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Knapik JJ, Hoedebecke SS. 21(2). 100 - 107. (Journal Article)
Abstract
Vitamin A is a generic term for compounds that have biological activity similar to that of retinol and includes carotenoids like β-carotene and α-carotene. Some studies suggest high dietary intake of vitamin A can increase bone fracture risk. This investigation involved a systematic review and meta-analysis examining the association between vitamin A and fracture risk. Published literature was searched to find studies that (1) involved human participants, (2) had prospective cohort or case-control study designs, (3) contained original quantitative data on associations between dietary intake of vitamin A and fractures, and (4) provided either risk ratios (RRs), odds ratios (ORs), or hazard ratios (HRs) with 95% confidence intervals (95% CIs) comparing various levels of vitamin A consumption to fracture risk. Thirteen studies met the review criteria. Meta-analyses indicated that risk of hip fracture was increased by high dietary intake of total vitamin A (RR = 1.29; 95% CI = 1.07-1.57) or retinol (RR = 1.23; 95% CI = 1.02-1.48). Hip fracture risk was reduced by high dietary intake of total carotene (RR = 0.62; 95% CI = 0.42-0.93), β-carotene (RR = 0.72; 95% CI = 0.58-0.89), or α-carotene (RR = 0.81; 95% CI = 0.67-0.97). Total fracture risk was not associated with any vitamin A compound. High intake of total vitamin A or retinol increased hip fracture risk, while high intake of some carotenoids reduced hip fracture risk.
Keywords: retinol; β-carotine; α-carotene; B-cryptoxanthin; hip fracture; total fracture
Knapik JJ, Hoedebecke SS. 21(2). 100 - 107. (Journal Article)
Abstract
Vitamin A is a generic term for compounds that have biological activity similar to that of retinol and includes carotenoids like β-carotene and α-carotene. Some studies suggest high dietary intake of vitamin A can increase bone fracture risk. This investigation involved a systematic review and meta-analysis examining the association between vitamin A and fracture risk. Published literature was searched to find studies that (1) involved human participants, (2) had prospective cohort or case-control study designs, (3) contained original quantitative data on associations between dietary intake of vitamin A and fractures, and (4) provided either risk ratios (RRs), odds ratios (ORs), or hazard ratios (HRs) with 95% confidence intervals (95% CIs) comparing various levels of vitamin A consumption to fracture risk. Thirteen studies met the review criteria. Meta-analyses indicated that risk of hip fracture was increased by high dietary intake of total vitamin A (RR = 1.29; 95% CI = 1.07-1.57) or retinol (RR = 1.23; 95% CI = 1.02-1.48). Hip fracture risk was reduced by high dietary intake of total carotene (RR = 0.62; 95% CI = 0.42-0.93), β-carotene (RR = 0.72; 95% CI = 0.58-0.89), or α-carotene (RR = 0.81; 95% CI = 0.67-0.97). Total fracture risk was not associated with any vitamin A compound. High intake of total vitamin A or retinol increased hip fracture risk, while high intake of some carotenoids reduced hip fracture risk.
Keywords: retinol; β-carotine; α-carotene; B-cryptoxanthin; hip fracture; total fracture
DeFeo DR, Givens ML. 18(1). 118 - 123. (Journal Article)
Abstract
The authors would like to introduce TCCC [Tactical Combat Casualty Care] + CBRN [chemical, biological, radiological, and nuclear] = (MARCHE)2 as a conceptual model to frame the response to CBRN events. This model is not intended to replace existing and well-established literature on CBRNE events but rather to serve as a response tool that is an adjunct to agent specific resources.
Keywords: MARCHE; (MARCHE)2; CBRN; CBRNE; triage; casualties
Armstrong M. 12(4). 1 - 4. (Journal Article)
Abstract
Our nation's servicemembers commonly use dietary supplements to enhance their performance. Despite this prolific use, many of these products have detrimental side-effects that compromise servicemembers' health and could, by proxy, compromise a mission. This paper presents the case of a 32-year old Navy Special Operations Forces (SOF) Sailor who, prior to physical training, used a supplement containing 1,3 Dimethylamylamine (DMAA), and then developed atrial fibrillation with rapid ventricular response. He required intravenous calcium channel blocker administration, followed by beta blockers, for rate control. As military providers, we routinely ask our patients about their use of supplements and while the regulation of these products is beyond the scope of practice for most of us, it is our duty to become better educated about the risks and benefits of these supplements. We must educate our patients and our commands on the potential harm that these supplements may pose.
Keywords: atrial fibriliation; supplement; DMAA; Special Operations; 1,3 Dimethylamylamine
Walker LH, Godbee DC, Palmer LE, Share MP, Mouri M. 22(2). 29 - 34. (Journal Article)
Abstract
The authors describe the 20th Special Forces Group-Airborne Non-Trauma Module refresher training for Special Forces medical sergeants and Special Operations combat medics.
Keywords: 20th Special Forces Group-Airborne Non-Trauma Module refresher training; training
Wentz LM, Eldred JD, Henry MD, Berry-Caban CS. 14(1). 58 - 66. (Journal Article)
Abstract
Vitamin D deficiency initiates a loss of combat effectiveness by impairing physical and cognitive functioning of combat Operators. Synthesized in response to sunlight and consumed in the diet, vitamin D functions as a hormone and regulates gene expression for nearly 300 genes throughout the human body. These target genes are involved processes essential to combat operations, such as immune function, response to stress, inflammation, and regulation of calcium movement. Since widespread vitamin D deficiency is observed across the U.S. population, poor vitamin D status is expected in Servicemembers. Physical conditions linked to vitamin D deficiency include increased risk for muscle or bone injury, muscle weakness, and reduced neuromuscular function. Hormonally, vitamin D levels have been positively correlated with testosterone levels. Vitamin D deficiency is also associated with cognitive decline, depression, and may prolong recovery following mild traumatic brain injury (mTBI). Since vitamin D deficiency elevates systemic inflammation, poor vitamin D status at the time of brain injury may prolong the inflammatory response and exacerbate postconcussive symptoms. Furthermore, veterans with mTBI experience chronic endocrine dysfunction. While vitamin D status has not been assessed post-mTBI, it is plausible that vitamin D levels are altered along with testosterone and growth hormone, raising the question of whether vitamin D deficiency results from trauma-related hormonal abnormalities or whether vitamin D deficiency increases the risk for endocrine dysfunction. Through its association with testosterone production, vitamin D deficiency may increase the risk for posttraumatic stress disorder (PTSD) since testosterone levels are altered in veterans with PTSD. Therefore, vitamin D status has a significant impact on Operator health and performance. Supplementing vitamin D to deficient Operators provides a noninvasive and low-cost intervention to maintain combat force.
Keywords: vitamin D; 25-hydroxyvitamin D; inflammation; neuroprotection; musculoskeletal performance; combat readiness
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
Wade M, O'Hara R, Caldwell L, Ordway J, Bryant D. 16(4). 41 - 47. (Journal Article)
Abstract
Background: The primary aim of this study was to investigate the effects of continuous one-arm kettlebell (KB) swing training on various US Air Force physical fitness testing components. Thirty trained male (n = 15) and female (n = 15) US Air Force (USAF) personnel volunteered and were sequentially assigned to one of three groups based on 1.5-mile run time: (1) KB one-arm swing training, (2) KB one-arm swing training plus highintensity running (KB + run), and (3) traditional USAF physical training (PT) according to Air Force Instruction 36-2905. Methods: The following measurements were made before and after 10 weeks of training: 1.5-mile run, 1-minute maximal push-ups, 1-minute maximal situps, maximal grip strength, pro agility, vertical jump, 40-yard dash, bodyweight, and percent body fat. Subjects attended three supervised exercise sessions per week for 10 weeks. During each exercise session, all groups performed a 10-minute dynamic warm-up followed by either (1) 10 minutes of continuous KB swings, (2) 10 minutes of continuous kettlebell swings plus 10 minutes of high-intensity running, or (3) 20 minutes of moderate intensity running plus push-ups and sit-ups. Average and peak heart rate were recorded for each subject after all sessions. Paired t tests were conducted to detect changes from pretesting to posttesting within each group and analysis of variance was used to compare between-group variability (ρ ≤ .05). Results: Twenty subjects completed the study. There were no statistically significant changes in 1.5-mile run time between or within groups. The 40- yard dash significantly improved within the KB swing (ρ ≤ .05) and KB + run group (ρ ≤ .05); however, there were no significant differences in the traditional PT group (ρ ≤ .05) or between groups. Maximal push-ups significantly improved in the KB + run group (ρ ≤ .05) and trends toward significant improvements in maximal push-ups were found in both the KB (ρ = .057) and traditional PT (ρ = .067) groups. Conclusions: This study suggests that continuous KB swing training may be used by airmen as a high-intensity, low-impact alternative to traditional USAF PT to maintain aerobic fitness and improve speed and maximal push-ups.
Keywords: kettelbell training; Air Force; 40-yard dash; physical fitness; military personnel
Downs JW. 14(2). 66 - 73. (Journal Article)
Abstract
The author gives a history of the formation of the 6th Ranger Infantry Battalion and varied aspects of Ranger medical operations, including personnel composition of the medical detachment, the work of the battalion's surgeon during combat and noncombat operations, medical aspects of operational planning, available medical supplies, medical evacuation procedures, and preventive care.
Keywords: 6th Ranger Infantry Battalion; medical operations; World War II
Anonymous A. 13(2). 1 - 2. (Journal Article)
Abstract
The Abdominal Aortic Tourniquet™ was used recently used in Afghanistan to control severe hemorrhage in a casualty who had traumatic bilateral amputations of the lower extremities. Excerpts from the medical provider's account of the tactical evacuation phase of care are provided.
Keywords: Abdominal Aortic Tourniquet ™; AAT; hemorrhage; amputations
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
Smith IM, Naumann DN, Guyver P, Bishop J, Davies S, Lundy JB, Bowley DM. 15(2). 86 - 93. (Journal Article)
Abstract
Background: Anatomic measures of injury burden provide key information for studies of prehospital and in-hospital trauma care. The military version of the Abbreviated Injury Scale [AIS(M)] is used to score injuries in deployed military hospitals. Estimates of total trauma burden are derived from this. These scores are used for categorization of patients, assessment of care quality, and research studies. Scoring is normally performed retrospectively from chart review. We compared data recorded in the UK Joint Theatre Trauma Registry (JTTR) and scores calculated independently at the time of surgery by the operating surgeons to assess the concordance between surgeons and trauma nurse coordinators in assigning injury severity scores. Methods: Trauma casualties treated at a deployed Role 3 hospital were assigned AIS(M) scores by surgeons between 24 September 2012 and 16 October 2012. JTTR records from the same period were retrieved. The AIS(M), Injury Severity Score (ISS), and New Injury Severity Score (NISS) were compared between datasets. Results: Among 32 matched casualties, 214 injuries were recorded in the JTTR, whereas surgeons noted 212. Percentage agreement for number of injuries was 19%. Surgeons scored 75 injuries as "serious" or greater compared with 68 in the JTTR. Percentage agreement for the maximum AIS(M), ISS, and NISS assigned to cases was 66%, 34%, and 28%, respectively, although the distributions of scores were not statistically different (median ISS: surgeons: 20 [interquartile range (IQR), 9-28] versus JTTR: 17.5 [IQR, 9-31.5], ρ = .7; median NISS: surgeons: 27 [IQR, 12-42] versus JTTR: 25.5 [IQR, 11.5-41], ρ = .7). Conclusion: There are discrepancies in the recording of AIS(M) between surgeons directly involved in the care of trauma casualties and trauma nurse coordinators working by retrospective chart review. Increased accuracy might be achieved by actively collaborating in this process.
Keywords: Injury Severity Score; Abbreviated Injury Scale; trauma; surgeon; trauma nurse coordinator
Rago AP, Sharma U, Sims K, King DR. 15(3). 39 - 45. (Journal Article)
Abstract
Background: Noncompressible hemorrhage is the leading cause of potentially survivable death on the battlefield. In Special Operations Forces (SOF), 50% of potentially survivable deaths have been related to noncompressible hemorrhage. Currently, there are no widely available presurgical interventions that can slow abdominal bleeding. Consequently, many of the preventable deaths occur en route to definitive care as a failure to rescue from exsanguination. A self-expanding polyurethane foam has been developed as a percutaneous damage control intervention to rescue casualties who would otherwise die of noncompressible hemorrhage, and allow them to survive long enough to reach surgical intervention. The purpose of this paper is to summarize the existing preclinical data, describe the role of SOF personnel in foam delivery-system development, and to integrate these together to conceptualize how foam could be incorporated into SOF medical care. Methods: All existing publications on self-expanding foam are reviewed. Additionally, eight SOF medical providers with combat experience provided end-user input to delivery-device design through an interactive human-factors testing process. Results: Ten preclinical publications described efficacy, safety, dose translation, and risk-benefit analysis of exsanguination rescue with percutaneous-foam damage control. SOF medical providers guided weight, cubic, operational requirements, and limits for the foam delivery device. Conclusion: Presurgical exsanguination rescue with percutaneous foam damage control is safe and effective with a favorable risk-benefit profile in preclinical studies. Battlefield, presurgical use by SOF medical providers is conceptually possible. Adoption of the technology on the battlefield should proceed with SOF medical provider input.
Keywords: hemorrhage; noncompressable; bleeding; foam; advanced medic; abdominal; austere; ResQFoam
Croushorn J. 14(2). 6 - 8. (Journal Article)
Abstract
"Junctional hemorrhage" is defined as bleeding from the areas at the junction of the trunk and its appendages. This is an important cause of potentially preventable deaths on the battlefield and a difficult condition to treat in the civilian prehospital setting. Having a solution to definitively treat the condition decreases the mortality and morbidity of these injuries. The Abdominal Aortic and Junctional Tourniquet™ is (1) a Food and Drug Administration-cleared device that is currently indicated for pelvic, inguinal, and axillary bleeding; (2) the only junctional tourniquet with an indication for pelvic bleeding; (3) the only junctional tourniquet reported with a successful axillary use; and (4) effective at lower tissue pressures than other junctional tourniquets available.
Keywords: Abdominal Aortic and Junctional Tourniquet; hemorrhage; gunshot wound
Stigall K, Blough PE, Rall JM, Kauvar DS. 21(1). 30 - 36. (Journal Article)
Abstract
Background: Two methods of controlling pelvic and inguinal hemorrhage are the Abdominal Aortic and Junctional Tourniquet (AAJT; Compression Works) and resuscitative endovascular balloon occlusion of the aorta (REBOA). The AAJT can be applied quickly, but prolonged use may damage the bowel, inhibit ventilation, and obstruct surgical access. REBOA requires technical proficiency but avoids many of the complications associated with the AAJT. Conversion of the AAJT to REBOA would allow for field hemorrhage control with mitigation of the morbidity associated with prolonged AAJT use. Methods: Yorkshire male swine (n = 17; 70-90kg) underwent controlled 40% hemorrhage. Subsequently, AAJT was placed on the abdomen, midline, 2cm superior to the ilium, and inflated. After 1 hour, the animals were allocated to an additional 30 minutes of AAJT inflation (continuous AAJT occlusion [CAO]), REBOA placement with the AAJT inflated (overlapping aortic occlusion [OAO]), or REBOA placement following AAJT removal (sequential aortic occlusion [SAO]). Following removal, animals were observed for 3.5 hours. Results: No statistically significant differences in survival, blood pressure, or laboratory values were found following intervention. Conversion to REBOA was successful in all animals but one in the OAO group. REBOA placement time was 4.3 ± 2.9 minutes for OAO and 4.1 ± 1.8 minutes for SAO (p = .909). No animal had observable intestinal injury. Conclusions: Conversion of the AAJT to infrarenal REBOA is practical and effective, but access may be difficult while the AAJT is applied.
Keywords: hemorrhage; Abdominal Aortic and Junctional Tourniquet; resuscitative endovascular balloon occlusion of the aorta; swine
Anonymous A. 13(2). 1 - 2. (Journal Article)
Abstract
The Abdominal Aortic Tourniquet™ was used recently used in Afghanistan to control severe hemorrhage in a casualty who had traumatic bilateral amputations of the lower extremities. Excerpts from the medical provider's account of the tactical evacuation phase of care are provided.
Keywords: Abdominal Aortic Tourniquet ™; AAT; hemorrhage; amputations
Riesberg JC, Gurney JM, Morgan M, Northern DM, Onifer DJ, Gephart WJ, Remley MA, Eickhoff E, Miller C, Eastridge BJ, Montgomery HR, Butler FK, Drew B. 21(4). 138 - 142. (Classical Conference)
Abstract
Historically, about 20% of hospitalized combat injured patients have an abdominal injury. Abdominal evisceration may be expected to complicate as many as one-third of battle-related abdominal wounds. The outcomes for casualties with eviscerating injuries may be significantly improved with appropriate prehospital management. While not as extensively studied as other forms of combat injury, abdominal evisceration management recommendations extend back to at least World War I, when it was recognized as a significant cause of morbidity and was especially associated with bayonet injury. More recently, abdominal evisceration has been noted as a frequent result of penetrating, ballistic trauma. Initial management of abdominal evisceration for prehospital providers consists of assessing for and controlling associated hemorrhage, assessing for bowel content leakage, covering the eviscerated abdominal contents with a moist, sterile barrier, and carefully reassessing the patient. Mortality in abdominal evisceration is more likely to be secondary to associated injuries than to the evisceration itself. Attempting to establish education, training, and a standard of care for nonmedical and medical first responders and to leverage current wound management technologies, the Committee on Tactical Combat Casualty Care (CoTCCC) conducted a systematic review of historical Service guidelines and recent medical studies that include abdominal evisceration. For abdominal evisceration injuries, the following principles of management apply: (1) Control any associated bleeding visible in the wound. (2) If there is no evidence of spinal cord injury, allow the patient to take the position of most comfort. (3) Rinse the eviscerated bowel with clean fluid to reduce gross contamination. (4) Cover exposed bowel with a moist, sterile dressing or a sterile water-impermeable covering. It is important to keep the wound moist; irrigate the dressing with warm water if available. (4) For reduction in wounds that do not have a substantial loss of abdominal wall, a brief attempt may be made to replace/reduce the eviscerated abdominal contents. If the external contents do not easily go back into the abdominal cavity, do not force or spend more than 60 seconds attempting to reduce contents. If reduction of eviscerated contents is successful, reapproximate the skin using available material, preferably an adhesive dressing like a chest seal (other examples include safety pins, suture, staples, wound closure devices, etc.). Do not attempt to reduce bowel that is actively bleeding or leaking enteric contents. (6) If unable to reduce, cover the eviscerated organs with water-impermeable, nonadhesive material (transparent preferred to allow ability to reassess for ongoing bleeding; examples include a bowel bag, IV bag, clear food wrap, etc.), and then secure the impermeable dressing to the patient using an adhesive dressing (e.g., Ioban, chest seal). (7) Do NOT FORCE contents back into abdomen or actively bleeding viscera. (8) Death in the abdominally eviscerated patient is typically from associated injuries, such as concomitant solid organ or vascular injury, rather than from the evisceration itself. (9) Antibiotics should be administered for any open wounds, including abdominal eviscerating injuries. Parenteral ertapenem is the preferred antibiotic for these injuries.
