Wall P, Buising CM, Jensen J, White A, Davis J, Renner CH. 23(4). 11 - 30. (Journal Article)
Abstract
Background: We investigated emergency-use limb tourniquet design features effects on application processes (this paper) and times to complete those processes (companion paper). Methods: Sixty-four appliers watched training videos and then each applied all eight tourniquets: Combat Application Tourniquet Generation 7 (CAT7), SOF™ Tactical Tourniquet-Wide Generation 3 (SOFTTW3), SOF™ Tactical Tourniquet-Wide Generation 5 (SOFTTW5), Tactical Mechanical Tourniquet (TMT), OMNA Marine Tourniquet (OMT), X8T tourniquet (X8T), Tactical Ratcheting Medical Tourniquet (Tac RMT), and RapidStop™ Tourniquet (RST). Application processes were scored from videos. Results: Thirty-three appliers had no prior tourniquet experience. All 512 applications were placed proximal to the recipient's simulated distal thigh injury. Thirty-one appliers (13 with no experience) had 66 problem-free applications (18 by no experience appliers). Tightening-system mechanical problems were more frequent with windlass rod systems (26 losing hold of the rod, 27 redoing rod turns, and 58 struggling to secure the rod) versus ratchet systems (3 tooth skips and 16 advance failures). Thirty-five appliers (21 with no experience) had 68 applications (45 by no experience appliers) with an audible Doppler pulse when stating "Done"; causes involved premature stopping (53), inadequate strap pull (1 SOFTTW3, 1 RST), strap/redirect understanding problem (1 SOFTTW5, 1 X8T, 4 Tac RMT, 1 RST), tightening-system understanding problem (2 CAT7, 1 SOFTTW3, 1 TMT, 1 RST), and physical inability to secure (1 SOFTTW3). Fifty-three appliers (32 no experience) had 109 applications (64 by no experience appliers) not correctly secured. Six involved strap/redirect understanding problems: 4 Tac RMT, 1 X8T, 1 SOFTTW5; 103 involved improper securing of non-self-securing design features: 47 CAT7 (8 strap, 45 rod), 31 TMT (17 strap, 19 rod), 22 OMT (strap), and 3 SOFTTW3 (rod). Conclusion: Self-securing systems have process advantages. Because most emergent tourniquet recipients require transport, we believe tourniquet security is a critical design aspect. Decisions regarding tourniquet choices may become very different when both occlusion and tourniquet security are considered.
Keywords: tourniquet; hemorrhage; first aid; emergency treatment
Wall P, Buising CM, White A, Jensen J, Davis J, Renner CH. 23(4). 31 - 42. (Journal Article)
Abstract
Background: We investigated emergency-use limb tourniquet design features effects on application processes (companion paper) and times to complete those processes (this paper). Methods: Sixty-four appliers watched training videos then each applied all eight tourniquets: Combat Application Tour- niquet Generation 7 (CAT7), SOF™ Tactical Tourniquet-Wide Generation 3 (SOFTTW3), SOF™ Tactical Tourniquet-Wide Generation 5 (SOFTTW5), Tactical Mechanical Tourniquet (TMT), OMNA Marine Tourniquet (OMT), X8T-Tourniquet (X8T), Tactical Ratcheting Medical Tourniquet (Tac RMT), and RapidStop Tourniquet (RST). Application processes times were captured from videos. Results: From "Go" to "touch tightening system" was fastest with clips and self-securing redirect buckles and without strap/redirect application process problems (n, median seconds: CAT7 n=23, 26.89; SOFTTW3 n=11, 20.95; SOFTTW5 n=16, 20.53; TMT n=5, 26.61; OMT n=12, 25.94; X8T n=3, 18.44; Tac RMT n=15, 30.59; RST n=7, 22.80). From "touch tightening system" to "last occlusion" was fastest with windlass rod systems when there were no tightening system understanding or mechanical problems (seconds: CAT7 n=48, 4.21; SOFTTW3 n=47, 5.99; SOFTTW5 n=44, 4.65; TMT n=38, 6.21; OMT n=51, 6.22; X8T n=48, 7.59; Tac RMT n=52, 8.44; RST n=40, 8.02). For occluded, tightening system secure applications, from "touch tightening system" to "Done" was fastest with self-securing tightening systems tightening from a tight strap (occluded, secure time in seconds from a tight strap: CAT7 n=17, 14.47; SOFTTW3 n=22, 10.91; SOFTTW5 n=38, 9.19; TMT n=14, 11.42; OMT n=44, 7.01; X8T n=12 9.82; Tac RMT n=20, 6.45; RST n=23, 8.64). Conclusions: Suboptimal processes in- crease application times. Optimal design features for fast, occlusive, secure tourniquet applications are self-securing strap/ redirect systems with an easily identified and easily used clip and self-securing tightening systems.
