case and Review

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McIntire S, Boujie L. 16(2). 52 - 56. (Journal Article)

Abstract

Inner ear barotrauma can occur when the gas-filled chambers of the ear have difficulty equalizing pressure with the outside environment after changes in ambient pressure. This can transpire even with small pressure changes. Hypobaric or hyperbaric environments can place significant stress on the structures of the middle and inner ear. If methods to equalize pressure between the middle ear and other connected gas-filled spaces (i.e., Valsalva maneuver) are unsuccessful, middle ear overpressurization can occur. This force can be transmitted to the fluid-filled inner ear, making it susceptible to injury. Damage specifically to the structures of the vestibulocochlear system can lead to symptoms of vertigo, hearing loss, and tinnitus. This article discusses the case of a 23-year-old male Marine who presented with symptoms of nausea and gait instability after performing underwater pool competency exercises to a maximum depth of 13 feet, without breathing compressed air. Diagnosis and management of inner ear barotrauma are reviewed, as is differentiation from inner ear decompression sickness.

Keywords: inner ear; barotrauma, inner ear; decompression sickness; inner ear; vertigo; tinnitus; hearing loss

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Effects of a New Cooling Technology on Physical Performance in US Air Force Military Personnel

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O'Hara R, Vojta C, Henry A, Caldwell L, Wade M, Swanton S, Linderman JK, Ordway J. 16(2). 57 - 61. (Journal Article)

Abstract

Introduction: Heat-related illness is a critical factor for military personnel operating in hyperthermic environments. Heat illness can alter cognitive and physical performance during sustained operations missions. Therefore, the primary purpose of this investigation was to determine the effects of a novel cooling shirt on core body temperature in highly trained US Air Force personnel. Methods: Twelve trained (at least 80th percentile for aerobic fitness according to the American College of Sports Medicine, at least 90% on the US Air Force fitness test), male Air Force participants (mean values: age, 25 ± 2.8 years; height, 178 ± 7.9cm; body weight 78 ± 9.6kg; maximal oxygen uptake, 57 ± 1.9mL/kg/ min; and body fat, 10% ± 0.03%) completed this study. Subjects performed a 70-minute weighted treadmill walking test and 10-minute, 22.7kg sandbag shuttle test under two conditions: (1) "loaded" (shirt with cooling inserts) and (2) "unloaded" (shirt with no cooling inserts). Results: Core body temperature, exercise heart rate, capillary blood lactate, and ratings of perceived exertion were recorded. Core body temperature was lower (ρ = .001) during the 70-minute treadmill walking test in the loaded condition. Peak core temperature during the 70-minute walking test was also significantly lower (ρ = .038) in the loaded condition. Conclusion: This lightweight (471g), passive cooling technology offers multiple hours of sustained cooling and reduced core and peak body temperature during a 70-minute, 22.7kg weighted-vest walking test.

Keywords: cooling; Special Forces; physical activity; hyperthermia; fatigue, volitional

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Integration of Tactical Emergency Casualty Care Into the National Tactical Emergency Medical Support Competency Domains

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Pennardt A, Callaway DW, Kamin R, Llewellyn C, Shapiro G, Carmona PA, Schwartz RB. 16(2). 62 - 66. (Journal Article)

Abstract

Tactical emergency medical support (TEMS) is a critical component of the out-of-hospital response to domestic high-threat incidents such as hostage scenarios, warrant service, active shooter or violent incidents, terrorist attacks, and other intentional mass casualty-producing acts. From its grass-roots inception in the form of medical support of select law enforcement special weapons and tactics (SWAT) units in the 1980s, the TEMS subspecialty of prehospital care has rapidly grown and evolved over the past 40 years. The National TEMS Initiative and Council (NTIC) competencies and training objectives are the only published recommendations of their kind and offer the opportunity for national standardization of TEMS training programs and a future accreditation process. Building on the previous work of the NTIC and the creation of acknowledged competency domains for TEMS and the acknowledged civilian translation of TCCC by the Committee for Tactical Emergency Casualty Care (C-TECC), the Joint Review Committee (JRC) has created an opportunity to bring forward the work in a form that could be operationally useful in an all-hazards and whole of community format.