Keywords: abdominal injury; abdominal evisceration; battle-related abdominal wounds; prehospital management
Cantle PM, Hurley MJ, Swartz MD, Holcomb JB. 18(2). 98 - 104. (Journal Article)
Abstract
Background: Noncompressible truncal hemorrhage (NCTH) after injury is associated with a mortality increase that is unchanged during the past 20 years. Current treatment consists of rapid transport and emergent intervention. Three early hemorrhage control interventions that may improve survival are placement of a resuscitative endovascular balloon occlusion of the aorta (REBOA), injection of intracavitary self-expanding foam, and application of the Abdominal Aortic Junctional Tourniquet (AAJT™). The goal of this work was to ascertain whether patients with uncontrolled abdominal or pelvic hemorrhage might benefit by the early or prehospital use of one of these interventions. Methods: This was a single-center retrospective study of patients who received a trauma laparotomy from 2013 to 2015. Operative reports were reviewed. The probable benefit of each hemorrhage control method was evaluated for each patient based on the location(s) of injury and the severity of their physiologic derangement. The potential scope of applicability of each control method was then directly compared. Results: During the study period, 9,608 patients were admitted; 402 patients required an emergent trauma laparotomy. REBOA was potentially beneficial for hemorrhage control in 384 (96%) of patients, foam in 351 (87%), and AAJT in 35 (9%). There was no statistically significant difference in the potential scope of applicability between REBOA and foam (ρ = .022). There was a significant difference between REBOA and AAJT (ρ < .001) and foam and AAJT™ (ρ < .001). The external surface location of signs of injury did not correlate with the internal injury location identified during laparotomy. Conclusion: Early use of REBOA and foam potentially benefits the largest number of patients with abdominal or pelvic bleeding and may have widespread applicability for patients in the preoperative, and potentially the prehospital, setting. AAJT may be useful with specific types of injury. The site of bleeding must be considered before the use of any of these tools.
Keywords: trauma; resuscitation; abdominal hemorrhage; foam; baloon aortic occlusion; junctional tourniquet
Riesberg JC, Gurney JM, Morgan M, Northern DM, Onifer DJ, Gephart WJ, Remley MA, Eickhoff E, Miller C, Eastridge BJ, Montgomery HR, Butler FK, Drew B. 21(4). 138 - 142. (Classical Conference)
Abstract
Historically, about 20% of hospitalized combat injured patients have an abdominal injury. Abdominal evisceration may be expected to complicate as many as one-third of battle-related abdominal wounds. The outcomes for casualties with eviscerating injuries may be significantly improved with appropriate prehospital management. While not as extensively studied as other forms of combat injury, abdominal evisceration management recommendations extend back to at least World War I, when it was recognized as a significant cause of morbidity and was especially associated with bayonet injury. More recently, abdominal evisceration has been noted as a frequent result of penetrating, ballistic trauma. Initial management of abdominal evisceration for prehospital providers consists of assessing for and controlling associated hemorrhage, assessing for bowel content leakage, covering the eviscerated abdominal contents with a moist, sterile barrier, and carefully reassessing the patient. Mortality in abdominal evisceration is more likely to be secondary to associated injuries than to the evisceration itself. Attempting to establish education, training, and a standard of care for nonmedical and medical first responders and to leverage current wound management technologies, the Committee on Tactical Combat Casualty Care (CoTCCC) conducted a systematic review of historical Service guidelines and recent medical studies that include abdominal evisceration. For abdominal evisceration injuries, the following principles of management apply: (1) Control any associated bleeding visible in the wound. (2) If there is no evidence of spinal cord injury, allow the patient to take the position of most comfort. (3) Rinse the eviscerated bowel with clean fluid to reduce gross contamination. (4) Cover exposed bowel with a moist, sterile dressing or a sterile water-impermeable covering. It is important to keep the wound moist; irrigate the dressing with warm water if available. (4) For reduction in wounds that do not have a substantial loss of abdominal wall, a brief attempt may be made to replace/reduce the eviscerated abdominal contents. If the external contents do not easily go back into the abdominal cavity, do not force or spend more than 60 seconds attempting to reduce contents. If reduction of eviscerated contents is successful, reapproximate the skin using available material, preferably an adhesive dressing like a chest seal (other examples include safety pins, suture, staples, wound closure devices, etc.). Do not attempt to reduce bowel that is actively bleeding or leaking enteric contents. (6) If unable to reduce, cover the eviscerated organs with water-impermeable, nonadhesive material (transparent preferred to allow ability to reassess for ongoing bleeding; examples include a bowel bag, IV bag, clear food wrap, etc.), and then secure the impermeable dressing to the patient using an adhesive dressing (e.g., Ioban, chest seal). (7) Do NOT FORCE contents back into abdomen or actively bleeding viscera. (8) Death in the abdominally eviscerated patient is typically from associated injuries, such as concomitant solid organ or vascular injury, rather than from the evisceration itself. (9) Antibiotics should be administered for any open wounds, including abdominal eviscerating injuries. Parenteral ertapenem is the preferred antibiotic for these injuries.
Keywords: abdominal injury; abdominal evisceration; battle-related abdominal wounds; prehospital management
Banting J, Meriano T. 15(1). 118 - 122. (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 operations medical technicians will be part of the feature.
Keywords: pain; abdominal pain; appendicitis; diagnosis; treatment
Avilla J, Rerucha C, Hu C. 23(2). 99 - 101. (Journal Article)
Abstract
The presentation of Type 3c diabetes is atypical, accounting for 0.5-1% of all types of diabetes. Combining this with the healthy Special Operations community is even more profound. A 38-year-old active-duty male in Special Operations developed acute abdominal pain and vomiting while deployed. He was diagnosed with severe acute necrotizing pancreatitis secondary to Type 3c diabetes, and the management of his condition became increasingly difficult. This case highlights Type 3c diabetes and the complexity of formulating a comprehensive treatment plan for a tactical athlete.
Keywords: tactical; type 3c diabetes; abdominal pain; pancreatitis; athlete; Special Operations
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
King DR, Larentzakis A. 14(2). 56 - 59. (Journal Article)
Abstract
Sea urchin injuries can be sustained in a variety of environments in which U.S. Forces are operating, and familiarity with this uncommon injury can be useful. Injuries by sea urchin spines can occur during military activities close to rocky salt aquatic ecosystems via three mechanisms. The author describes these mechanisms and discusses the diagnosis, management, and treatment of sea urchin injuries.
Keywords: sea urchin; spines; laser; ablation
Goldmann J, Braunstein B, Sanno M, Kurzner S, Brüggemann G, Mester J. 14(2). 80 - 83. (Journal Article)
Abstract
Objectives: Short-term exposure (2-30 seconds) to segmental mechanical vibrations with frequencies between 20 and 80 Hz affects proprioception of the central nervous system and manual dexterity and strength of man. It could be supposed that during fast-roping, Soldiers are exposed to hand-arm vibrations caused by the geometry of the rope. After the maneuver, Soldiers are encouraged to operate with high precision (e.g., aiming and shooting) within a few seconds. For safety, disturbances of the sensory system should be strongly avoided. The purpose of the study was to determine the vibrations induced by different rope geometries during fast-roping. Methods: Eight men of the German Special Forces performed 10 fast-roping maneuvers with two different shaped ropes (slightly molded versus deeply molded). Vibration data and frequency spectrum for each trial were measured by using fast Fourier transformation. Results: The analysis of data showed that fast-roping with a slightly molded rope produced frequencies of up to 10 Hz, while the frequencies with a deeply molded rope accounted for 18 to 60 Hz. The ropes differed significantly (ρ < .001) in frequencies between 20 and 50 Hz. The exposure time of vibration lasted between 3 and 5 seconds. Conclusion: Considering the negative effects associated with vibrations, prudence is required when using deeply molded ropes due to the increased vibrations of about 20 Hz.
Keywords: fast-roping; vibrations; motion; rope; sensations; rappelling; abseiling; kinesthetic illusions; Special Operations Forces
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
Florance JM, Florance C. 18(3). 28 - 32. (Journal Article)
Abstract
Background: Given a denied or resource-limited area of operations, when air medical evacuation would require extended delay, should dismounted movement through difficult terrain dissuade an attempt of immediate ground evacuation? Understanding the magnitude of external forces during dismounted movement would inform planning in such circumstances. Objectives: We assessed the mechanical impact experienced during dismounted evacuation from mountainous terrain. We also describe a protocol using a portable accelerometer to evaluate evacuation. Materials and Methods: A triaxial accelerometer and a semiflexible litter were used to collect data during the Army Mountain Warfare School Rough Terrain Evacuation Course. We used the generalized extreme value (GEV) distribution, using maximum likelihood estimation, to model maximum acceleration values. Results: It was determined that the accelerometer should be mounted directly onto a mannequin when using semiflexible litters. GEV analysis from a mannequin-mounted trial revealed that for 1-minute evacuation intervals, 10% would have a maximum acceleration over a value between 2.4g and 3.7g. This interval encompasses the maximum acceleration from evacuation using a Mine-Resistant Ambush Protected (MRAP) vehicle, measured by the US Army Aeromedical Research Laboratory. The peak acceleration from a 75-minute, mannequin-mounted trial was 5.5g, approximately twice as large as the MRAP maximum. Conclusion: For the evacuee, the acceleration experienced during dismounted evacuation in mountainous terrain can be comparable to MRAP evacuation, especially with sufficient planning that avoids points of maximum impact. Leaders can consider this comparison during planning.
Keywords: acceleration; movement; military personnel; emergencies; warfare; stretchers; transportation; rescue work
Thabouillot O, Boddaert G, Travers S, Dubecq C, Derkenne C, Kedzierewicz R, Bertho K, Prunet B. 21(3). 36 - 40. (Journal Article)
Abstract
Background: Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a technique that uses internal clamping of the aorta to control abdominal, pelvic, or junctional bleeding. We created a course to train military physicians in both civilian prehospital use and battlefield use. To determine the effectiveness of this training, we conducted REBOA training for French military emergency physicians. Methods: We trained 15 military physicians, organizing the training as follows: a half-day of theoretical training, a half-day of training on mannequins, a half-day on human corpses, and a half-day on a living pig. The primary endpoint was the success rate after training. We defined success as the balloon being inflated in zone 1 of a PryTime mannequin. The secondary endpoints were the progression of each trainee during the training, the difference between the median completion duration before and after training, the median post-training duration, and the median duration for the placement of the sheath introducer before and after training. Results: Fourteen of the physicians (93%) correctly placed the balloon in the mannequin at the end of the training period. During the training, the success rate increased from 73% to 93% (p = .33). The median time for REBOA after training was only 222 seconds (interquartile range [IQR] 194-278), significantly faster than before training (330 seconds, IQR 260-360.5; p = .0033). We also found significantly faster sheath introducer placement (148 seconds, IQR 126-203 versus 145 seconds, IQR 115.5 - 192.5; p = .426). Conclusion: The training can be performed successfully and paves the way for the use of REBOA by emergency physicians in austere conditions.
Keywords: accident and emergency medicine; education and training; trauma management; REBOA; military
Gattere M, Scaffei N, Gozzetti L, Alessandrini M. 21(1). 120 - 123. (Journal Article)
Abstract
As a result of the increasing use and application of military tourniquets in civilian settings, it is necessary to evaluate the size and effectiveness of the equipment on patients that differ from the military-aged population for whom the devices have been primarily created. This case report describes the application of a tourniquet on a pediatric patient while also profiling a common situation in which the Combat Application Tourniquet GEN 7 (C-A-T Resources) might be used in civilian care systems. The case is that of a 14-month-old child who suffered a limb amputation secondary to a road accident in Italy and the ensuing life-saving treatment. The intervening nurse at the scene had been trained on the use of hemorrhage-control devices through the American College of Surgeons "Stop the Bleed" campaign.
Keywords: tourniquet; hemorrhage; child; pediatric; military personnel; accidents; amputation; Stop the Bleed; NATO Special Operations Combat Medic; NSCOM
Plackett TP, Nielsen JS, Hahn CD, Rames JM. 16(1). 51 - 56. (Journal Article)
Abstract
Background: Accurate point-of-injury reports and casualty evacuation requests allow for optimal resource utilization. However, the accuracy of these reports has not been previously studied. Methods: All trauma patients treated at one of three forward surgical elements (FSE) in Western Afghanistan during May-August 2012 were prospectively included. North American Treaty Organization (NATO) 9-line medical evacuation request and mechanism, injuries, signs, and treatments (MIST) reports were compared to the initial findings on arrival to the FSE. Results: There were 179 casualty evacuation reports and 298 patients. NATO 9-line and/or MIST reports were available for 70% of these. Triage was accurate for 77%, but there was 17% overtriage and 6% undertriage (k = .619). The number of patients was accurate in 95% of reports, the mechanism of injury was accurate for 98%, and the body region involved was accurate for 92% (k = .850, .943, and .870, respectively). There was no difference between the mean vital signs at the point of injury or on arrival at the FSE. When analyzed individually, however, there was no correlation between each casualty's pulse, mean arterial pressure, or respiratory rate between the two time points. Discussion: There was a high degree of correlation between the triage category of casualty evacuation reports and the patient's actual medical needs. There was also a highly significant association with the number of patients, mechanism of injury, and bodily injuries. However, there was discordance between the vital signs at an individual level, which may represent regression toward the resuscitation threshold.
Keywords: triage; trauma; war; Afghanistan; combat; accuracy
Gerold KB, Gibbons ME, Fisette RE, Alves D. 15(1). 62 - 69. (Journal Article)
Abstract
Excited delirium syndrome (ExDS) is a term used to describe patients experiencing a clinical condition characterized by bizarre and aggressive behavior, often in association with the use of chronic sympathomimetic drug abuse. The agitated and disruptive behavior of persons with ExDS often results in a call to police resulting in an arrest for disorderly conduct. The suspect's inability to comply with police commands during the arrest frequently results in a struggle and the use of physical or chemical control measures, including the use of conductive energy weapons (CEWs). Deaths from this hypermetabolic syndrome are infrequent but potentially preventable with early identification, a coordinated aggressive police intervention, and prompt medical care. Preliminary experiences suggest that ExDS is a medical emergency treated most effectively using a coordinated response between police officers and emergency medical providers. Once the person suspected of experiencing ExDS is in custody, medical providers should rapidly sedate noncompliant patients with medications such as ketamine or an antipsychotic drug such as haloperidol in combination with a benzodiazepine drug such as midazolam or diazepam. Once sedated, patients should undergo a screening medical assessment and undergo initial treatment for conditions such as hyperthermia and dehydration. All patients exhibiting signs of ExDS should be transported rapidly to a medical treatment facility for further evaluation and treatment. This article reviews the epidemiology, clinical presentation, diagnosis, and treatment options for ExDS.
Keywords: excited delirium; excited delirium syndrome; delirium; sudden death; in-custody death; hyperthermia; sympathomimetic drug use; cocaine; phencyclidine; lysergic acid diethylamide; ketamine; haloperidol; taser; conductive energy weapon; Agitated Chaotic Event&tm;; ACE; medical emergency; emergency medical services; police
Vokoun ES. 15(2). 71 - 73. (Journal Article)
Abstract
Use of intravenous acetaminophen has increased recently as an opioid-sparing strategy for patients undergoing major surgery. Its characteristics and efficacy suggest that it would a useful adjunct in combat trauma medicine. This article reviews those characteristics, which include rapid onset, high peak plasma concentration, and favorable side-effect profile. Also discussed is the hepatotoxicity risk of acetaminophen in a combat trauma patient. It concludes that intravenous acetaminophen should be considered as an addition to the US Special Operations Command Tactical Trauma Protocols and supplied to medics for use in field care.
Keywords: acetaminophen, intravenous; trauma, combat; prolonged field care
Bowles JM, Joas C, Head S. 15(3). 1 - 3. (Journal Article)
Abstract
Acute hemolytic anemia (AHA) due to glucose 6-phosphate dehydrogenase (G6PD) deficiency has rarely been recognized as a contributor to the development of frostbite. We discuss a case of frostbite in a 32-year-old male Marine with G6PD deficiency during military training on Mount Mckinley in Alaska, which eventually led to a permanent disability. In this report, the pathophysiology of G6PD deficiency, the effects of hemolytic anemia, and factors that contribute to frostbite will be discussed, as well as the clinical findings, treatment course, and the outcome of this case. The patient was evacuated and admitted to Alaska Regional Hospital. He was treated for fourth-degree frostbite, ultimately resulting in the complete or partial amputation of all toes. Although it cannot be proved that AHA occurred in this patient, this case potentially adds frostbite to the list of rare but possible clinical presentations of G6PD deficiency.
Keywords: G6PD Deficiency; frostbite; acetazolamide; acute hemolytic anemia; oxidative stress; reactive oxygen species
Levri JM, Ocon A, Schunk P, Cunningham CW. 17(3). 21 - 23. (Journal Article)
Abstract
Acute ischemic stroke (AIS) treatment guidelines include various recommendations for treatment once the patient arrives at the hospital. Prehospital care recommendations, however, are limited to expeditious transport to a qualified hospital and supportive care. The literature has insufficiently considered prehospital antiplatelet therapy. An otherwise healthy 30-year-old black man presented with headache for about 3 hours, left-sided facial and upper extremity numbness, slurred speech, miosis, lacrimation, and general fatigue and malaise. The presentation occurred at a time and location where appropriate resources to manage potential AIS were limited. The patient received a thorough physical examination and electrocardiogram. Acetylsalicylic acid (ASA) 325mg was administered within 15 minutes of history and examination. A local host-nation ambulance arrived approximately 30 minutes after presentation. The patient's neurologic symptoms had abated by the time the ambulance arrived. The patient did not undergo magnetic resonance imaging (MRI) until 72 hours after being admitted, owing to lack of neurology staff over the weekend. The MRI showed evidence of a left-sided, posteriorinferior cerebellar artery stroke. The patient was then taken to a different hospital, where he received care for his acute stroke. The patient eventually was prescribed a statin, ASA, and an angiotensin-converting enzyme inhibitor. The patient has no lingering symptoms or neurologic deficits.