Keywords: tourniquet; hemorrhage; first aid; emergency treatment
Cole R, Steffens K, Flash Z, Conley S, Givens ML. 23(4). 43 - 46. (Journal Article)
Abstract
The Advanced Combat Medical Experience (ACME) is a progressive simulation-based training held for second-year medical students at the Uniformed Services University (USU). This study explored the impact of participating in ACME on students' tourniquet application skills. A panel of emergency medicine physician experts developed an assessment to evaluate the participants' performance. Trained raters then scored students' tourniquet application performance before and after participating in ACME. We conducted a Wilcoxon signed-rank test to detect any significant difference in the participants' pretest and posttest ratings as well as time it took them to apply the tourniquet. Our results indicated a significant difference in the pre- and posttest ratings of students as well as the time it took them to apply the tourniquet. This study confirms the effectiveness of progressive simulation-based education for teaching TCCC skills to military medical trainees.
Keywords: simulation; education; medical student; medical education; tourniquet; combat; ACME; Advanced Combat Medical Experience
Edlow BL, Gilmore N, Tromly SL, Deary KB, McKinney IR, Hu CG, Kelemen JN, Maffei C, Tseng CJ, Llorden GR, Healy BC, Masood M, Cali RJ, Baxter T, Yao EF, Belanger HG, Benjamini D, Basser PJ, Priemer DS, Kimberly WT, Polimeni JR, Rosen BR, Fischl B, Zurcher NR, Greve DN, Hooker JM, Huang SY, Caruso A, Smith GA, Szymanski TG, Perl DP, Dams-O'Connor K, Mac Donald CL, Bodien YG. 23(4). 47 - 56. (Journal Article)
Abstract
United States Special Operations Forces (SOF) personnel are frequently exposed to explosive blasts in training and combat. However, the effects of repeated blast exposure on the human brain are incompletely understood. Moreover, there is currently no diagnostic test to detect repeated blast brain injury (rBBI). In this "Human Performance Optimization" article, we discuss how the development and implementation of a reliable diagnostic test for rBBI has the potential to promote SOF brain health, combat readiness, and quality of life.
Keywords: blast overpressure; brain injury; Special Operations Forces; SOF; human performance optimization
Schlocker C, Grosser S, Spaulding C, Beltrech B, Brady R. 23(4). 57 - 61. (Journal Article)
Abstract
This study evaluated the effect of an airway localization device (ALD) on surgical cricothyrotomy (SC) success rates and prehospital provider confidence. SC is indicated in 0.62% to 1.8% of all patients with military trauma, especially those presenting with traumatic airway obstruction. The effect of ALD was evaluated in an airway mannequin model during SC with the Committee on Tactical Combat Casualty Care (CoTCCC)-recommended Control-Cric Cricothyrotomy System. Outcomes included procedural time, Likert measures of operator confidence, and qualitative data/feedback for suggested future improvements in device design and training. The average procedural times of the hospital corpsmen (HM) including 20 men and 8 women were 67 seconds (without ALD) and 87 seconds (with ALD) respectively, which were statistically significant. Provider confidence for all SC procedural steps increased significantly after SC with and without ALD. The average procedural times of the Navy Special Operations Forces (SOF) group comprising 8 males were 56 seconds (without ALD) and 64 seconds (with ALD), which was not statistically significant. Provider confidence for two SC procedural steps (adequate hook retraction and first-attempt SC tube insertion) increased significantly after SC with and without ALD. First-attempt SC success rates were 90% in each group. Both groups provided feedback on the Control-Cric and ALD, with qualitative feedback analyzed for further SC training recommendations. Procedural times were increased with ALD when compared to those without ALD, although the increase may not be clinically significant in this classroom setting.
Keywords: airway; trauma; military medicine; surgical cricothyrotomy; procedural time; operator confidence; hospital corpsmen; Special Operations Forces; SOF
Jeschke EA, Baker JB, Wyma-Bradley J, Dorsch J, Huffman SL. 23(4). 64 - 68. (Journal Article)
Abstract
This is the third of nine planned papers drawn from the findings of our ethnographic study entitled "The Impact of Catastrophic Injury Exposure on Resilience in Special Operations Surgical Teams." Building from our strategic framework, this paper will establish that resilience is better understood as cohesive adaptation within a Special Operation Forces (SOF) cultural ecosystem. Exploring unconventional resilience as the inter-relationship across the organization, team, and individual, we will use qualitative quotes to describe the ecosystem of dynamic freedom of maneuver in ambiguity. To achieve our goals, we will: 1) compare conventional and unconventional resilience to operationalize the components of our strategic framework; 2) use qualitative quotes to show how the ecosystem of unconventional resilience functions at each level supporting our operational model; and 3) describe how the operational model of unconventional resilience links to tactical performance through five social determinants. We conclude by gesturing to how transformational change-agency applies to practical performance of all SOF medics.