Keywords: National TEMS Initiative and Council; tactical emergency medical support; Committee on Tactical Combat Casualty Care; incidents, domestic high-threat

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Field Electronic Medical Records

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Cauchi T, Cameron O. 16(2). 69 - 70. (Journal Article)

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Sea State Green

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Banting J, Meriano T. 16(2). 78 - 81. (Journal Article)

Abstract

The series objective is to review various clinical conditions/ presentations, including the latest evidence on management, and to dispel common myths. In the process, core knowledge and management principles are enhanced. A clinical case will be presented. Cases will be drawn from real life but phrased in a context that is applicable to the Special Operations Forces (SOF) or tactical emergency medical support (TEMS) environment. Details will be presented in such a way that the reader can follow along and identify how they would manage the case clinically depending on their experience and environment situation. Commentary will be provided by currently serving military medical technicians. The medics and author will draw on their SOF experience to communicate relevant clinical concepts pertinent to different operational environments including SOF and TEMS. Commentary and input from active special op

Keywords: motion sickness; medication, antimotion sickness

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Pain as a Barrier to Human Performance: A Focus on Function for Self-Reporting Pain With the Defense Veterans Pain Rating Scale

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Buckenmaier CC, Galloway KT, Polomano RC, Deuster PA. 16(2). 82 - 87. (Journal Article)

Abstract

The intense physical demands and dangerous operational environments common to Special Operations Forces (SOF) result in a variety of painful conditions, including musculoskeletal pain, headaches, and acute and chronic pain from combat injuries. Pain is a wellaccepted barrier to human performance. The Pain Management Task Force and the development of the Defense Veterans Pain Rating Scale (DVPRS) are discussed to provide a framework for changing the culture of pain management away from intensity of pain to interference with function and performance. The emergence of complementary and integrative pain management (CIM) practices is briefly reviewed as viable alternatives to the traditional reliance on opioids and other prescription medications. The SOF community can be the change agent for the DVPRS and CIM approaches to pain management, which will in the end serve to accelerate recovery and return SOF operators to duty faster and with an enhanced ability to perform with less pain.

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Japanese Encephalitis

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Burnett MW. 16(2). 89 - 90. (Journal Article)

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Avoiding Program-Induced Cumulative Overload (PICO)

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Orr R, Knapik JJ, Pope R. 16(2). 91 - 95. (Journal Article)

Abstract

This article defines the concept of program-induced cumulative overload (PICO), provides examples, and advises ways to mitigate the adverse effects. PICO is the excessive cumulative physical workload that can be imparted to military personnel by a military training program with an embedded physical training component. PICO can be acute (accumulating within a single day) or chronic (accumulating across the entirety of the program) and results in adverse outcomes for affected personnel, including detrimental fatigue, performance degradation, injuries, or illness. Strategies to mitigate PICO include focusing administration and logistic practices during the development and ongoing management of a trainee program and implementing known musculoskeletal injury prevention strategies. More training is not always better, and trainers need to consider the total amount of physical activity that military personnel experience across both operational training and physical training if PICO is to be mitigated.

Keywords: injuries, overload; training; prevention; programming

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Lesions Arising in a Tattoo of an Active Duty US Marine Corps Woman

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Winn AE, Rivard SC, Green B. 16(2). 96 - 100. (Journal Article)

Abstract

Tattoos are ubiquitous in modern society; however, they do not come without risk of medical complications. When complications arise in the military community, a particularly thorough differential diagnosis should be considered based on the increased exposures service members have during deployment and throughout their military career. We present a case of a 38-year-old active duty US Marine Corps woman with worsening skin lesions arising within a tattoo 6 weeks after acquiring the tattoo on her right chest. Given environmental exposures from a recent deployment to the Middle East, a wide differential was considered. Ultimately, a skin biopsy revealed early hypertrophic scar formation responsive to therapy with intralesional triamcinolone acetonide (Kenalog&reg; [ILK]). However, given the Marine had recently deployed and is part of the active duty population, consideration of alternative, albeit rare, etiologies was imperative.