Keywords: stroke, acute ischemic; prehospital treatment; acetylsalicylic acid; antiplatelet
Griffin J, Barnhill JC, Washington MA. 19(1). 14 - 15. (Case Reports)
Abstract
The genus Acinetobacter has long been associated with war wounds. Indeed, A baumannii was responsible for so many infected wounds during Operation Iraqi Freedom that it was given the nickname "Iraqibacter." Therefore, it is important to monitor the occurrence and spread of Acinetobacter species in military populations and to identify new or unusual sources of infection. A junii is an infrequently reported human pathogen. Here, we report a case of a slow-healing wound infection with A junii in a woman on the island of Oahu. This case highlights the pathogenic potential of this organism and the need for proper wound care when dealing with slow-healing wounds of unknown etiology. It also underscores the need for identifying species of Acinetobacter that are not A baumannii to better understand the epidemiology of slow-healing wound infections.
Keywords: Acinetobacter junii; emerging infection; Hawaii; Oahu; wound
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
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
Thompson P, Hudson AJ. 19(4). 62 - 65. (Journal Article)
Abstract
Treating hemorrhagic shock is challenging, the pathology is complex, and time is critical. Treatment requires resources in mental bandwidth (i.e., focused attention), drugs and blood products, equipment, and personnel. Providers must focus on treatment options in order of priority while also maintaining a dynamic assessment of the patient's response to treatment and considering potential differential diagnoses. In this process, the cognitive load is substantial. To avoid errors of clinical reasoning and practical errors of commission, omission, or becoming fixated, it is necessary to use evidence-based treatment recommendations that are concise, in priority order, and easily recalled. This is particularly the case in the austere, remote, or tactical environment. A simple mnemonic acronym, SMART, is presented in this article. It is a clinical heuristic that can be used as an aide-mémoire during the initial phases of resuscitation of the trauma patient with hemorrhagic shock: Start the clock and Stop the bleeding; Maintain perfusion; Administer antifibrinolytics; Retain heat; Titrate blood products and calcium; Think of alternative causes of shock.
Keywords: hemorrhage; shock; treatment; mnemonic; acronym; heuristic
Yarnell AM, Deuster PA. 16(1). 81 - 85. (Journal Article)
Abstract
Recovery is an essential component of maintaining, sustaining, and optimizing cognitive and physical performance during and after demanding training and strenuous missions. Getting sufficient amounts of rest and sleep is key to recovery. This article focuses on sleep and discusses (1) why getting sufficient sleep is important, (2) how to optimize sleep, and (3) tools available to help maximize sleep-related performance. Insufficient sleep negatively impacts safety and readiness through reduced cognitive function, more accidents, and increased military friendly-fire incidents. Sufficient sleep is linked to better cognitive performance outcomes, increased vigor, and better physical and athletic performance as well as improved emotional and social functioning. Because Special Operations missions do not always allow for optimal rest or sleep, the impact of reduced rest and sleep on readiness and mission success should be minimized through appropriate preparation and planning. Preparation includes periods of "banking" or extending sleep opportunities before periods of loss, monitoring sleep by using tools like actigraphy to measure sleep and activity, assessing mental effectiveness, exploiting strategic sleep opportunities, and consuming caffeine at recommended doses to reduce fatigue during periods of loss. Together, these efforts may decrease the impact of sleep loss on mission and performance.
Keywords: actigraphy; caffeine; cognitive; napping; readiness; sleep
Stopyra JP, Bozeman WP, Callaway DW, Winslow J, McGinnis HD, Sempsrott J, Evans-Taylor L, Alson RL. 16(3). 36 - 40. (Journal Article)
Abstract
There is some controversy about whether ballistic protective equipment (body armor) is required for medical responders who may be called to respond to active shooter mass casualty incidents. In this article, we describe the ongoing evolution of recommendations to optimize medical care to injured victims at such an incident. We propose that body armor is not mandatory for medical responders participating in a rapid-response capacity, in keeping with the Hartford Consensus and Arlington Rescue Task Force models. However, we acknowledge that the development and implementation of these programs may benefit from the availability of such equipment as one component of risk mitigation. Many police agencies regularly retire body armor on a defined time schedule before the end of its effective service life. Coordination with law enforcement may allow such retired body armor to be available to other public safety agencies, such as fire and emergency medical services, providing some degree of ballistic protection to medical responders at little or no cost during the rare mass casualty incident. To provide visual demonstration of this concept, we tested three "retired" ballistic vests with ages ranging from 6 to 27 years. The vests were shot at close range using police-issue 9mm, .40 caliber, .45 caliber, and 12-gauge shotgun rounds. Photographs demonstrate that the vests maintained their ballistic protection and defeated all of these rounds.
Keywords: body armor; ballistics; active shooter; active assailant; mass-casualty event
Kragh JF, Zhao NO, Aden JK, Dubick MA. 18(4). 57 - 63. (Journal Article)
Abstract
Background: The purpose of this study was to simulate first aid by mechanical use of a limb tourniquet on a thigh with and without bone to better understand best caregiving practices. Methods: Two investigators studied simulated first aid on a new pool "noodle," a plastic cylinder with a central air tunnel into which we inserted a wood dowel to simulate bone. Data were gathered by group (study and control, n = 12 each). The control group comprised data collected from simulated tourniquet use on the model with bone present. The study group comprised data from simulated tourniquet use on the model without bone. Results: Comparing compression with and without bone, the mean volumes of compressed soft tissues alone were 303mL and 306mL, respectively. When bone was present, the volume of soft tissues was squeezed more, yielding a smaller size by 3mL (1%). The bone had a volume of 41mL and pressed statically outward with an equal force oppositely directed to the inward compression of the overlying soft tissues. With bone removed and compression applied, the mean residual void was 16mL, because 25mL (i.e., 41mL minus 16mL) of soft tissues had collapsed inward. The volume of the limb under the tourniquet with and without bone was 344mL and 322mL, respectively. The collapse volume, 25mL, was 3mL more than the difference of the mean volume of the limb under the tourniquet. More limb squeeze (22mL) looked like better compression, but it was actually worse-an illusion created by collapse of the hidden void. Conclusion: In simulated first aid, mechanical modeling demonstrated how tourniquet compression applied to a limb squeezed the soft tissues better when underlying bone was present. Bone loss altered the compression profile and may complicate control of bleeding in care. This knowledge, its depiction, and its demonstration may inform first-aid instructors.
Keywords: caregiver; choice behavior; public health; medical device; active learning; tourniquet; mechanics
Stopyra JP, Bozeman WP, Callaway DW, Winslow J, McGinnis HD, Sempsrott J, Evans-Taylor L, Alson RL. 16(3). 36 - 40. (Journal Article)
Abstract
There is some controversy about whether ballistic protective equipment (body armor) is required for medical responders who may be called to respond to active shooter mass casualty incidents. In this article, we describe the ongoing evolution of recommendations to optimize medical care to injured victims at such an incident. We propose that body armor is not mandatory for medical responders participating in a rapid-response capacity, in keeping with the Hartford Consensus and Arlington Rescue Task Force models. However, we acknowledge that the development and implementation of these programs may benefit from the availability of such equipment as one component of risk mitigation. Many police agencies regularly retire body armor on a defined time schedule before the end of its effective service life. Coordination with law enforcement may allow such retired body armor to be available to other public safety agencies, such as fire and emergency medical services, providing some degree of ballistic protection to medical responders at little or no cost during the rare mass casualty incident. To provide visual demonstration of this concept, we tested three "retired" ballistic vests with ages ranging from 6 to 27 years. The vests were shot at close range using police-issue 9mm, .40 caliber, .45 caliber, and 12-gauge shotgun rounds. Photographs demonstrate that the vests maintained their ballistic protection and defeated all of these rounds.
Keywords: body armor; ballistics; active shooter; active assailant; mass-casualty event
Chovaz M, Patel RV, March JA, Taylor SE, Brewer KL. 18(4). 82 - 86. (Journal Article)
Abstract
Background: Historically, staging of civilian emergency medical services (EMS) during an active shooter incident was in the cold zone while these professionals awaited the scene to be completely secured by multiple waves of law enforcement. This delay in EMS response has led to the development of a more effective method: the Rescue Task Force (RTF). The RTF concept has the second wave of law enforcement escorting civilian EMS into the warm zone, thus decreasing EMS response time. To our knowledge, there are no data regarding the willingness of EMS professionals to enter a warm zone as part of an RTF. In this study, we assessed the willingness of EMS providers to respond to an active shooter incident as part of an RTF. Methods: A survey was distributed at an annual, educational EMS conference in North Carolina. The surveys were distributed on the first day of the conference at the beginning of a general session that focused on EMS stress and wellness. Total attendance was measured using identification badges and scanners on exiting the session. Data were assessed using χ2 analysis, as were associations between demographics of interest and willingness to respond under certain conditions. A p value < .01 indicated statistical significance. Results: The overall response rate was 76% (n = 391 of 515 session attendees). Most surveys were completed by paramedics (74%; n = 288 of 391). Most EMS professionals (75%; n = 293 of 391) stated they would respond to the given active shooter scenario as part of an RTF (escorted by the second wave of law enforcement) if they were given only ballistic gear. However, most EMS professionals (61%; n = 239 of 391) stated they would not respond if they were provided no ballistic gear and no firearm. Those with tactical or military training were more willing to respond with no ballistic gear and no firearm (49.6%; n = 68 of 137) versus those without such training (31%; n = 79 of 250; odds ratio, 2.2; 95% confidence interval, 1.4-3.3; p < .001). Conclusion: EMS professionals are willing to put themselves in harm's way by entering a warm zone if they are simply provided the proper training and ballistic equipment.
Keywords: emergency medical services; EMS; active shooter incident; Rescue Task Force
Neal DJ, Loconti P, Mengel T, Holway K, Wenner D. 22(4). 60 - 64. (Journal Article)
Abstract
On October 10, 2019, the Loudoun County Sheriff's Office (LCSO) and Loudoun County Fire and Rescue (LCFR) led one of the largest act of violence (AVI) exercises ever conducted in Loudoun County, Virginia. Over 300 participants and 50 role-players participated across 15 county departments and agencies within Loudoun County. The exercise identified an important recommendation: "future joint unified command trainings are needed throughout the fire and law enforcement command structures." Effective, unified command is an essential NFPA 3000 principle of responding to an AVI. "The success or failure of the response will hinge on the quality of unified command." After-action reports from AVIs across the United States emphasized the importance of unified command. A second exercise recommendation proposed "a joint AVI unified command competency scenario between LCFR and LCSO should be developed and delivered across all levels of supervision... this scenario should demonstrate 'best practices' for establishing and operating unified command between LCFR and LCSO." The authors developed two active shooter command competency simulations that require LCSO and LCFR to form unified command and manage the initial response. The simulations reinforced accepted response practices, such as identification of cold/warm/hot zones, early unified command, rescue task force team deployment, and protected corridor establishment. The simulations were packaged into a unified command competency training and simulation program. Through the facilitated debriefings with participants and facilitator debriefs, three types of lessons learned were identified: 1) high threat incident response lessons, 2) lessons for conducting AVIs in the command competency lab, and 3) active threat operational considerations for command officers.
Keywords: active shooter training; Rescue Task Force; unified command; mass casualty; training
Brown J, Soto MA, Lindsay KG, Harris M, Karagosian SA, Bailey K, Hutchins A. 24(2). 44 - 50. (Journal Article)
Abstract
Background: This study assessed omega-3 fatty acid (O3FA) status, previous brain injury risk exposures, and associations between O3FA status and risk exposures among active-duty military personnel. Methods: O3FA status was measured by a Holman omega-3 blood test. A survey was conducted to assess brain injury risk history and dietary O3FA factors. Results: More than 50% of the participants had high-risk status, based on an omega-3 index (O3I) <4%, while less than 2% of the participants recorded low-risk O3I (>8%). O3FA supplementation (p<.001, Cramer's V=0.342) and fish consumption (p<.001, Cramer's V=0.210) were positively correlated with O3FA status. Only 5 O3FA supplement users (n=97 [5.2%]) had a low-risk O3I status, while all nonusers (n=223) had moderateto high-risk O3I status. Conclusions: Supplementing with O3FA was associated with better O3I status in this population. However, only a few participants achieved optimal O3I status even when taking an O3FA supplement. Participants who ate fish and did not supplement were in the moderateor high-risk O3I groups.
Keywords: omega-3 fatty acids; brain health; brain injury; brain injury risk; traumatic brain injury; TBI; active-duty military; Special Operations; Special Operations Forces; SOF
Knapik JJ. 15(1). 123 - 127. (Journal Article)
Abstract
Physical fitness can be defined as a set of attributes that allows the ability to perform physical activity. The attributes or components of fitness were identified by testing large numbers of individuals on physical performance tests (e.g., sit-ups, push-ups, runs, pull-ups, rope climbs, vertical jump, long jumps), and using statistical techniques to find tests that seem to share common performance requirements. These studies identified strength, muscular endurance, cardiorespiratory endurance, coordination, balance, flexibility, and body composition as important fitness components. Military studies have clearly shown that individuals with lower levels of cardiorespiratory endurance or muscular endurance are more likely to be injured and that improving fitness lowers injury risk. Those who are more fit perform activity at a lower percentage of their maximal capability and so can perform the task for a longer period of time, fatigue less rapidly, recover faster, and have greater reserve capacity for subsequent tasks. Fatigue alters movement patterns, putting stress on parts of the body unaccustomed to it, possibly increasing the likelihood of injury. Soldiers should develop and maintain high levels of physical fitness, not only for optimal performance of occupational tasks but also to reduce injury risk.
Keywords: physical fitness; injury prevention; activity; stress; cardiorespiratory endurance; injuries; muscular endurance
Guthrie RM, Chorba R. 16(1). 1 - 5. (Case Reports)
Abstract
Purpose: Chronic mechanical neck pain can have a complex clinical presentation and is often difficult to treat. This case study illustrates a successful physical therapy treatment approach using dry needling and auricular acupuncture techniques. Case Report: A 51-year-old active-duty, male US Marine was treated by a physical therapist in a direct-access military clinic for chronic neck pain poorly responsive to previous physical therapy, pharmacologic, and surgical interventions. Needling techniques were combined with standard physical therapy interventions to address the comprehensive needs of the patient. Within five treatments, the patient reported reduced pain levels from 8-9/10 to 0-2/10, improved sleep quality, and increased function with daily activities. Over several months, the patient reduced multiple medication use by greater than 85%. The effects of treatment were lasting, and the patient accomplished a successful transition to an independent maintenance program. Conclusion: Needling techniques have the potential to expedite favorable physical therapy outcomes for active-duty service members suffering from chronic mechanical and degenerative neck pain. The dramatic improvements observed in this case warrant additional exploration of treatment efficacy and delineation of best practices in the delivery of these techniques.
Keywords: pain, neck; physical therapy; dry needling; acupuncture; acupuncture, battlefield; pain management
Guthrie RM, Chorba R. 16(1). 1 - 5. (Case Reports)
Abstract
Purpose: Chronic mechanical neck pain can have a complex clinical presentation and is often difficult to treat. This case study illustrates a successful physical therapy treatment approach using dry needling and auricular acupuncture techniques. Case Report: A 51-year-old active-duty, male US Marine was treated by a physical therapist in a direct-access military clinic for chronic neck pain poorly responsive to previous physical therapy, pharmacologic, and surgical interventions. Needling techniques were combined with standard physical therapy interventions to address the comprehensive needs of the patient. Within five treatments, the patient reported reduced pain levels from 8-9/10 to 0-2/10, improved sleep quality, and increased function with daily activities. Over several months, the patient reduced multiple medication use by greater than 85%. The effects of treatment were lasting, and the patient accomplished a successful transition to an independent maintenance program. Conclusion: Needling techniques have the potential to expedite favorable physical therapy outcomes for active-duty service members suffering from chronic mechanical and degenerative neck pain. The dramatic improvements observed in this case warrant additional exploration of treatment efficacy and delineation of best practices in the delivery of these techniques.
Keywords: pain, neck; physical therapy; dry needling; acupuncture; acupuncture, battlefield; pain management
Lee JD, Bowley DM, Miles JA, Muzaffar J, Poole R, Orr LE. 20(4). 104 - 111. (Journal Article)
Abstract
Frontline military personnel are at high risk of acute acoustic trauma (AAT) caused by impulse noise, such as weapon firing or blast. This can result in anatomic disruption of the tympanic membrane and damage to the middle and inner ear, leading to conductive, sensorineural, or mixed hearing loss that may be temporary or permanent. AAT reduces warfighters' operational effectiveness and has implications for future quality of life. Hearing protection devices can mitigate AAT but are not completely protective. Novel therapeutic options now exist; therefore, identification of AAT as soon as possible from point of injury is vital to ensure optimal treatment and fulfillment of the duty of care. Early recognition and treatment of frontline AAT can maintain the deployed team's capabilities, avoid unnecessary case evacuation (CASEVAC), and raise awareness of military occupational AAT. This will help prioritize hearing preservation, maintain the fighting force, and ultimately retain personnel in service. The UK Defence hearWELL research collaboration has developed a frontline protocol for the assessment of AAT utilizing future-facing technology developed by the US Department of Defense: the Downrange Acoustic Toolbox (DAT). The DAT has been operationally deployed since 2019 and has successfully identified AAT requiring treatment, thereby improving casualties' hearing and reducing unnecessary repatriation.