Keywords: resilience; performance; operational model; SOF medic; ecosystem
Washington M, Dinh DT, Ibarra C, Kua SC. 23(4). 70 - 74. (Journal Article)
Abstract
The malevolent application of neuroscience is an emerging threat to the U.S. military. At present, U.S. military medical personnel are not capable of adequately diagnosing or treating the injuries and illnesses that may result from exposure to potential neuroweapons. This fact was illustrated in 2016 when U.S. diplomats serving in Havana, Cuba reported hearing strange noises accompanied by a constellation of unexplained health effects. Similar incidents have been reported in China and Russia. Although various hypotheses have been put forward to explain these symptoms, none of them have been verified. The reported symptoms were analogous to the physiological responses that have been produced in the laboratory by exposing volunteers to pulsed microwave energy. However, these incidents of undetermined origin demonstrate that widespread neurological illness can be disruptive to U.S. government operations and that it is currently not possible to identify the cause, determine the correct treatment, or ascribe attribution to potential neuroweapon use in an overseas setting. Since it is likely that Special Operations medical personnel will be among the first to respond to neuroweapon attacks in the deployed environment, it is essential that they be made aware of this emerging threat and that efforts be made to incorporate potential directed energy neuroweapons and other neuroweapon configurations into future Chemical, Biological, Radiological, Nuclear, and high yield Explosives (CBRN-E) training modules. The intention of this article is to introduce the concept of the neuroweapon to military medical personnel and to provide a brief review of the relevant literature.
Keywords: neuroweapon; neuroscience; Havana syndrome; microwave weapon; neurological injury
Stinner D, McEvoy C, Broussard MA, Nikolaus AD, Parker CH, Santana H, Karnopp JM, Patel JA. 23(4). 75 - 80. (Journal Article)
Abstract
Background: The Committee on En Route Combat Casualty Care recently ranked the patient handoff as their fourth research priority. Bluetooth technology has been introduced to the battlefield and has the potential to improve the tactical patient handoff. The purpose of this study is to compare the traditional methods of communication used in tactical medical evacuation by Special Operations medical personnel (radio push-to-talk [PTT] and Tactical Medic Intercom System [TM-ICS]) to Bluetooth communication. Methods: Twenty-four simulated tactical patient handoffs were performed to compare Bluetooth and traditional methods of communication used in tactical medical evacuation. Patient scenario order and method of communication were randomized. Accuracy and time required to complete the patient handoff were determined. The study took place using a rotary-wing aircraft kept at level 2 to simulate real-world background noise. Preferred method of communication for each study participant was determined. Results: There were no differences in accuracy of the received patient handoffs between groups or patient handoff transmission times at the ramp of the aircraft. However, when comparing patient handoff times to the medical team within the aircraft, Bluetooth communication was significantly faster than both TM-ICS and radio PTT, while Bluetooth PTT and radio PTT were also significantly faster than TM-ICS. Bluetooth communication was ranked as the preferred method of handoff by all study participants. Conclusion: The study demonstrated that utilization of Bluetooth technology for patient handover results in faster handoffs compared with traditional methods without sacrificing any accuracy in a scenario with high levels of noise.