Keywords: scar, hypertrophic; keloid collagen; tattoo; allergy, red ink; Mycobacterium, cutaneous atypical; sacroidosis, cutaneous; foreign body granuloma; cellulitis

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An Evaluation of Common Cleaning Methods for the Removal of a Clinical Isolate of Escherichia coli in Personal Hydration System Water Reservoirs

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Helmus S, Blythe J, Guevara P, Washington MA. 16(2). 101 - 104. (Journal Article)

Abstract

Waterborne infection is an important cause of morbidity and mortality throughout the world. Personal hydration packs have been used by military personnel since the Gulf War and are now a common issue item. Since military personnel tend to operate under austere conditions and may use a variety of water sources, preventing the acquisition of waterborne infections is extremely important. Further, since hydration pack water reservoir replacements may not be available during combat operations, the development of a reliable cleaning protocol for use in the field is essential. Several methods for cleaning have been described. In the current study, three common cleaning methodologies-bleach treatment, baking soda treatment, and proprietary CAMELBAK Cleaning Tabs™-were evaluated for the ability to remove Escherichia coli contamination from hydration pack water reservoirs. The study results suggest that the use of bleach and proprietary CAMELBAK tablets should be encouraged since they both operate by releasing bactericidal chlorine compounds into solution, which is more effective at reducing post-treatment bacterial burden. It should be noted that no method was 100% effective at completely eliminating bacteria from the reservoirs and that mechanical cleaning was not attempted.

Keywords: CAMELBAK Cleaning Tab&tm;; infection, waterborne; hydration packs, personal; cleaning methodologies; Escherichia coli contamination

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Prolonged Field Care Working Group Update

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Keenan S. 16(2). 105 - 106. (Journal Article)

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"SWAT Is a Lifestyle; It's a Way of Life"

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Kragh JF. 16(2). 108 - 110. (Interview)

Abstract

Ray Casillas on a Career in Operational Medicine

Searching for Sustainability: How Niger's CASEVAC Success Is Leading the African Continent and Educating the GHE/IHS Community

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Flatau P. 16(2). 111 - 114. (Journal Article)

Abstract

Against all odds and despite significant challenges and scarce resources, Niger's Armed Forces (FAN) continues to lead a successful casualty evacuation (CASEVAC) program. This program and the Special Operations Command Africa (SOCAFR) model that influenced it has become a template for the Global Health Engagement (GHE)/International Health Specialist (IHS) community. This article provides a summary of the overall CASEVAC mission, outlines the final phase sustainable execution of this program, and provides the reader with critical lessons learned for best practice GHE approaches.

Keywords: Niger; casualty evacuations; Special Operations Command Africa

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Modern Irregular Warfare in Defense Policy and as a Military Phenomenon

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Farr W. 16(2). 115 - 115. (Book Review)

Abstract

English Edition: von der Heydte, Friedrich August Freiherr. Modern Irregular Warfare in Defense Policy and as a Military Phenomenon. New York, NY: New Benjamin Franklin House; 1986.
ISBN: 0-933488-49-1. 299 pages.

German Edition: von der Heydte, Friedrich August Freiherr. Der moderne Kleinkrieg als wehrpolitisches und militärisches Phänomen. Würzburg, West Germany: Holzner-Verlag; 1986.
ISBN-10: 3925725032/ISBN-13: 978-3925725036. 312 pages.

Team of Teams: New Rules of Engagement for a Complex World

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Forsten RD. 16(2). 116 - 116. (Book Review)

Abstract

McChrystal, Stanley; Collins, Tantum; Silverman, David; Fussell, Chris. Team of Teams: New Rules of Engagement for a Complex World. Westminster, London, UK: Portfolio; 2015. 304 pages.
ISBN-10: 1591847486, ISBN-13: 978-1591847489.

Tactical Combat Casualty Care: Top Lessons for Civilian EMS Systems from 14 Years of War

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Butler FK. 16(2). 120 - 137. (Classical Conference)

Committee on Tactical Combat Casualty Care Meeting. 2-3 February 2016, Atlanta, Georgia: Meeting Minutes

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Anonymous A. 16(2). 138 - 147. (Classical Conference)

Proceedings of the 2016 Spring/Summer Meeting of the Committee for Tactical Emergency Casualty Care

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Tang N, Shapiro G, Smith ER, Kamin R, Callaway DW. 16(2). 148 - 150. (Classical Conference)