Keywords: hearing loss, noise-induced; acute acoustic trauma; noise, occupational; military personnel; hearing protective devices; telemedicine; steroid
Farber SJ, Kantar RS, Rodriguez ED. 18(3). 62 - 66. (Journal Article)
Abstract
As the United States continues to increase its use of Special Operations Forces worldwide, treatment of craniomaxillofacial (CMF) trauma must be adapted to meet the needs of the warfighter. The remoteness of Special Operations can result in potentially longer times until definitive treatment may be reached. A significant portion of Servicemembers incur injury to the CMF region (42%). Severe CMF trauma can result in substantial hemorrhage and airway compromise. These can be immediately life threatening and must be addressed expeditiously. Numerous devices and techniques for airway management have been made available to the forward provider. A thorough review of nonsurgical and surgical airway management of the patient with facial injury for the forward provider and providers at receiving facilities is provided in this article. Techniques to address flail segments of the facial skeleton are critical in minimizing airway compromise in these patients. There are many methods to control hemorrhage from the head and neck region. Hemorrhage control is critical to ensure survival in the austere environment and allow for transport to a definitive care facility. Associated injuries to the cervical spine, globe, skull base, carotid artery, and brain must be carefully evaluated and addressed in these patients. Management of vision- threatening orbital compartment syndrome is critical in patients with CMF injuries. Because the head and neck region remains relatively vulnerable in the warfighter, combat CMF trauma will continue to occur. Forward providers will benefit from a review of the acute treatment of CMF traumatic injury. Properly triaging and treating facial injuries is necessary to afford the best chance of survival for patients with a devastating combat CMF injury.
Keywords: craniomaxillofacial trauma; airway management; acute care; hemorrhage; ocular trauma
Smedick BC, van Wyck D. 16(3). 5 - 9. (Journal Article)
Abstract
Acute compartment syndrome (ACS) involving the leg can occur in association with various traumatic and nontraumatic conditions, and it can have serious longterm consequences when unrecognized or untreated. Nontraumatic causes of ACS, such as those associated with cases of prolonged immobilization and/or extremity compression, can be easily overlooked, and several cases of ACS occurring with prolonged surgical positioning can be found in the literature. We present the case of a 19-year-old Army paratrooper who developed acute anterior and lateral compartment syndrome of the lower extremity after being immobilized in an aircraft for hours with several hundred pounds of equipment compressing his lower extremities. To our knowledge, this is the first documented case of ACS occurring as a result of prejump conditions. It demonstrates a potentially serious complication that could result in medical separation and/or permanent disability of the service member. ACS of the extremity should be considered in any Soldier who is required to bear heavy loads, is immobilized for several hours at a time, and complains of symptoms such as extremity pain, numbness, and weakness.
Keywords: acute compartment syndrome, pressure; immobilization
Bowles JM, Joas C, Head S. 15(3). 1 - 3. (Journal Article)
Abstract
Acute hemolytic anemia (AHA) due to glucose 6-phosphate dehydrogenase (G6PD) deficiency has rarely been recognized as a contributor to the development of frostbite. We discuss a case of frostbite in a 32-year-old male Marine with G6PD deficiency during military training on Mount Mckinley in Alaska, which eventually led to a permanent disability. In this report, the pathophysiology of G6PD deficiency, the effects of hemolytic anemia, and factors that contribute to frostbite will be discussed, as well as the clinical findings, treatment course, and the outcome of this case. The patient was evacuated and admitted to Alaska Regional Hospital. He was treated for fourth-degree frostbite, ultimately resulting in the complete or partial amputation of all toes. Although it cannot be proved that AHA occurred in this patient, this case potentially adds frostbite to the list of rare but possible clinical presentations of G6PD deficiency.
Keywords: G6PD Deficiency; frostbite; acetazolamide; acute hemolytic anemia; oxidative stress; reactive oxygen species
Burnett MW. 17(3). 114 - 115. (Journal Article)
Abstract
Keywords: infectious disease; hepatitis E virus; acute icteric hepatitis
Weidner DA, Yoo MJ. 22(3). 70 - 74. (Case Reports)
Abstract
Acute kidney injury (AKI) is a serious, often silent, medical condition with diverse etiologies and complex pathophysiology. We discuss the case of a patient injured in a single vehicle rollover. Included is a discussion of prevention and supportive care, with a focus on electrolyte repletion, fluid correction, minimization of nephrotoxic exposures, and identification and treatment of the root cause.
Keywords: acute kidney injury; supportive care; nephrotoxic exposures
Palmer LE. 18(2). 105 - 109. (Journal Article)
Abstract
Pyotraumatic dermatitis (a.k.a., hot spot) is a rapidly developing, superficial, moist, exudative dermatitis commonly induced by self-inflicted trauma. Although not acutely life threatening, these lesions are extremely pruritic and distracting and significantly interfere with the canine's operational effectiveness and ability to stay on task. The review discusses a case, including clinical presentation, diagnosis, treatment, and prognosis.
Keywords: Operational K9s; dog keepers; pyotraumatic dermatitis; hot spot; acute moist dermatitis
Reese JM, Fisher SD, Robbins DP. 12(3). 52 - 56. (Journal Article)
Abstract
Rhabdomyolysis is a common syndrome that can range from asymptomatic to a severe life-threatening condition. It is the result of acute muscle fiber necrosis leading to cell lysis and subsequent transfer of those byproducts into the circulatory system. The most significant constituent of these byproducts is myoglobin, which has been known to cause renal failure in 10-50% of patients that develop rhabdomyolysis. In addition, the electrolytes contained within these cells are leached into the blood stream, which can lead to significant electrolyte abnormalities. The etiology of rhabdomyolysis is broad and includes inherited diseases, drugs, toxins, muscle compression or overexertion, infections, and more. This syndrome may carry a mortality rate ranging from 7-80%. We describe five patients assigned to various companies within 160th Special Operations Aviation Regiment (Airborne) that developed exertional rhabdomyolysis of the bilateral upper extremities between June 2011 and January 2012. In this case series we will describe the events leading up to the diagnosis, lack of risk factors or family history, diagnostic criteria, treatment, and future concerns related to the condition.
Keywords: rhabdomyolysis; acute renal failure; myoglobinuria; creatinine kinase; overexertion exercise
Davis G, Czarnik J, Evans J, McGrane OL. 23(2). 107 - 109. (Case Reports)
Abstract
In contrast to shallow water (hypoxic) blackout and swimming-induced pulmonary edema (SIPE), acute electrolyte disturbance secondary to acute respiratory alkalosis is not considered a common Combat Swimmer injury but has the potential to be life-threatening. We present the case of a 28-year-old Special Operations Dive Candidate who presented to the Emergency Department after a near-drowning incident with altered mental status, generalized weakness, respiratory distress, and tetany. He was found to have severe symptomatic hypophosphatemia (1.00mg/dL) and mild hypocalcemia secondary to intentional hyperventilation between subsurface "cross-overs," causing subsequent acute respiratory alkalosis. This is a unique presentation of a common electrolyte abnormality in a highly specialized population that is self-limiting when caused by acute respiratory alkalosis but poses a significant danger to Combat Swimmers if rescue personnel are not able to respond quickly.
Keywords: hypophosphatemia; combat swimmer; acute respiratory alkalosis; hyperventilation
Choi JH, Roberts TR, Sieck K, Harea GT, Karaliou V, Wendorff DS, Beely BM, Cancio LC, Sams VG, Batchinsky AI. 20(1). 65 - 70. (Journal Article)
Abstract
Background: We investigated the expression of high mobility group box 1 (HMGB1) protein in a combat-relevant polytrauma/ acute respiratory distress syndrome (ARDS) model. We hypothesized that systemic HMGB1 expression is increased after injury and during aeromedical evacuation (AE) at altitude. Methods: Female Yorkshire swine (n =15) were anesthetized and cannulated with a 23Fr dual-lumen catheter. Venovenous extracorporeal life support (VV ECLS) was initiated via the right jugular vein and carried out with animals uninjured on day 1 and injured by bilateral pulmonary contusion on day 2. On both days, animals underwent transport and simulated AE. Systemic HMGB1 expression was measured in plasma by ELISA. Plasma-free Hb (pfHb) was measured with the use of spectrophotometric methods. Results: Plasma HMGB1 on day 1 was transiently higher at arrival to the AE chambers, increased significantly after injury, reaching highest values at 8,000 ft on day 2, after which levels decreased but remained elevated versus baseline at each time point. pfHb decreased on day 1 at 30,000 ft and significantly increased on day 2 at 8,000 ft and postflight. Conclusions: Systemic HMGB1 demonstrated sustained elevation after trauma and altitude transport and may provide a useful monitoring capability during en route care.
Keywords: acute respiratory distress syndrome; polytrauma; evacuation; altitude physiology; HMGB1
Nam JJ, McCravy MS, Haines KL, Thomas SB, Aden JK, Johnston LR, Mason PE, Gurney J, Sams VG. 22(4). 111 - 116. (Journal Article)
Abstract
Background: The purpose of our study was to assess risks/ outcomes of acute respiratory distress syndrome (ARDS) in US combat casualties. We hypothesized that combat trauma patients with ARDS would have worse outcomes based on mechanism of injury (MOI) and labs/vital signs aberrancies. Materials and Methods: We reviewed data on military Servicemembers serving in Iraq and Afghanistan from 1 January 2003 to 31 December 2015 diagnosed with ARDS by ICD-9 code. We extracted patient demographics, injury specifics, and mortality from the Department of Defense Trauma Registry (DoDTR). Results: The most common MOI was an explosion, accounting for 67.6% of all injuries. Nonsurvivors were more likely to have explosion-related injuries, have higher injury severity score (ISS), higher international normalized ratio (INR), lower platelet count, greater base deficit, lower temperature, lower Glasgow Coma Scale (GCS) score, and lower pH. There was no significant difference in deaths across time. Conclusion: By identifying characteristics of patients with higher mortality in trauma ARDS, we can develop treatment guidelines to improve outcomes. Given the high mortality associated with trauma ARDS and relative paucity of clinical data available, we need to improve battlefield data capture to better guide practice and ultimately improve care. The management of ARDS will be increasingly relevant in prolonged casualty care (PCC; formerly prolonged field care) on the modern battlefield.
Keywords: PCC; PFC; prolonged casualty care; prolonged field care; ARDS; acute respiratory distress syndrome; combat casualties; combat trauma; mechanism of injury
Beely BM, Harea GT, Wendorff DS, Choi JH, Sieck K, Karaliou V, Cannon JW, Lantry JH, Cancio LC, Sams VG, Batchinsky AI. 22(1). 64 - 69. (Journal Article)
Abstract
Background: We assessed the use of an FDA-cleared transport ventilator with limited functions and settings during ground transport in a swine model of ground evacuation. We hypothesized that when used as an adjunct to extracorporeal life support (ECLS), the device would enable safe mobile ventilatory support during ground evacuation. Methods: Female Yorkshire swine (n = 11; mean, 52.4 ± 1.3 kg) were sedated and anesthetized and received mechanical ventilation (MV) with a standard intensive care unit (ICU) ventilator and were transitioned to the Simplified Automated Ventilator II (SAVe II; AutoMedx) during ground transport. MV served as an adjunct to ECLS in all animals. Ventilator performance was assessed in the uninjured state on day 1 and after bilateral pulmonary contusion on day 2. Data were collected pre- and post-transport on both days. Results: During 33 transports, the SAVe II provided similar ventilation support as the ICU ventilator. Mean total transport time was 38.8 ± 2.1 minutes. The peak inspiratory pressure (PIP) limit was the only variable to show consistent differences pre- and post-transport and between ventilators. No adverse events occurred. Conclusion: As an adjunctive supportive device during ground transport, the SAVe II performed adequately without failure or degradation in subject status. Further testing is warranted to elucidate the clinical limits of this device during standalone use.
Keywords: acute respiratory distress syndrome; trauma; extracorporeal life support; Mechanical Ventilation; expeditionary ground evacuation
Papalski W, Siedler J, Callaway DW. 22(2). 93 - 96. (Journal Article)
Abstract
Noninvasive positive-pressure ventilation (NPPV) is a form of ventilatory support that does not require the placement of an advanced airway. The authors discuss the use of NPPV on patients who will likely benefit. The use of NPPV has reduced the need for patients to require intubation and/or mechanical ventilation in some cases, as well as benefits.
Keywords: noninvasive positive-pressure ventilation (NPPV); continuous positive airway pressure (CPAP); bilevel positive airway pressure (BiPAP); noninvasive ventilation (NIV); acute respiratory failure (ARF)
Kelly K, Pautz CM, Palombo LJ, Jensen AE, Melau J, Turcotte LP, Solberg PA. 23(3). 74 - 81. (Journal Article)
Abstract
Introduction: Little data exist on the effect of extremely cold-water diving on thermo-metabolic hormone secretion. Moreover, the impact of repetitive dives on the stress response is unknown. The purpose of this study was to determine the effects of two daily bouts of cold-water diving on the hormonal and metabolic profile of elite military personnel and to measure the stress response. Methods: Healthy, male, Norwegian Special Forces operators (n = 5) volunteered for this study. Physiological and hormone data were analyzed prior to and following twice-daily Arctic dives (3.3°C). Results: Core temperature was maintained (p > .05), whereas skin temperature was significantly reduced over the course of each dive (p < .01). Pairwise comparisons revealed adrenocorticotropic hormone (ACTH) and cortisol concentration significantly decreased across both dives and days (p < .001). Adrenaline and noradrenaline significantly increased across both time and day (p < .001). Leptin, testosterone, and IGF-1 significantly decreased over time but recovered between days. Conclusion: The main findings of this effort are that there is a rapid sympathetic-adreno-medullary (SAM/SNS) response to cold-water diving and a suppression of the hypothalamic-pituitary-adrenal (HPA) axis and hormones related to repair and recovery. While the sample size was too small to determine the role of SAM/SNS, HPA, and thyroid hormone effect on thermoregulation, it addresses a gap in our understanding of physiological adaptions that occurs in extreme environments.
Keywords: military diving; Arctic; acute stress response; testosterone; leptin
Conkright W, Deuster PA. 19(1). 107 - 112. (Journal Article)
Abstract
Modern-day warfare and operational tempo require Special Operations Forces (SOF) personnel to be ready and able to perform optimally on the battlefield at all times. To do this, US Special Operations Command has invested in high-performance training centers and human performance staff, including performance dietitians. Performance dietitians are critical, because it is widely recognized that nutrition affects all aspects of health and performance, particularly for the SOF Operator. These aspects include everything from physical and sensory to psychosocial and cognitive factors, as well as environmental exposures and genetic predispositions. The impact of nutrition on performance has been well established, with specific recommendations and position stands on fueling for athletics from multiple international organizations. However, sports nutrition guidelines are based on outcomes from sample means rather than individual changes in performance. Precision performance nutrition solutions must include a systems-based approach and consider the individuality of the Operator along with their interactions with their environment. The purpose of this article is to summarize what is known about performance nutrition and outline what can be done to move toward personalized precision nutrition. We discuss pitfalls and challenges with regard to mission-specific goals, optimization versus adaptation, and longitudinal tracking; and present our view of the future.
Keywords: adaptation; fueling; longitudinal tracking; metabolomics; microbiome; military; nutrigenomics; personalized nutrition
Zink N, Merelman A, Fisher AD, Lauria MJ. 23(1). 54 - 58. (Journal Article)
Abstract
Clinicians involved in the care of critically ill patients are often exposed to demanding and stressful situations that require immediate action. Evidence suggests that human performance can be significantly diminished when multiple stressors and stimuli are present. Humans have developed conscious and unconscious methods of dealing with this type of cognitive overload in various high-risk occupations, but these coping methods have not necessarily been structured and adapted to the provision of emergency medical care. Emergency reflex action drills (ERADs) are derived from available evidence in specific domains (e.g., airway management) and develop automaticity of critical skills which engender quick, effective, and reproducible performance with minimal cognitive load. These are pre-planned, practiced responses to specific, high-demand and time-sensitive situations. This article outlines the psychological, cognitive, and behavioral effects of stress that affect performance and necessitate development of ERADs. It also reviews the scientific underpinnings behind how humans have adapted cognitive behavioral techniques to manage under high-stress situations. Finally, this article recommends the adoption of these cognitive tactics via ERADs to enhance clinical practice and provides an example in the context of airway management.
Keywords: adaption; error; performance; stress; training
O'Hara R, Sussman LR, Sheehan R, Keizer B, Tiede JM. 22(4). 65 - 69. (Journal Article)
Abstract
The flotation-restriction environmental stimulation technique (FR) may have utility as a recovery tool for improving performance in elite competitive athletes and Special Operations Forces Operators (SOs). Studies suggest that FR may ameliorate various neurophysiological disorders and improve performance in recreational and elite athletic populations. We sought to understand whether there is evidence to support the use of FR to enhance physiological and psychological performance parameters in the SO population and to provide postulations as to the mechanisms of action of FR therapy. We performed an online literary search of publications dating from 1982 to 2021 and identified 34 sources addressing the aims, depending on population and condition or conditions, being treated. The reported physiological and psychological benefits of FR range from immediate to lasting 4 months. Overall, eight to twelve FR treatment sessions of from 40 to 90 minutes each may provide variable long-term benefits. The associated synergistic benefits of FR may be attributed to its thermal, chemical, and mechanical effects but deserve further exploration. Based on the current evidence, FR may serve as an effective performance-recovery therapy for improving pain, sleep, and performance measures (e.g., marksmanship and physical performance) in trained, untrained, and healthy adults. Future research focusing on FR as a unimodal recovery intervention is warranted in a specialized group of SOs.
Keywords: adult; humans; pain; sleep; exercise; athletes; physical functional performance
Deuster PA. 18(4). 131 - 136. (Journal Article)
Abstract
Dietary supplement (DS) use by military members and Special Operations Forces (SOF), in particular, is high. The "sports nutrition" market is expected to be one of the fastest growing segments because a "performance edge" is certainly desirable within the military. DS products are readily available in retail stores on military bases, over the Internet, and in niche stores near military bases. Thus, use of some DSs raises a number of unique concerns, particularly considering the potential for interactions among combinations of DS ingredients and concurrent medications taken under military operational conditions. All those who work with SOF should have a basic understanding of the DS world. This article briefly reviews selected DS regulations, identifies concerns and risks related to various DS products, and describes the purpose, functions, and resources of Operation Supplement Safety. Examples of regulatory concerns, adverse events, red flags, and tools are provided to help SOF communities sustain their health and performance.