Keywords: Tactical Combat Casualty Care; TCCC; communication; Bluetooth; medical evacuation; handoff
Hynes A, Murali S, Bass GA, Kheirbek T, Qasim Z, George N, Yelon JA, Chreiman KC, Martin ND, Cannon JW. 23(4). 81 - 86. (Journal Article)
Abstract
Background: Hemorrhagic shock requires timely administration of blood products and resuscitative adjuncts through multiple access sites. Intraosseous (IO) devices offer an alternative to intravenous (IV) access as recommended by the massive hemorrhage, A-airway, R-respiratory, C-circulation, and H-hypothermia (MARCH) algorithm of Tactical Combat Casualty Care (TCCC). However, venous injuries proximal to the site of IO access may complicate resuscitative attempts. Sternal IO access represents an alternative pioneered by military personnel. However, its effectiveness in patients with shock is supported by limited evidence. We conducted a pilot study of two sternal-IO devices to investigate the efficacy of sternal-IO access in civilian trauma care. Methods: A retrospective review (October 2020 to June 2021) involving injured patients receiving either a TALON® or a FAST1® sternal-IO device was performed at a large urban quaternary academic medical center. Baseline demographics, injury characteristics, vascular access sites, blood products and medications administered, and outcomes were analyzed. The primary outcome was a successful sternal-IO attempt. Results: Nine males with gunshot wounds transported to the hospital by police were included in this study. Eight patients were pulseless on arrival, and one became pulseless shortly thereafter. Seven (78%) sternal-IO placements were successful, including six TALON devices and one of the three FAST1 devices, as FAST1 placement required attention to Operator positioning following resuscitative thoracotomy. Three patients achieved return of spontaneous circulation, two proceeded to the operating room, but none survived to discharge. Conclusions: Sternal-IO access was successful in nearly 80% of attempts. The indications for sternal-IO placement among civilians require further evaluation compared with IV and extremity IO access.
Keywords: intraosseous; resuscitation; sternum; sternal intraosseous; sternal vascular access; vascular access
Melau J, Bergan-Skar P, Callender N, Rognhaug M, Bekkestad E. 23(4). 87 - 91. (Journal Article)
Abstract
Background: The war in Ukraine urged a need for prompt deliverance and resupply of tourniquets to the front. Producing tourniquets near the battlefront was a feasible option with respect to resupply and cost. Methods: A locally produced 3D-printed tourniquet (Ukrainian model) from the "Tech Against Tanks" charity was tested against commercially available and Committee of Tactical Combat Casualty Care (CoTCCC)-recommended tourniquets (C-A-T™ and SOF™TT-W). We tested how well the tourniquets could hold pressure for up to 2 hours. Results: A Kruskal-Wallis test revealed significant differences between the groups (p<.05). Post-hoc testing revealed a significant difference between the C-A-T and the Ukrainian tourniquet (p=.004). A similar significance was not found between the SOF™TT-W Wide and the Ukrainian model (p=.08). Discussion: The Ukrainian model can hold pressure as well as the commercially available tourniquets. There is much value if this can be produced close to the battlefield. Factors including logistics, cost, and self-sufficiency are important during wartime. Conclusion: We found that our sample of 3D-printed tourniquets, currently used in the war in Ukraine, could maintain pressure as well as the commercially available tourniquets. Indeed, our tests demonstrated that it could maintain a significantly higher pressure.
Keywords: tourniquet; hemorrhage; armed conflicts; 3D printing; battlefront resupply
Nelson T, Youngblade L, Goldberg P, Bricker D, Werth K, Riesberg JC, Surrett GW. 23(4). 92 - 108. (Journal Article)
Abstract
Background: The purpose of this study was to evaluate the effectiveness of the physical domain (PD) to improve performance in all the POTFF domains (physical, psychological, social/family, and spiritual) among Special Forces (SF) Operators. Methods: This was a cross-sectional study of active SF Operators assigned to the United States Army Special Operations Command (USASOC). Recruitment began in October 2016. Testing began on 1 January 2017, and concluded on 28 February 2020. Participants completed physical testing, blood draws, and questionnaires to determine domain metrics. Means, medians, and proportions were compared by level of participation in the PD. Results: A total of 231 Soldiers participated; n=63 in the control group, n=93 in the <4 days PD/week (PD <4) group, and n=66 in the >4 days PD/week (PD =4) group. The average age was 31 years (range 21-47 y). The average time in the Special Operations Forces (SOF) was 4 years (range 0-19 y). The PD =4 group showed significantly greater overall upper (p=.01) and lower (p=0) body strength, power (p=.01), and positive affect (p=.04). The PD =4 group also had significantly lower anxiety (p=.03), stress (p=.04), and depression (p=.02) than the control group. Conclusion: The PD and psychological domain metrics were most associated with PD participation. This finding is consistent with the goals of the PD, which are to increase physical and mental capabilities and decrease injury recovery time.
Keywords: physical domain; spiritual domain; POTFF; United States Army Special Operations Command; USASOC; Special Forces; psychological domain; social/family domain
Schauer S, Long B, Fisher AD, Stednick PJ, Bebarta VS, Ginde AA, April MD. 23(4). 110 - 111. (Editorial)
Keywords: airway; military; video; laryngoscopy; trauma
Lenard D, Josse F. 23(4). 112 - 121. (Clinical Conference)
Keywords: trauma; combat medicine; prolonged field care; tactical casualty care; Special Operations