Keywords: adulteration; human performance; new dietary ingredient; regulations; tainted products; supplements
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
Rago AP, Sharma U, Sims K, King DR. 15(3). 39 - 45. (Journal Article)
Abstract
Background: Noncompressible hemorrhage is the leading cause of potentially survivable death on the battlefield. In Special Operations Forces (SOF), 50% of potentially survivable deaths have been related to noncompressible hemorrhage. Currently, there are no widely available presurgical interventions that can slow abdominal bleeding. Consequently, many of the preventable deaths occur en route to definitive care as a failure to rescue from exsanguination. A self-expanding polyurethane foam has been developed as a percutaneous damage control intervention to rescue casualties who would otherwise die of noncompressible hemorrhage, and allow them to survive long enough to reach surgical intervention. The purpose of this paper is to summarize the existing preclinical data, describe the role of SOF personnel in foam delivery-system development, and to integrate these together to conceptualize how foam could be incorporated into SOF medical care. Methods: All existing publications on self-expanding foam are reviewed. Additionally, eight SOF medical providers with combat experience provided end-user input to delivery-device design through an interactive human-factors testing process. Results: Ten preclinical publications described efficacy, safety, dose translation, and risk-benefit analysis of exsanguination rescue with percutaneous-foam damage control. SOF medical providers guided weight, cubic, operational requirements, and limits for the foam delivery device. Conclusion: Presurgical exsanguination rescue with percutaneous foam damage control is safe and effective with a favorable risk-benefit profile in preclinical studies. Battlefield, presurgical use by SOF medical providers is conceptually possible. Adoption of the technology on the battlefield should proceed with SOF medical provider input.
Keywords: hemorrhage; noncompressable; bleeding; foam; advanced medic; abdominal; austere; ResQFoam
Butler FK, Holcomb JB, Shackelford SA, Barbabella S, Bailey JA, Baker JB, Cap AP, Conklin CC, Cunningham CW, Davis MS, DeLellis SM, Dorlac WC, DuBose JJ, Eastridge BJ, Fisher AD, Glasser JJ, Gurney JM, Jenkins DA, Johannigman J, King DR, Kotwal RS, Littlejohn LF, Mabry RL, Martin MJ, Miles EA, Montgomery HR, Northern DM, O'Connor KC, Rasmussen TE, Riesberg JC, Spinella PC, Stockinger Z, Strandenes G, Via DK, Weber MA. 18(4). 37 - 55. (Journal Article)
Abstract
TCCC has previously recommended interventions that can effectively prevent 4 of the top 5 causes of prehospital preventable death in combat casualties-extremity hemorrhage, junctional hemorrhage, airway obstruction, and tension pneumothorax- and deaths from these causes have been markedly reduced in US combat casualties. Noncompressible torso hemorrhage (NCTH) is the last remaining major cause of preventable death on the battlefield and often causes death within 30 minutes of wounding. Increased use of whole blood, including the capability for massive transfusion, if indicated, has the potential to increase survival in casualties with either thoracic and/or abdominopelvic hemorrhage. Additionally, Zone 1 Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) can provide temporary control of bleeding in the abdomen and pelvis and improve hemodynamics in casualties who may be approaching traumatic cardiac arrest as a result of hemorrhagic shock. Together, these two interventions are designated Advanced Resuscitative Care (ARC) and may enable casualties with severe NCTH to survive long enough to reach the care of a surgeon. Although Special Operations units are now using whole blood far-forward, this capability is not routinely present in other US combat units at this point in time. REBOA is not envisioned as care that could be accomplished by a unit medic working out of his or her aid bag. This intervention should be undertaken only by designated teams of advanced combat medical personnel with special training and equipment.
Keywords: Advanced Resuscitative Care; Committee on Emergency Casualty Care; guidelines
Yue I, Allen DS, Chung J, Ruppert A, Papalski WN, Sons N, Zarow GJ, Good CJ, Devenny LE, Cady HJ, Sonntag EM, Adams RC, Hildreth AL. 24(3). 49 - 57. (Journal Article)
Abstract
Training needs of Special Operations Forces (SOF) medics were surveyed and new training initiatives have been created to meet their needs. SOF medics perform an array of medical procedures in austere environments with minimal supervision. Medical skills decay over time after initial training and the perceived training needs of active SOF medics were unclear. To fill this gap, active SOF medics (n=57) completed a survey that included confidence ratings and indications of whether additional training would make them more proficient in 70 medical knowledge and procedural skills, assembled into categories by a panel of experts (airway, trauma, neuro, differential diagnosis, administrative, infection, critical care, environmental, other). Data were analyzed with analysis of variance (ANOVA) and nonparametric statistics at P<.05. Confidence was highest in the trauma, administrative, and airway categories, and lowest in the infection, differential diagnosis, and neuro categories (P<.05 or less). Categories indicating the greatest need for additional training were environmental and critical care, while those indicating lowest need were the airway and trauma categories (P=.05). Additional training was endorsed by >75% of participants in each category. SOF medics also wanted additional training in all areas, preferably hands-on with live patients in realistic scenarios, taught by experienced medics. Findings highlight the training needs of SOF medics and demonstrate the value of bottom-up feedback toward optimizing sustainment training. Based on present findings, two TACMED (Tactical Medicine) Divisions at the SOF Echelon III level were created to meet the sustainment training needs of SOF medics
Keywords: special warfare; Special Operations; advanced tactical provider; medical sustainment program; medical training; TACMED
Paquette R, Quinene M, Blackbourne LH, Allen PB. 21(3). 78 - 85. (Journal Article)
Abstract
Background: Penetrating thoracic injuries account for an essential subset of battlefield and civilian injuries that result in death. Current recommendations are to use commercially available nonocclusive chest seals. We review current evidence for which chest seal(s) is likely to be the most effective in treating open pneumothoraces. Methods: A systematic review was conducted in accordance with the PRIMSA 2009 standard systematic review methodology, except where noted. The databases Pubmed, MEDLINE, CINAHL, Scopus, and gray sources were searched for all English-language, full-manuscript, experimental, quantitative studies of humans and animals concerning seal adherence or their efficacy at preventing tension pneumothoraces published between 1990 and 2020. A numerical analysis was used to provide the consensus recommendation. Results: Of 683 eligible identified articles [PubMed 528 (77.3%), Scopus 87 (12.7%), CINAHL 67 (9.8%), one (0.1%) unpublished], six (0.9%) articles were included. Synthesis of all studies' results suggests a consensus recommendation for the Hyfin Vent Chest Seal and Russell Chest Seal. These two were the most effective chest seals, as previously investigated in a quantifiable, experimental study. Conclusion: While chest seals are recommended in civilian and military prehospital medicine to improve patient survival, current evidence concerning the individual device's efficacy is limited. Further scientific, quantitative research is needed to clarify which commercially available chest seals are most effective and provide patients with penetrating chest trauma the best possible method for preventing or mitigating tension pneumothoraces.
Keywords: pneumothorax; chest seal; chest trauma; Tactical Combat Casualty Care; advanced trauma life support; systematic review
Stevens R, Pierce B, Tilley L. 22(4). 72 - 76. (Journal Article)
Abstract
Military medicine has made significant advancements in decreasing mortality by addressing the lethal triad - metabolic acidosis, coagulopathy, and hypothermia. However, casualties are still succumbing to injury. Recent conflict zones have led to the development of remarkable life-saving innovations, including the management of compressible hemorrhage and whole blood transfusions. Nevertheless, hypothermia prevention and treatment techniques remain relatively unchanged. Hypothermia prevention is anticipated to become more critical in future operations due to a predicted increase in evacuation times and reliance on Prolonged Casualty Care (PCC). This is likely secondary to increasingly distanced battlespaces and the mobility challenges of operating in semi-/non-permissive environments. Innovation is essential to combat this threat via active airway rewarming in the vulnerable patient. Thus, we propose the development, fabrication, and efficacy testing of a device in which we estimate being able to control temperature and humidity at physiologic levels in the PCC setting and beyond.
Keywords: Advanced Trauma Life Support care; airway management; critical care; emergency medicine; intellectual property; military medicine; patent; prehospital emergency care; prolonged casualty care; prolonged field care; resuscitation; technological innovations; war-related trauma; wilderness medicine hypothermia
Grambusch DM, Hoedebecke KL. 12(3). 36 - 42. (Journal Article)
Abstract
Leptospirosis is a bacterial zoonosis with worldwide distribution and is potentially lethal to those infected if left untreated. Due to the global posture of the U.S. Special Operations community, there is a seemingly perfect overlap of the regions in which they deploy and areas with concurrent endemic leptospirosis infection. Furthermore, Special Operations Forces (SOF) personel are known for working by, with, and through the host nation defense force, who tend to be commonly affected and often serve as a reservoir for this infection. Other risk factors including the usage of infected military working dogs, contaminated training sites, and certain recreational activities associated with water increase the danger of exposure for this cohort. Due to this increased risk of leptospirosis by U.S. Special Operations service members, medical providers within this community must understand and utilize proper preventive medicine, prophylaxis, early detection, diagnosis, and treatment for this potentially lethal infection.
Keywords: leptospirosis; operational medicine; adventure racing; zoonosis; zoonotic disease; spirochetes; working dogs; Special Operations
Tong RL, Bohlke CW, Clemente Fuentes RW, Moncada M, Schloe AD, Ashley RL. 21(2). 29 - 33. (Journal Article)
Abstract
Background: Administration of fresh whole blood (FWB) is a life-saving treatment that prolongs life until definitive surgical intervention can be performed; however, collecting FWB is a time-consuming and resource-intensive process. Furthermore, it may be difficult to collect sufficient FWB to treat critically wounded patients or multiple-hemorrhaging casualties. This study describes the effect of airdrop on FWB and explores the possibility of using airdrop to deliver FWB to combat medics treating casualties in the prehospital setting when FDA-approved, cold-stored blood products are not readily available and timely casualty evacuation (CASEVAC) is not feasible. Methods: Four units of FWB were collected from volunteer donors and loaded into a blood cooler that was dropped from a fixed-wing aircraft under a standard airdrop training bundle (SATB) parachute. A control group of 4 units of FWB was stored in a blood cooler that was not dropped. Baseline and postintervention laboratory samples were measured in both airdropped and control units, including full blood counts, prothrombin time/partial thromboplastin time/international normalized ratio (PT/PTT/INR), pH, lactate, potassium, indirect bilirubin, glucose, fibrinogen, lactate dehydrogenase, and peripheral blood smears. Results: The blood cooler, cooling bags, and all 4 FWB units did not sustain any damage from the airdrop. There was no evidence of hemolysis. All airdropped blood met parameters for transfusion per the Whole Blood Transfusion Clinical Practice Guideline of the Joint Trauma System (JTS). Conclusions: Airdrop of FWB in a blood cooler with a SATB parachute may be a viable way of delivering blood products to combat medics treating hemorrhaging patients in the prehospital setting, although further research is needed to fully validate the safety of this method of FWB delivery.
Keywords: fresh whole blood transfusion; airdrop; airdrop blood; aerial resupply; Tactical Combat Casualty Care
Fuentes RW, Shawler EK, Smith WD, Tong RL, Barnes WJ, Moncada M, Bohlke CW, Mitchell AL. 22(3). 9 - 14. (Journal Article)
Abstract
Background: Transfusion of whole blood (WB) is a lifesaving treatment that prolongs life until definitive surgical intervention can be performed; however, collecting WB is a time-consuming and resource-intensive process. Furthermore, it may be difficult to collect sufficient WB at the point of injury to treat critically wounded patients or multiple hemorrhaging casualties. This study is a follow-up to the proof-of-concept study on the effect of airdrop on WB. In addition, this study confirms the statistical significance for the plausibility of using airdrop to deliver WB to combat medics treating casualties in the pre-hospital setting when Food and Drug Administration (FDA)-approved cold-stored blood products are not available. Methods: Forty-eight units of WB were collected and loaded into a blood cooler that was dropped from a fixed-wing aircraft under a Standard Airdrop Training Bundle (SATB) parachute or 68-in pilot chute. Twenty-four of these units were dropped from a C-145 aircraft, and 24 were dropped from a C-130 aircraft. A control group of 15 units of WB was storedin a blood cooler that was not dropped. Baseline and post-intervention laboratory tests were measured in both airdroppedand control units, including complete blood count; prothrombin time/partial thromboplastin time (PT/PTT); pH, lactate, potassium, bilirubin, glucose, fibrinogen, and lactate dehydrogenase (LDH) levels; and peripheral blood smears. Results: The blood cooler, cooling packs, and all 48 WB units did not sustain any major damage from the airdrop. There was no evidence of hemolysis. Except for the one slightly damaged bag that was not sampled, all airdropped blood met parameters for transfusion per the Joint Trauma System Whole Blood Transfusion Clinical Practice Guideline and the Association for the Advancement of Blood and Biotherapies (AABB) Circular of Information for the Use of Human Blood and Blood Components. Conclusions: Airdrop of fresh or stored WB in a blood cooler with a chute is a viable way of delivering blood products to combat medics treating hemorrhaging patients in the pre-hospital setting. This study also demonstrated the portability of this technique for multiple aircraft. The techniques evaluated in this study have the potential for utilizationin other austere settings such as wilderness medicine or humanitarian disasters where an acute need for WB delivery by airdrop is the only option.
Keywords: whole blood transfusion; airdrop; airdrop blood; aerial resupply; Tactical Combat Casualty Care
Le Clerc S, McLennan J, Kyle A, Mann-Salinas EA, Russell RJ. 14(4). 48 - 52. (Journal Article)
Abstract
The administration of blood products to battlefield casualties in the prehospital arena has contributed significantly to the survival of critically injured patients in Afghanistan over the past 5 years. Given as part of an established military "chain of survival," blood product administration has represented a step-change improvement in capability for both UK and US tactical aeromedical evacuation (TACEVAC) platforms. The authors explore current concepts, analyzing and exploring themes associated with early use of blood products (fresh frozen plasma [FFP] and red blood cells [RBCs]), and they compare and evaluate a US/UK study analyzing the differences and recommending future strategy. The subject matter expert (SME) consensus guidelines developed for use by the US Army Air Ambulance units commonly known as call sign "DUSTOFF." These TACEVAC assets in Afghanistan were validated in this retrospective study. Using statistical analysis, the authors were able to ascertain that the current DUSTOFF SME-derived guidelines offer a sensitivity of 63.04% and a specificity of 89.07%. By adjusting the indicators to include a single above-ankle amputation with a systolic blood pressure (SBP) less than 90mmHg and pulse greater than 120/min, the sensitivity could be increased to 67.39% while maintaining the specificity at 89.07%. In our data set, a single amputation above the ankle, in combination with an SBP of less than 100mmHg and a pulse of greater than 120/min, increased the sensitivity to 76% but with a slight drop in specificity to 86%. Further study of military prehospital casualty data is under way to identify additional physiological parameters that will allow simple scoring tools in the remote setting to guide the administration of prehospital blood products.
Keywords: trauma; prehospital; blood products; military; scoring tool; tactical; aeromedical evacuation
Leone R, Remondelli MH, Smith SS, Moore BJ, Wuss SL, D'Angelo M. 24(2). 86 - 90. (Editorial)
Abstract
Keywords: aeromedical evacuation; Special Operations; damage control resuscitation; damage control surgery; en-route care; AFRICOM
Reid P, George C, Byrd CM, Miller L, Lee SJ, Motsinger-Reif A, Breen M, Hayduk DW. 18(1). 74 - 76. (Journal Article)
Abstract
Special Operations Forces and their accompanying tactical multipurpose canines (MPCs) who are involved in repeated live-fire exercises and military operations have the potential for increased blood lead levels and toxicity due to aerosolized and environmental lead debris. Clinical lead-toxicity symptoms can mimic other medical disorders, rendering accurate diagnosis more challenging. The objective of this study was to examine baseline lead levels of MPCs exposed to indoor firing ranges compared with those of nontactical military working dogs (MWDs) with limited or no exposure to the same environment. In the second part of the study, results of a commercially available, human-blood lead testing system were compared with those of a benchtop inductively coupled plasma-mass spectrometry (ICP-MS) analysis technique. Blood samples from 18 MPCs were tested during routine clinical blood draws, and six samples from a canine group with limited exposure to environmental lead (nontactical MWDs) were tested for comparison. There was a high correlation between results of the commercial blood-testing system compared with ICP-MS when blood lead levels were higher than 4.0µg/dL. Both testing methods recorded higher blood lead levels in the MPC blood samples than in those of the nontactical MWDs, although none of the MPC samples tested contained lead levels approaching those at which symptoms of lead toxicity have previously been reported in animals (i.e., 35µg/dL).
Keywords: heavy metal toxicity; aerosolization; lead, blook toxicity analysis; canines, multipurpose; dogs, military working
King DR, Kragh JF, Blackbourne LH. 13(2). 20 - 24. (Journal Article)
Abstract
Background: Recent efforts to improve the quality of care in the Afghanistan theater have focused on extremity compartment syndrome, a common, disabling, and costly problem. To identify opportunities to improve care, the present survey was undertaken to observe the use of two standard methods-the traditional, improvised method and the common, off-the-shelf method-for determining intracompartmental pressures in the lower extremities of combat casualties. Methods: As part of a quality of care improvement effort during Operation Enduring Freedom, all combat casualties presenting to a forward surgical team at Forward Operating Base Shank from August to November 2011 with lower-extremity major trauma were evaluated for signs and symptoms of compartment syndrome. Results: Ten casualties had pressure measurement surveyed simultaneously using both methods. A two one-sided test analysis demonstrated a mean difference of -0.13 (90% confidence interval, -0.36 to 0.096), which indicated that the methods were similar. A repeated-measures analysis yielded a p value of .72, indicating no statistical difference between the methods. The receiver operating characteristic curve demonstrated excellent agreement within the prespecified limits (±2mm Hg, area under the curve 1.0), which indicated that the methods were similar. Conclusion: The main finding of the quality of care effort was that clinicians received similar information from use of two standard methods for far forward measurement of pressures to detect extremity compartment syndrome. This finding may help clinicians improve the quality of care in the theater in detecting, diagnosing, and monitoring compartment syndrome.
Keywords: fascia wounds; injuries; emergency medical services; Afghan Campaign 2001-present; military medicine
Florance JM, Hicks M. 19(4). 16 - 18. (Case Reports)
Abstract
The Combined Joint Special Operations Task Force-Afghanistan (CJSOTF-A) Surgeon partnered with the Afghan National Army Special Operations Command (ANASOC) Surgeon to complete medical screening of a repatriated ANASOC soldier following a 2019 combined raid on a Taliban prison that freed 35 prisoners of war (POWs). This article discusses the presentation and management of the ANASOC POW while also providing a literature review of common pathologies within the POW population. The purpose of this document is to address a unique aspect of military medicine in the expectation that future military providers are prepared to receive repatriated soldiers and prepared to care for fellow prisoners should they themselves become captured.
Keywords: Afghanistan; Afghan Campaign 2001-present; military medicine; warfare; war wounds; military personnel; prisoners; veterans; prisons; terrorism
Irizarry DJ, Tate C, Bingham MT, Wey P, Batjom E, Nicholas TA, Boedeker BH. 12(1). 24 - 30. (Journal Article)
Abstract
The Medical Civic Assistance Program (MEDCAP) is a military commander's tool developed during the Vietnam War to gain access to and positively influence an indigenous population through the provision of direct medical care provided by military medical personnel, particularly in Counter Insurgency Operations (COIN). An alternative to MEDCAPs is the medical seminar (MEDSEM). The MEDSEM uses a Commander's military medical assets to share culturally appropriate medical information with a defined indigenous population in order to create a sustainable training resource for the local population's health system. At the heart of the MEDSEM is the "train the trainer" concept whereby medical information is passed to indigenous trainers who then pass that information to an indigenous population. The MEDSEM achieves the Commander's objectives of increasing access and influence with the population through a medical training venue rather than direct patient care. Previous MEDSEMS conducted in Afghanistan by military forces focused on improvement of rural healthcare through creation of Village Health Care Workers. This model can also be used to engage host nation (HN) medical personnel and improve medical treatment capabilities in population centers. The authors describe a modification of the MEDSEM, a Medical Mentorship (MM), conducted in November 2010 in Kabul, Afghanistan, at the Afghan National Army (ANA) National Medical Hospital. This training was designed to improve intubation skills in Afghan National Army Hospitals by ANA medical providers, leave residual training capability, and build relationships within the institution that not only assist the institution, but can also be leveraged to foster Commanders' objectives, such as health and reconstruction initiatives and medical partnering for indigenous corps and medical forces described below.
Keywords: Counter-Insurgency; Medical Support; airway training; Afghan National Army
Plackett TP, Nielsen JS, Hahn CD, Rames JM. 16(1). 51 - 56. (Journal Article)
Abstract
Background: Accurate point-of-injury reports and casualty evacuation requests allow for optimal resource utilization. However, the accuracy of these reports has not been previously studied. Methods: All trauma patients treated at one of three forward surgical elements (FSE) in Western Afghanistan during May-August 2012 were prospectively included. North American Treaty Organization (NATO) 9-line medical evacuation request and mechanism, injuries, signs, and treatments (MIST) reports were compared to the initial findings on arrival to the FSE. Results: There were 179 casualty evacuation reports and 298 patients. NATO 9-line and/or MIST reports were available for 70% of these. Triage was accurate for 77%, but there was 17% overtriage and 6% undertriage (k = .619). The number of patients was accurate in 95% of reports, the mechanism of injury was accurate for 98%, and the body region involved was accurate for 92% (k = .850, .943, and .870, respectively). There was no difference between the mean vital signs at the point of injury or on arrival at the FSE. When analyzed individually, however, there was no correlation between each casualty's pulse, mean arterial pressure, or respiratory rate between the two time points. Discussion: There was a high degree of correlation between the triage category of casualty evacuation reports and the patient's actual medical needs. There was also a highly significant association with the number of patients, mechanism of injury, and bodily injuries. However, there was discordance between the vital signs at an individual level, which may represent regression toward the resuscitation threshold.
Keywords: triage; trauma; war; Afghanistan; combat; accuracy
Christensen PA. 18(1). 150 - 154. (Journal Article)
Abstract
Austere care of the wounded is challenging for all Western medical professionals-nurse, medic, or physician. There can be no doubt that working for the first time, either for a nongovernment organization or in the Special Forces, you will be taking care of wounded patients outside your training and experience. You must have the ability to adapt to and overcome lack of resources and equipment, and accept standards of treatment often very different and lower than that common in western hospitals. The International Committee of the Red Cross (ICRC) was asked to provide relief for the Pakistan Red Crescent in 1982 and set up the ICRC Hospital for Afghan War Wounded in Peshawar on the border to Afghanistan. This article relates how a western-trained young anesthetist on a ICRC surgical team experienced this, at the time, austere environment.
Keywords: austere; ICRC; Pakistan; Afghanistan; nongovernment organization
Florance JM, Hicks M. 19(4). 16 - 18. (Case Reports)
Abstract
The Combined Joint Special Operations Task Force-Afghanistan (CJSOTF-A) Surgeon partnered with the Afghan National Army Special Operations Command (ANASOC) Surgeon to complete medical screening of a repatriated ANASOC soldier following a 2019 combined raid on a Taliban prison that freed 35 prisoners of war (POWs). This article discusses the presentation and management of the ANASOC POW while also providing a literature review of common pathologies within the POW population. The purpose of this document is to address a unique aspect of military medicine in the expectation that future military providers are prepared to receive repatriated soldiers and prepared to care for fellow prisoners should they themselves become captured.
Keywords: Afghanistan; Afghan Campaign 2001-present; military medicine; warfare; war wounds; military personnel; prisoners; veterans; prisons; terrorism
Florance JM, Hicks M. 19(4). 59 - 61. (Journal Article)
Abstract
The Afghan National Army Special Operations Command (ANASOC) uses several documents for casualty reporting. By analyzing these documents from a period of March to December 2018, the authors demonstrate the predominance of gunshot fatalities within ANASOC at approximately 63% of combat deaths and a high rate of prehospital death at approximately 97% of combat deaths. The data also demonstrate relatively few cases of long-term disability from ANASOC soldiers wounded in action. The authors used these conclusions to create a Combined Joint Special Operations Task Force-Afghanistan (CJSOTF-A) working group that recommended changes to the medical curriculum at the ANASOC School of Excellence. These recommendations centered on an increased emphasis on bleeding control to prevent death from hemorrhagic shock.
Keywords: Afghanistan; military medicine; warfare; wounds and injuries; war wounds; violence; military personnel; wounds; gunshot; wounds; penetrating; blast injuries
Schoenberger T, Foret B, Evans J, Shishido AA. 23(2). 114 - 117. (Journal Article)
Abstract
Prolonged Casualty Care (PCC) has become an essential component to Special Operations Forces (SOF) pre-mission training. However, it has not regularly been required in recent combat operations with the availability of medical evacuation (MEDEVAC) support. Poor weather conditions at an austere SOF outpost created an emergency unreachable by aeromedical evacuation. Herein, we report a case of an emergency bilateral above-the-knee amputation procedure performed by three Special Forces Medical Sergeants (18D(a), 18D(b), and 18D(c)) and supporting Army medics with minimal telemedicine consult and guidance.
Keywords: amputation; austere; MEDEVAC; special operation; Afghanistan; emergency; telemedicine; combat
Givens ML, Lynch JH. 14(3). 107 - 110. (Journal Article)
Abstract
This article regarding Special Operations Forces (SOF) medical operations in Africa is an introduction to a follow- on series of articles that will address in more detail pertinent medical topics which pertain to operations on the African continent. Medical operations in Africa require dynamic and systematic approaches that consider the myriad challenges, yet offer flexible solutions applied as situations and environments dictate. We believe this series of articles will be of high interest to readers and provide key information that will be germane to future SOF operations.
Keywords: medical operations; evacuation; tropical infectious disease; tactical medicine; Africa; wilderness medicine
Lynch JH, Verlo AR, Givens ML, Munoz CE. 14(4). 113 - 121. (Journal Article)
Abstract
The natural health threats in Africa pose daunting clinical challenges for any provider, as evidenced by the current Ebola epidemic in West Africa, but the threat is multiplied for the Special Operations provider on the continent who faces these challenges with limited resources and the tyranny of distance. The majority of operationally significant health risks can be mitigated by strict adherence to a comprehensive force health protection plan. The simplest, yet most effective, technique for preventing mosquito-borne diseases is the prevention of mosquito bites with repellent, bed nets, and appropriate clothing in addition to chemoprophylaxis. Some of the more likely or lethal infectious diseases encountered on the continent include malaria, Chikungunya, dengue, human immunodeficiency virus, and Ebola. Venomous snakes pose a particular challenge since the treatment can be as deadly as the injury. Providers supporting African operations should educate themselves on the clinical characteristics of possible envenomations in their area while promoting snake avoidance as the primary mitigation measure. To succeed in Africa, the Special Operations provider must consider how to meet these challenges in an environment where there may not be reliable evacuation, hospitalization, or logistics channels.
Keywords: Africa; tactical medicine; tropical infectious disease; chemoprophylaxis; malaria; dengue; Chikungunya; HIV; Ebola; snake evenomation; antivenin; wilderness medicine
Givens ML, Verlo AR. 15(1). 105 - 112. (Journal Article)
Abstract
Medical Capacity for African Nations-Growing Regional Operability (MEDCAN-GRO) is a framework for addressing healthcare engagements that are intended to provide sustainable capacity building with partner nations. MEDCAN-GRO provides SOF units with a model that can be scaled to partner nation needs and aligned with the goals of the TSOC in an effort to enhance partner nation security.
Keywords: MEDCAN-GRO; Africa; partner nations
Hellums JS, Klapperich K. 15(1). 113 - 117. (Journal Article)
Abstract
Dermatologic complaints are common in the deployed environment. Preventive medicine and knowledge of indigenous flora and fauna are cornerstones for forward deployed medical personnel. This article describes a case of Paederus dermatitis in an austere environment, reviews dermatologic terminology, and provides a reminder of the importance of exercising good preventive medicine procedures.
Keywords: Africa; dermatology; Special Operations medic; Paederus dermatitis
Verlo AR, Bailey HH, Cook MR. 15(3). 114 - 119. (Journal Article)
Abstract
Military deployments will always result in exposure to health hazards other than those from combat operations. The occupational and environmental health and endemic disease health risks are greater to the Special Operations Forces (SOF) deployed to the challenging conditions in Africa than elsewhere in the world. SOF are deployed to locations that lack life support infrastructures that have become standard for most military deployments; instead, they rely on local resources to sustain operations. Particularly, SOF in Africa do not generally have access to advanced diagnostic or monitoring capabilities or to medical treatment in austere locations that lack environmental or public health regulation. The keys to managing potential adverse health effects lie in identifying and documenting the health hazards and exposures, characterizing the associated risks, and communicating the risks to commanders, deployed personnel, and operational planners.
Keywords: Africa; health risk assessment; food and water ; occupational and environmental health; site survey
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
Strohmayer J, Matthews I, Locke R. 16(3). 47 - 52. (Journal Article)
Abstract
Schistosomiasis is a parasitic infection acquired through freshwater exposure in the tropics. It is an infection that can have devastating implications to military personnel if it is not recognized and treated, especially later in life. While there is an abundance of information available about schistosomiasis in endemic populations, the information on nonendemic populations, such as deployers, is insufficient. Definitive studies for this population are lacking, but there are actions that can and should be taken to prevent infection and to treat patients. This literary review presents a case study, reviews basic science, and explores the information available about schistosomiasis in nonendemic populations. Specifically, the authors provide recommendations for the prevention, diagnosis, and postexposure management in military personnel.
Keywords: Africa; schistosomiasis; disease, tropical; military personnel; DEET; praziquantel; Schistosoma spp.
Schauer SG, Naylor JF, Fisher AD, Hyams DG, Carius BM, Escandon MA, Linscomb CD, McDonald H, Cap AP, Bynum J. 21(3). 66 - 70. (Journal Article)
Abstract
Background: United States Africa Command (US AFRICOM) is one of six US Defense Department's geographic combatant commands and is responsible to the Secretary of Defense for military relations with African nations, the African Union, and African regional security organizations. A full-spectrum combatant command, US AFRICOM is responsible for all US Department of Defense operations, exercises, and security cooperation on the African continent, its island nations, and surrounding waters. We seek to characterize blood product administration within AFRICOM using the in-transit visibility tracking tool known as TRAC2ES (TRANSCOM Regulating and Command & Control Evacuation System). Methods: We performed a retrospective review of TRAC2ES medical evacuations from the AFRICOM theater of operations conducted between 1 January 2008 and 31 December 2018. Results: During this time, there were 963 cases recorded in TRAC2ES originating within AFRICOM, of which 10 (1%) cases received blood products. All patients were males. One was a Department of State employee, one was a military working dog, and the remainder were military personnel. Of the ten humans, seven were the result of trauma, most by way of gunshot wound, and three were due to medical causes. Among human subjects receiving blood products for traumatic injuries, a total of 5 units of type O negative whole blood, 29 units of packed red blood cells (pRBCs), and 9 units of fresh frozen plasma (FFP) were transfused. No subjects underwent massive transfusion of blood products, and only one subject received pRBCs and FFP in 1:1 fashion. All subjects survived until evacuation. Conclusions: Within the TRAC2ES database, blood product administration within AFRICOM was infrequent, with some cases highlighting lack of access to adequate blood products. Furthermore, the limitations within this database highlight the need for systems designed to capture medical care performance improvement, as this database is not designed to support such analyses. A mandate for performance improvement within AFRICOM that is similar to that of the US Central Command would be beneficial if major improvements are to occur.
Keywords: prehospital; blood; Africa; prolonged field care; AFRICOM
Schauer SG, Naylor JF, Fisher AD, Hyams DG, Carius BM, Escandon MA, Linscomb CD, McDonald H, Cap AP, Bynum J. 21(3). 66 - 70. (Journal Article)
Abstract
Background: United States Africa Command (US AFRICOM) is one of six US Defense Department's geographic combatant commands and is responsible to the Secretary of Defense for military relations with African nations, the African Union, and African regional security organizations. A full-spectrum combatant command, US AFRICOM is responsible for all US Department of Defense operations, exercises, and security cooperation on the African continent, its island nations, and surrounding waters. We seek to characterize blood product administration within AFRICOM using the in-transit visibility tracking tool known as TRAC2ES (TRANSCOM Regulating and Command & Control Evacuation System). Methods: We performed a retrospective review of TRAC2ES medical evacuations from the AFRICOM theater of operations conducted between 1 January 2008 and 31 December 2018. Results: During this time, there were 963 cases recorded in TRAC2ES originating within AFRICOM, of which 10 (1%) cases received blood products. All patients were males. One was a Department of State employee, one was a military working dog, and the remainder were military personnel. Of the ten humans, seven were the result of trauma, most by way of gunshot wound, and three were due to medical causes. Among human subjects receiving blood products for traumatic injuries, a total of 5 units of type O negative whole blood, 29 units of packed red blood cells (pRBCs), and 9 units of fresh frozen plasma (FFP) were transfused. No subjects underwent massive transfusion of blood products, and only one subject received pRBCs and FFP in 1:1 fashion. All subjects survived until evacuation. Conclusions: Within the TRAC2ES database, blood product administration within AFRICOM was infrequent, with some cases highlighting lack of access to adequate blood products. Furthermore, the limitations within this database highlight the need for systems designed to capture medical care performance improvement, as this database is not designed to support such analyses. A mandate for performance improvement within AFRICOM that is similar to that of the US Central Command would be beneficial if major improvements are to occur.
Keywords: prehospital; blood; Africa; prolonged field care; AFRICOM
Leone R, Remondelli MH, Smith SS, Moore BJ, Wuss SL, D'Angelo M. 24(2). 86 - 90. (Editorial)
Abstract
Keywords: aeromedical evacuation; Special Operations; damage control resuscitation; damage control surgery; en-route care; AFRICOM
DeSoucy ES, Shackelford S, DuBose JJ, Zweben S, Rush SC, Kotwal RS, Montgomery HR, Keenan S. 17(1). 121 - 129. (Journal Article)
Abstract
Background: Prolonged field care (PFC) is field medical care applied beyond doctrinal planning time-lines. As current and future medical operations must include deliberate and contingency planning for such events, data are lacking to support efforts. A case review was conducted to define the epidemiology, environment, and operational factors that affect PFC outcomes. Methods: A survey distributed to US military medical providers solicited details of PFC encounters lasting more than 4 hours and included patient demographics, environmental descriptors, provider training, modes of transportation, injuries, mechanism of injury, vital signs, treatments, equipment and resources used, duration of PFC, and morbidity and mortality status on delivery to the next level of care. Descriptive statistics were used to analyze survey responses. Results: Surveys from 54 patients treated during 41 missions were analyzed. The PFC provider was on scene at time of injury or illness for 40.7% (22/54) of cases. The environment was described as remote or austere for 96.3% (52/54) of cases. Enemy activity or weather also contributed to need for PFC in 37.0% (20/54) of cases. Care was provided primarily outdoors (37.0%; 20/54) and in hardened nonmedical structures (37.0%; 20/54) with 42.6% (23/54) of cases managed in two or more locations or transport platforms. Teleconsultation was obtained in 14.8% (8/54) of cases. The prehospital time of care ranged from 4 to 120 hours (median 10 hours), and five (9.3%) patients died prior to transport to next level of care. Conclusion: PFC in the prehospital setting is a vital area of military medicine about which data are sparse. This review was a novel initial analysis of recent US military PFC experiences, with descriptive findings that should prove helpful for future efforts to include defining unique skillsets and capabilities needed to effectively respond to a variety of PFC contingencies.
Keywords: prolonged field care; after action review; military medicine; prehospital; medical evacuation
Carius BM, Dodge PM, Fisher AD, Loos PE, Thompson D, Schauer SG. 21(2). 49 - 53. (Journal Article)
Abstract
Background: After-action reviews (AARs) in the Prehospital Trauma Registry (PHTR) enable performance improvements and provide commanders feedback on care delivered at Role 1. No published data exist exploring overall trends of end-user performance-improvement feedback. Methods: We performed an expert panel review of AARs within the PHTR in Afghanistan from January 2013 to September 2014. When possible, we categorized our findings and selected relevant medical provider comments. Results: Of 737 registered patient encounters found, 592 (80%) had AAR documentation. Most AAR patients were male (98%, n = 578), injured by explosion (48%, n = 283), and categorized for urgent evacuation (64%, n = 377). Nearly two thirds of AARs stated areas needing improvement (64%, n = 376), while the remainder left the improvement section blank (23%, n = 139) or specified no improvements (13%, n = 76). The most frequently cited areas for improvement were medical knowledge (23%, n = 136), evacuation coordination (19%, n = 115), and first responder training (16%, n = 95). Conclusions: Our expert panel reviewed AARs within the PHTR and found substantial numbers of AARs without improvements recommended, which limits quality improvement capabilities. Our analysis supports previous calls for better documentation of medical care in the prehospital combat setting.
Keywords: trauma; prehospital; military; after action review; performance
Armstrong EL, Bryan CJ, Stephenson JA, Bryan AO, Morrow CE. 14(2). 26 - 34. (Journal Article)
Abstract
Objectives: Combat exposure is associated with increased mental health symptom severity among military personnel, whereas unit support is associated with decreased severity. However, to date no studies have examined these relationships among U.S. Air Force pararescuemen (PJs), who have a unique and specialized career field that serves in both medical and combatant capacities. Design: Crosssectional self-report survey. Methods: Self-reported survey data regarding depression symptoms, posttraumatic stress disorder (PTSD) symptoms, perceived unit support, and exposure to traditional combat experiences (e.g., firefights) and medical consequences of combat (e.g., injuries and human remains) were collected from 194 PJs in seven rescue squadrons. Results: Levels of combat exposure were compared with previously published findings from combat units, and levels of medical exposure were compared with previously published findings among military medical professionals. Medical exposure intensity showed a stronger relationship with PTSD severity (ß = .365, p = .018) than with combat exposure intensity (ß = .136, ρ = .373), but neither combat nor medical exposure was associated with depression severity (ßs < .296, ρs > .164). Unit support was associated with less severe PTSD (ß = -.402, ρ < .001) and depression (ß = -.259, ρ = .062) symptoms and did not moderate the effects of combat or medical exposure. Conclusions: Medical stressors contribute more to PTSD among PJs than do traditional combat stressors. Unit support is associated with reduced PTSD and depression severity regardless of intensity of warzone exposure among PJs.
Keywords: unit support; military; trauma; combat exposure; pararescue; aftermath
Gerold KB, Gibbons ME, Fisette RE, Alves D. 15(1). 62 - 69. (Journal Article)
Abstract
Excited delirium syndrome (ExDS) is a term used to describe patients experiencing a clinical condition characterized by bizarre and aggressive behavior, often in association with the use of chronic sympathomimetic drug abuse. The agitated and disruptive behavior of persons with ExDS often results in a call to police resulting in an arrest for disorderly conduct. The suspect's inability to comply with police commands during the arrest frequently results in a struggle and the use of physical or chemical control measures, including the use of conductive energy weapons (CEWs). Deaths from this hypermetabolic syndrome are infrequent but potentially preventable with early identification, a coordinated aggressive police intervention, and prompt medical care. Preliminary experiences suggest that ExDS is a medical emergency treated most effectively using a coordinated response between police officers and emergency medical providers. Once the person suspected of experiencing ExDS is in custody, medical providers should rapidly sedate noncompliant patients with medications such as ketamine or an antipsychotic drug such as haloperidol in combination with a benzodiazepine drug such as midazolam or diazepam. Once sedated, patients should undergo a screening medical assessment and undergo initial treatment for conditions such as hyperthermia and dehydration. All patients exhibiting signs of ExDS should be transported rapidly to a medical treatment facility for further evaluation and treatment. This article reviews the epidemiology, clinical presentation, diagnosis, and treatment options for ExDS.
Keywords: excited delirium; excited delirium syndrome; delirium; sudden death; in-custody death; hyperthermia; sympathomimetic drug use; cocaine; phencyclidine; lysergic acid diethylamide; ketamine; haloperidol; taser; conductive energy weapon; Agitated Chaotic Event&tm;; ACE; medical emergency; emergency medical services; police
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
Bollinger JW. 24(3). 32 - 36. (Journal Article)
Abstract
There is no concise guideline on how to manage a full range of emergency psychiatric conditions that are likely to be encountered on the battlefield. This article examines the best practices on how to best assess and treat suicidality, psychosis, agitation, malingering, and combat stress reactions in accordance with multiple clinical practice guidelines. The result is a proposed model for battlefield emergency psychiatric care.
Keywords: ICOVER; PIES; combat stress reaction; agitation; suicidality; clinical practice guideline; psychosis; mania; malingering; medical evacuation
Schauer SG, Naylor JF, Uhaa N, April MD, De Lorenzo RA. 20(1). 61 - 64. (Journal Article)
Abstract
Introduction: Tactical Combat Casualty Care (TCCC) recommends life-saving interventions; however, these interventions can only be implemented if military prehospital providers carry the necessary equipment to the injured casualty. Combat medics primarily use aid bags to transport medical materiels forward on the battlefield. We seek to assess combat medic materiel preparedness to employ TCCC-recommended interventions by inventorying active duty, combat medic aid bags. Methods: We sought combat medics organic to combat arms units stationed at Joint Base Lewis McChord. Medics volunteered to complete a demographic worksheet and have the contents of their aid bag photographed and inventoried. We spoke with medic unit leadership prior to their participation and asked that the medics bring their aid bags in the way they would pack for a combat mission. We categorized medic aid bag contents in the following manner: (1) hemorrhage control; (2) airway management; (3) pneumothorax treatment, or (4) volume resuscitation. We compared the items found in the aid bags against the contemporary TCCC guidelines. Results: In January 2019, we prospectively inventoried 44 combat medic aid bags. Most of the medics were male (86%), in the grade of E4 (64%), and had no deployment experience (64%). More medics carried a commercial aid bag (55%) than used the standard issue M9 medical bag (45%). Overall, the most frequently carried medical device was an NPA (93%). Overall, 91% of medics carried at least one limb tourniquet, 2% carried a junctional tourniquet, 31% carried a supraglottic airway (SGA), 64% carried a cricothyrotomy setup/kit, 75% carried a chest seal, and 75% carried intravenous (IV) fluid. The most commonly stocked limb tourniquet was the C-A-T (88%), the airway kit was the H&H cricothyrotomy kit (38%), the chest injury set were prepackaged needle decompression kits (81%), and normal saline was the most frequently carried fluid (47%). Most medics carried a heating blanket (54%). Conclusions: Most medics carried materiels that address the common causes of preventable death on the battlefield. However, most materiels stowed in aid bags were not TCCC-preferred items. Moreover, there was a small subset of medics who were not prepared to handle the major causes of death on the battlefield based on the current state of their aid bag.
Keywords: combat; medic; aid bag; military
Studer NM, Horsley GW, Godbee DC. 14(2). 14 - 19. (Journal Article)
Abstract
Introduction: Many Servicemembers rely on nondeployed Role 1 facilities, such as troop medical clinics, as their primary source of healthcare. At geographically isolated military installations, these facilities are the "only game in town" for medical care. Servicemembers may present to these facilities with emergent conditions, regardless of designed intent of the facility or the wishes of staff. The U.S. Army Troop Medical Clinic, Camp Blanding is such a facility. Methods: The clinic was reorganized with a 5S approach, streamlining supply, equipment, and workflow processes. This was accomplished to allow the facility to not only improve its general delivery of care but also ensure capability to handle at least one medical or trauma resuscitation. Equipment, disposable supplies, documentation, and staff training were addressed.Results/ Discussion/ Conclusion: Despite facility intention, lack of supplies/equipment, or staff inexperience with emergency care, an acute ill or injured Servicemember must be stabilized at the nondeployed Role 1 facility while awaiting transport to a higher level of care. This expectation is the same as that of deployed Role 1 facilities. A cost-savings can also be realized when minor "emergencies" are handled in-house.
Keywords: aid station; troop medical clinic; sick bay; resuscitation; emergency medicine; primary care; National Guard; rural medicine; sick call
Schober P, Schwarte LA. 19(3). 22 - 23. (Journal Article)
Abstract
Helicopter air ambulance services (HAA) increasingly operate during darkness, and the cockpit crew prefers a dimmed light to be used in the cabin. Our HAA team is currently researching the use of dimmed red light. We encountered a downside to the use of red light-some texts and symbols became virtually invisible.
Keywords: helicopter; air ambulance; red light
Boyer NL, Mazarella JA, Thronson EE, Brillhart DB. 21(4). 99 - 103. (Journal Article)
Abstract
In a rapidly changing operational environment, in which there has been an emphasis on prolonged field care and limited evacuation platforms, military providers must practice to the full scope of their training to maximize outcomes. In addition to pushing military providers further into combat zones, the Department of Defense has relied on contracted personnel to help treat and evacuate servicemembers. This article is a retrospective review on the interoperability of the expeditionary resuscitative surgical team (ERST) and a contracted personnel recovery (CPR) team in a far-forward austere environment and will discuss actual patient transport case reviews that used multiple evacuation platforms across thousands of miles of terrain. To effectively incorporate CPR personnel into a military transport team model, we recommend including cross-training on equipment and formularies, familiarization with CPR evacuation platforms, and mass casualty (MASCAL) exercises that incorporate the different platforms available.
Keywords: patient transport; air evacuation; prolonged field care; Special Operations; Expeditionary Resuscitative Surgical Team; contract personnel recovery; austere
Wade M, O'Hara R, Caldwell L, Ordway J, Bryant D. 16(4). 41 - 47. (Journal Article)
Abstract
Background: The primary aim of this study was to investigate the effects of continuous one-arm kettlebell (KB) swing training on various US Air Force physical fitness testing components. Thirty trained male (n = 15) and female (n = 15) US Air Force (USAF) personnel volunteered and were sequentially assigned to one of three groups based on 1.5-mile run time: (1) KB one-arm swing training, (2) KB one-arm swing training plus highintensity running (KB + run), and (3) traditional USAF physical training (PT) according to Air Force Instruction 36-2905. Methods: The following measurements were made before and after 10 weeks of training: 1.5-mile run, 1-minute maximal push-ups, 1-minute maximal situps, maximal grip strength, pro agility, vertical jump, 40-yard dash, bodyweight, and percent body fat. Subjects attended three supervised exercise sessions per week for 10 weeks. During each exercise session, all groups performed a 10-minute dynamic warm-up followed by either (1) 10 minutes of continuous KB swings, (2) 10 minutes of continuous kettlebell swings plus 10 minutes of high-intensity running, or (3) 20 minutes of moderate intensity running plus push-ups and sit-ups. Average and peak heart rate were recorded for each subject after all sessions. Paired t tests were conducted to detect changes from pretesting to posttesting within each group and analysis of variance was used to compare between-group variability (ρ ≤ .05). Results: Twenty subjects completed the study. There were no statistically significant changes in 1.5-mile run time between or within groups. The 40- yard dash significantly improved within the KB swing (ρ ≤ .05) and KB + run group (ρ ≤ .05); however, there were no significant differences in the traditional PT group (ρ ≤ .05) or between groups. Maximal push-ups significantly improved in the KB + run group (ρ ≤ .05) and trends toward significant improvements in maximal push-ups were found in both the KB (ρ = .057) and traditional PT (ρ = .067) groups. Conclusions: This study suggests that continuous KB swing training may be used by airmen as a high-intensity, low-impact alternative to traditional USAF PT to maintain aerobic fitness and improve speed and maximal push-ups.
Keywords: kettelbell training; Air Force; 40-yard dash; physical fitness; military personnel
Thompson WD. 10(4). 41 - 44. (Journal Article)
Abstract
This radiological case study of scapula fracture is reported in a 22 year-old active duty male Soldier who sustained a static line injury during an airborne operation at Fort Bragg, North Carolina. This is the first reported scapula fracture secondary to this mechanism since a 1973 report by Heckman and Levine. The fracture was neither identified by Emergency Department nor Orthopedic Surgery providers, and was reported in the radiologist's formal read. Ten emergency physicians and emergency medicine physician assistants reviewed the radiographical studies and none successfully identified the injury. Because this injury was uniformly missed by experienced emergency medicine providers it is presented as a radiographic case study in hopes that this injury will not go undiagnosed, potentially causing increased morbidity and mortality in this patient population. The patient was treated with a posterior splint and immobilization and seen by the orthopedic service the next day. Interestingly, the orthopedic surgeon also did not recognize this fracture. This mechanism of injury is rarely seen in clinical practice outside of the airborne community. Scapula fractures can be an indicator of serious thoracic trauma and may prompt the need for further diagnostic studies. The fact that so many providers missed the injury reinforces the need to evaluate the patient as a whole and to be ever suspicious of missing concomitant injuries in the trauma patient.
Keywords: Scapula Fracture; emergency department; Orthopedic; Radiograph; airborne
Cunningham CW, Kotwal RS, Kragh JF. 13(2). 4 - 7. (Case Reports)
Abstract
The U.S. military has been conducting static-line parachute jumps for nearly a century. Beginning with World War II, military forces have also employed full-scale airborne operations as a method for insertion into combat. Through the years, injuries from blunt trauma as a result of static-line parachute jumps have evolved little with the refinement of equipment, training, and tactics. Parachute jumps continue to invoke primarily musculoskeletal injuries, especially to the lower extremities, back, neck, and head. These injuries are usually straightforward in their presentation and diagnosis. We describe the delayed diagnosis of a pelvic hematoma due to an uncommon blunt trauma jump injury. The purpose of this case report is to increase awareness of injury patterns during paratrooper operations, as well as to review the diagnosis and management of occult hemorrhage. Specific objectives for the readers are to (1) know the common injury types and patterns for airborne operations, (2) know the descent rate of T-10C/D parachutes and factors influencing the rate, (3) recognize signs and symptoms associated with a pelvic hematoma, and (4) recognize common complications resulting from a pelvic hematoma.
Keywords: airborne; paratrooper; parachute (T-10, T-11, SF-10); pelvic trauma; hemorrhage; hematoma; ultrasound; combat-load
McIntire S, Boujie L, Leasiolagi J. 16(3). 11 - 14. (Journal Article)
Abstract
Injuries involving rupture of the pectoralis major are relatively rare. When they do occur, it is mostly frequently in a young, athletic man. The most common cause is weight lifting that results in eccentric muscle contraction (muscle contraction against an overbearing force, leading to muscle lengthening)-specifically, the bench press. Other mechanisms for this injury include forceful abduction and external rotation of the arm. Injury can occur anywhere along the pectoralis major from its medial origin on the sternum and clavicle to its lateral tendinous insertion on the humerus. At the time of injury, patients may report feeling a tearing sensation or hearing a pop, with immediate onset of pain. Physical examination findings can include a deformed appearance of the chest, ecchymosis of the chest and upper arm, pain and weakness with arm adduction and internal rotation, or noticeable asymmetry of the anterior axilla with arm abduction. Magnetic resonance imaging is the imaging study of choice to aid diagnosis. In a young and active population, such as the Special Operations community, appropriate and timely diagnosis is important because surgical intervention often is recommended. This report presents the case of an active-duty Servicemember who sustained a pectoralis major injury while exiting an aircraft during the Basic Airborne Course.
Keywords: pectoralis major; rupture; avulsion; tear; airborne; parachute; static line
Montagnon R, Rouffilange L, Wagnon G, Balasoupramanien K, Texier G, Aigle L. 24(3). 44 - 48. (Journal Article)
Abstract
Introduction: A systematic radiological examination is needed for military airborne troops in order to detect subclinical medical contraindications for airborne training. Many potential recruits are excluded because of scoliosis, kyphosis, or spondylolisthesis. This study aimed to determine whether complementary radiological assessment excludes too many recruits and whether medical standards might be lowered without increasing medical risk to appointees. Methods: This retrospective, epidemiological, cross-sectional single-center study spanned 5 years at the French paratroopers' initial training center. We analyzed all medical files and full-spine X-ray results of all enlisted troops during this period. Secondary evaluation by an orthopedic surgeon enabled 23 enlisted personnel, deemed medically unacceptable because of X-ray findings, to be given waivers for airborne training. A follow-up review of their 23 files was conducted to determine whether static-line parachute jumps were hazardous to those who were initially declared medically unacceptable. Results: Of the 3,993 full-spine X-rays, 67.5% (2,695) were described as having normal alignment and structure; 21.8% (871) had lateral spinal deviation; and 10.7% (427) had scoliosis. Sixty-six recruits (1.6%) were deemed unfit because of findings that did not meet the standard on the fullspine X-ray: 53 enlisted personnel had scoliosis greater than 15°, and 13 had spondylolisthesis (grade II or III). Of the 23 patients granted waivers, 82.3% with scoliosis (14) and all patients with kyphosis had not declared any back pain after 5 years. Conclusion: The findings, supported by a literature review of foreign military data, suggest that spondylolisthesis above grade I and low back pain are more significant than scoliosis and kyphosis for establishing airborne standards.
Keywords: military medicine; airborne; scoliosis; kyphosis; spondylolisthesis
Knapik JJ. 19(4). 109 - 113. (Journal Article)
Abstract
This is part 2 of an article detailing the reduction in airbornerelated injuries over time. Part 1 examined the early history of airborne operations and provided evidence for the reduction in injuries over time; part 2 discusses interventions associated with the decline in injury rates. In 1943 at the United States (US) Army Airborne School, data showed that injuries were substantially reduced from 120 to 18 injuries/1000 trainees. Credit for the reduction was given to development of the parachute landing fall (PLF), better supervision of students while in initial airborne training, intensive ground training prior to actual jumping, and elimination of dangerous and unnecessary training procedures (like practice jumps from 11-foot heights). Compared to the older T-10 parachute introduced in the 1950s, the newer T-11 parachute introduced in 2010 reduced injuries by 43% in operational training (9.1 vs 5.2 injuries/1000 jumps). In aircraft with jump doors on both sides, alternating jumps between the doors so that the jumpers exit at slightly different times reduced high-altitude and mid-altitude entanglement injuries by 85% (0.13 to 0.02 injury/ 1000 jumps). Data from six scientific studies involving more than 1,300,000 jumps and two systematic reviews indicated that the parachute ankle brace (PAB) reduced ankle injuries and ankle fractures by about half with an estimated return on investment of at least $7 in medical and personnel costs for every $1 spent on the PAB. However, the PAB is not currently used or even well-known within the airborne community because of a lack of acceptance and promotion. While some airborne injury-reducing innovations are discussed here it is likely that there have been others that have not been documented. It is important to detail these interventions so future paratroopers and leaders can better understanding their rationale and effectiveness.
Keywords: T-10 parachute; T-11 parachute; parachute ankle brace; Controlled Alternating Parachute Exit System (CAPES); airborne school
Tong RL, Bohlke CW, Clemente Fuentes RW, Moncada M, Schloe AD, Ashley RL. 21(2). 29 - 33. (Journal Article)
Abstract
Background: Administration of fresh whole blood (FWB) is a life-saving treatment that prolongs life until definitive surgical intervention can be performed; however, collecting FWB is a time-consuming and resource-intensive process. Furthermore, it may be difficult to collect sufficient FWB to treat critically wounded patients or multiple-hemorrhaging casualties. This study describes the effect of airdrop on FWB and explores the possibility of using airdrop to deliver FWB to combat medics treating casualties in the prehospital setting when FDA-approved, cold-stored blood products are not readily available and timely casualty evacuation (CASEVAC) is not feasible. Methods: Four units of FWB were collected from volunteer donors and loaded into a blood cooler that was dropped from a fixed-wing aircraft under a standard airdrop training bundle (SATB) parachute. A control group of 4 units of FWB was stored in a blood cooler that was not dropped. Baseline and postintervention laboratory samples were measured in both airdropped and control units, including full blood counts, prothrombin time/partial thromboplastin time/international normalized ratio (PT/PTT/INR), pH, lactate, potassium, indirect bilirubin, glucose, fibrinogen, lactate dehydrogenase, and peripheral blood smears. Results: The blood cooler, cooling bags, and all 4 FWB units did not sustain any damage from the airdrop. There was no evidence of hemolysis. All airdropped blood met parameters for transfusion per the Whole Blood Transfusion Clinical Practice Guideline of the Joint Trauma System (JTS). Conclusions: Airdrop of FWB in a blood cooler with a SATB parachute may be a viable way of delivering blood products to combat medics treating hemorrhaging patients in the prehospital setting, although further research is needed to fully validate the safety of this method of FWB delivery.
Keywords: fresh whole blood transfusion; airdrop; airdrop blood; aerial resupply; Tactical Combat Casualty Care
Fuentes RW, Shawler EK, Smith WD, Tong RL, Barnes WJ, Moncada M, Bohlke CW, Mitchell AL. 22(3). 9 - 14. (Journal Article)
Abstract
Background: Transfusion of whole blood (WB) is a lifesaving treatment that prolongs life until definitive surgical intervention can be performed; however, collecting WB is a time-consuming and resource-intensive process. Furthermore, it may be difficult to collect sufficient WB at the point of injury to treat critically wounded patients or multiple hemorrhaging casualties. This study is a follow-up to the proof-of-concept study on the effect of airdrop on WB. In addition, this study confirms the statistical significance for the plausibility of using airdrop to deliver WB to combat medics treating casualties in the pre-hospital setting when Food and Drug Administration (FDA)-approved cold-stored blood products are not available. Methods: Forty-eight units of WB were collected and loaded into a blood cooler that was dropped from a fixed-wing aircraft under a Standard Airdrop Training Bundle (SATB) parachute or 68-in pilot chute. Twenty-four of these units were dropped from a C-145 aircraft, and 24 were dropped from a C-130 aircraft. A control group of 15 units of WB was storedin a blood cooler that was not dropped. Baseline and post-intervention laboratory tests were measured in both airdroppedand control units, including complete blood count; prothrombin time/partial thromboplastin time (PT/PTT); pH, lactate, potassium, bilirubin, glucose, fibrinogen, and lactate dehydrogenase (LDH) levels; and peripheral blood smears. Results: The blood cooler, cooling packs, and all 48 WB units did not sustain any major damage from the airdrop. There was no evidence of hemolysis. Except for the one slightly damaged bag that was not sampled, all airdropped blood met parameters for transfusion per the Joint Trauma System Whole Blood Transfusion Clinical Practice Guideline and the Association for the Advancement of Blood and Biotherapies (AABB) Circular of Information for the Use of Human Blood and Blood Components. Conclusions: Airdrop of fresh or stored WB in a blood cooler with a chute is a viable way of delivering blood products to combat medics treating hemorrhaging patients in the pre-hospital setting. This study also demonstrated the portability of this technique for multiple aircraft. The techniques evaluated in this study have the potential for utilizationin other austere settings such as wilderness medicine or humanitarian disasters where an acute need for WB delivery by airdrop is the only option.
Keywords: whole blood transfusion; airdrop; airdrop blood; aerial resupply; Tactical Combat Casualty Care
Tong RL, Bohlke CW, Clemente Fuentes RW, Moncada M, Schloe AD, Ashley RL. 21(2). 29 - 33. (Journal Article)
Abstract
Background: Administration of fresh whole blood (FWB) is a life-saving treatment that prolongs life until definitive surgical intervention can be performed; however, collecting FWB is a time-consuming and resource-intensive process. Furthermore, it may be difficult to collect sufficient FWB to treat critically wounded patients or multiple-hemorrhaging casualties. This study describes the effect of airdrop on FWB and explores the possibility of using airdrop to deliver FWB to combat medics treating casualties in the prehospital setting when FDA-approved, cold-stored blood products are not readily available and timely casualty evacuation (CASEVAC) is not feasible. Methods: Four units of FWB were collected from volunteer donors and loaded into a blood cooler that was dropped from a fixed-wing aircraft under a standard airdrop training bundle (SATB) parachute. A control group of 4 units of FWB was stored in a blood cooler that was not dropped. Baseline and postintervention laboratory samples were measured in both airdropped and control units, including full blood counts, prothrombin time/partial thromboplastin time/international normalized ratio (PT/PTT/INR), pH, lactate, potassium, indirect bilirubin, glucose, fibrinogen, lactate dehydrogenase, and peripheral blood smears. Results: The blood cooler, cooling bags, and all 4 FWB units did not sustain any damage from the airdrop. There was no evidence of hemolysis. All airdropped blood met parameters for transfusion per the Whole Blood Transfusion Clinical Practice Guideline of the Joint Trauma System (JTS). Conclusions: Airdrop of FWB in a blood cooler with a SATB parachute may be a viable way of delivering blood products to combat medics treating hemorrhaging patients in the prehospital setting, although further research is needed to fully validate the safety of this method of FWB delivery.
Keywords: fresh whole blood transfusion; airdrop; airdrop blood; aerial resupply; Tactical Combat Casualty Care
Fuentes RW, Shawler EK, Smith WD, Tong RL, Barnes WJ, Moncada M, Bohlke CW, Mitchell AL. 22(3). 9 - 14. (Journal Article)
Abstract
Background: Transfusion of whole blood (WB) is a lifesaving treatment that prolongs life until definitive surgical intervention can be performed; however, collecting WB is a time-consuming and resource-intensive process. Furthermore, it may be difficult to collect sufficient WB at the point of injury to treat critically wounded patients or multiple hemorrhaging casualties. This study is a follow-up to the proof-of-concept study on the effect of airdrop on WB. In addition, this study confirms the statistical significance for the plausibility of using airdrop to deliver WB to combat medics treating casualties in the pre-hospital setting when Food and Drug Administration (FDA)-approved cold-stored blood products are not available. Methods: Forty-eight units of WB were collected and loaded into a blood cooler that was dropped from a fixed-wing aircraft under a Standard Airdrop Training Bundle (SATB) parachute or 68-in pilot chute. Twenty-four of these units were dropped from a C-145 aircraft, and 24 were dropped from a C-130 aircraft. A control group of 15 units of WB was storedin a blood cooler that was not dropped. Baseline and post-intervention laboratory tests were measured in both airdroppedand control units, including complete blood count; prothrombin time/partial thromboplastin time (PT/PTT); pH, lactate, potassium, bilirubin, glucose, fibrinogen, and lactate dehydrogenase (LDH) levels; and peripheral blood smears. Results: The blood cooler, cooling packs, and all 48 WB units did not sustain any major damage from the airdrop. There was no evidence of hemolysis. Except for the one slightly damaged bag that was not sampled, all airdropped blood met parameters for transfusion per the Joint Trauma System Whole Blood Transfusion Clinical Practice Guideline and the Association for the Advancement of Blood and Biotherapies (AABB) Circular of Information for the Use of Human Blood and Blood Components. Conclusions: Airdrop of fresh or stored WB in a blood cooler with a chute is a viable way of delivering blood products to combat medics treating hemorrhaging patients in the pre-hospital setting. This study also demonstrated the portability of this technique for multiple aircraft. The techniques evaluated in this study have the potential for utilizationin other austere settings such as wilderness medicine or humanitarian disasters where an acute need for WB delivery by airdrop is the only option.
Keywords: whole blood transfusion; airdrop; airdrop blood; aerial resupply; Tactical Combat Casualty Care
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
Stancil S, Miller J, Riddle M. 14(3). 74 - 77. (Journal Article)
Abstract
Previous studies have sought to determine the feasibility of exchanging the laryngeal mask airway (LMA) for an endotracheal tube (ETT) over a gum elastic bougie (GEB) and found the practice to have a success rate of about 50%. It has been speculated that the poor success rate may be due to the upward angle of the bougie tip meeting resistance against the anterior laryngeal wall. The use of a 90- to 180-degree twist technique to angle the bougie tip away from the anterior tracheal wall and caudally along the trachea theoretically could improve results. We conducted a prospective cadaveric study to determine if the use of a bougie 90- to 180-degree twist technique or the use of a more flexible pediatric bougie would improve previously published success rates. Emergency medicine personnel attempted exchange of an LMA for an ETT over a GEB using a twisting technique. Despite using the twisting technique, successful exchange over a bougie remained at 50%, similar to previous studies. Using a smaller, more flexible pediatric bougie led to a successful exchange in only 28% of attempts. In this study, the adding of a twist technique or using a pediatric bougie did not result in consistent successful exchange to an ETT from an LMA.
Keywords: laryngeal mask airway; endotracheal tube; gum elastic bougie; supraglottic airway devices; intubation; airway; tube exchange
Barnard EB, Ervin AT, Mabry RL, Bebarta VS. 14(4). 35 - 39. (Journal Article)
Abstract
Introduction: Airway compromise is the third most common cause of potentially preventable combat death. Surgical cricothyrotomy is an infrequently performed but lifesaving airway intervention. There are limited published data on prehospital cricothyrotomy in civilian or military settings. Our aim was to prospectively describe the survival rate and complications associated with cricothyrotomy performed in the military prehospital and en route setting. Methods: The Life-Saving Intervention (LSI) study is a prospective, institutional review boardapproved, multicenter trial examining LSIs performed in the prehospital combat setting. We prospectively recorded LSIs performed on patients in theater who were transported to six combat hospitals. Trained site investigators evaluated patients on arrival and recorded demographics, vital signs, and LSIs performed. LSIs were predefined and include cricothyrotomies, chest tubes, intubations, tourniquets, and other procedures. From the large dataset, we analyzed patients who had a cricothyrotomy performed. Hospital outcomes were cross-referenced from the Department of Defense Trauma Registry. Descriptive statistics or Wilcoxon test (nonparametric) were used for data comparisons; statistical significance was set at ρ < .05. The primary outcome was success of prehospital and en route cricothyrotomy. Results: Of the 1,927 patients enrolled, 34 patients had a cricothyrotomy performed (1.8%). Median age was 24 years (interquartile range [IQR]: 22.5-25 years), 97% were men. Mechanisms of injury were blast (79%), penetrating (18%), and blunt force (3%), and 83% had major head, face, or neck injuries. Median Glasgow Coma Scale score (GCS) was 3 (IQR: 3-7.5) and four patients had GCS higher than 8. Cricothyrotomy was successful in 82% of cases. Reasons for failure included left main stem intubation (n = 1), subcutaneous passage (n = 1), and unsuccessful attempt (n = 4). Five patients had a prehospital basic airway intervention. Unsuccessful endotracheal intubation preceded 15% of cricothyrotomies. Of the 24 patients who had the provider type recorded, six had a cricothyrotomy by a combat medic (pre-evacuation), and 18 by an evacuation helicopter medic. Combat-hospital outcome data were available for 26 patients, 13 (50%) of whom survived to discharge. The cricothyrotomy patients had more LSIs than noncricothyrotomy patients (four versus two LSIs per patient; ρ < .0011). Conclusion: In our prospective, multicenter study evaluating cricothyrotomy in combat, procedural success was higher than previously reported. In addition, the majority of cricothyrotomies were performed by the evacuation helicopter medic rather than the prehospital combat medic. Prehospital military medics should receive training in decision making and be provided with adjuncts to facilitate this lifesaving procedure.
Keywords: airway management; airway obstruction; military medicine; war; emergency medical services; cricothyrotomy; airway
Hart D, McNeil M, Hegarty C, Rush RM, 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
Regner D, Frykholm P. 18(2). 90 - 96. (Journal Article)
Abstract
Background: Airway management is a critical skill that may be essential in the battlefield. The aim of this study was to determine if combat life savers and medics with no or limited clinical experience could provide airway control using the disposable laryngeal suction tube (LTS-D) and the Ambu® AuraOnce ™ disposable laryngeal mask (LMA). Methods: Eight military medics with limited clinical experience and no airway management experience secured the airway on 19 intrahospital anesthetized patients using the LTS-D and the LMA. Each patient was treated with both airway adjuncts in a randomized order. Each medic was studied on at least two and not more than three patients. Success of insertion, number of attempts, and time to correct placement with verified ventilation were recorded. Results: When using the LTS-D, the first-attempt success rate for the medics with the first patient was 50% (four of eight) and 75% (six of eight) on the second attempt. With the second patient, the first-attempt success rate was 87.5% (seven of eight), and on the third patient, it was 100% (three of three). For all patients, the accumulated first-attempt success rate was 73.7% (14 of 19) and 84.2% (16 or 19) for second attempts with the LTS-D. The success rate on first attempt with the LMA was 100% (19 of 19) on the first patient. On the second intervention with the LMA, there was a significant decrease in mean time to verified ventilation, from 56.4 seconds to 27.7 seconds (ρ = .043), and time to verified ventilation with no leakage, from 61.3 seconds to 32.3 seconds (ρ = .029). Insertion attempts for three LTS-Ds and one LMA failed. Conclusion: This study suggests that for the safe use of the laryngeal tube suction by inexperienced airway providers, a clinical training program is required. The LMA proved superior to the LTS-D with a 100% success rate at the first attempt, which suggests that minimal training is needed before clinical use. We therefore recommend the LMA as the primary airway adjunct for military medics, despite a hypothetically inferior protection from aspiration.
Keywords: airway; airway management; combat; education; laryngeal tube; laryngeal tube suction; laryngeal mask; military medicine; supraglottic airway
Palmer LE. 19(1). 99 - 106. (Journal Article)
Abstract
Similar to people, airway obstruction is a potentially preventable cause of combat and line of duty death for civilian law enforcement Operational K9s (OpK9) and military working dogs (MWD). Basic (i.e., body positioning, manual maneuvers, bag-valve-mask ventilation) and advanced (i.e., endotracheal intubation, surgical airways) airway techniques are designed to establish a patent airway, oxygenate and ventilate, and protect from aspiration. A surgical airway (cricothyrotomy [CTT] or tracheostomy [TT]) is warranted for difficult airway scenarios in which less invasive means fail to open an airway (aka "Cannot intubate, cannot oxygenate"). In people, the surgical CTT is the preferred surgical airway procedure; most human prehospital providers are not even trained on the TT. Currently, only the TT is described in the veterinary literature as an emergent surgical airway for MWDs. This article describes the novel approach of instituting the surgical CTT for managing the canine difficult airway. The information provided is applicable to personnel operating within the US Special Operations Command as well as civilian tactical emergency medical services that may have the responsibility of providing medical care to an OpK9 or MWD.
Keywords: canine; cricothyrotomy; airway; trauma; tracheostomy; Operational K9s
Schauer SG, Naylor JF, Chow AL, Maddry JK, Cunningham CW, Blackburn MB, Nawn CD, April MD. 19(2). 91 - 94. (Journal Article)
Abstract
Background: Airway compromise is the second leading cause of preventable death on the battlefield. Unlike a cricothyrotomy, supraglottic airway (SGA) placement does not require an incision and is less technically challenging. We compare the survival of causalities undergoing cricothyrotomy versus SGA placement. Methods: We used a series of emergency department (ED) procedure codes to search within the Department of Defense Trauma Registry (DODTR) from January 2007 to August 2016. This is a subanalysis of that data set. Results: During the study period, 194 casualties had a documented cricothyrotomy and 22 had a documented SGA as the sole airway intervention. The two groups had similar proportions of explosive injuries (57.7% versus 63.6%, p = .328), similar composite injury severity scores (25 versus 27.5, p = .168), and similar AIS for the head, face, extremities, and external body regions. The cricothyrotomy group had lower AIS for the thorax (0 versus 3, p = .019), a trend toward lower AIS for the abdomen (0 versus 0, p = .077), more serious injuries to the head (67.5% versus 45.5%, p = .039), and similar rates of serious injuries to the face (4.6% versus 4.6%, p = .984). Glasgow Coma Scale (GCS) scores were similar on arrival to the ED (3 versus 3, p = .467) as were the proportion of patients surviving to discharge (45.4% versus 40.9%, p = .691). On repeated multivariable analyses, the odds ratios for survival were not significantly different between the two groups. Conclusions: We found no difference in short-term outcomes between combat casualties who received an SGA vs those who received a cricothyrotomy. Military prehospital personnel rarely used either advanced airway intervention during the recent conflicts in Afghanistan and Iraq.
Keywords: airway; supraglottic; extraglottic; prehospital; cricothyroidotomy
Anonymous A. 19(3). 18 - 21. (Classical Conference)
Abstract
Keywords: case reports; airway; TCCC
Miller BM, Kinder C, Smith-Steinert R. 19(3). 64 - 70. (Journal Article)
Abstract
Background: An Army Reserve Combat Medic's training is focused on knowledge attainment, skill development, and building experience and training to prepare them to perform in austere conditions with limited resources like on the battlefield. Unfortunately, the exposure to skills they may be responsible for performing is limited. Research shows that greater than 90% of battlefield deaths occur in the prehospital setting, 24% of which are potentially survivable. Literature demonstrates that 91% of these deaths are related to hemorrhage; the remaining are related to other causes, including airway compromise. The skill and decision-making of this population are prime targets to optimize outcomes in the battlefield setting. Methods: Army Reserve combat medics were selected to voluntarily participate in an educational intervention provided by anesthesia providers focusing on airway management. Participants completed a preintervention assessment to evaluate baseline knowledge levels as well as comfort with airway skills. Medics then participated in a simulated difficult airway scenario. Next, airway management was reviewed, and navigation of the difficult airway algorithm was discussed. The presentation was followed by simulations at four hands-on stations, which focused on fundamental airway concepts such as bag-mask ventilation and placement of oral airways, tracheal intubation, placement of supraglottic airways, and cricothyrotomy. Pre/post knowledge assessments and performance evaluation tools were used to measure the effectiveness of the intervention. Results: Statistically significant results were found in self-reported confidence levels with airway skills (z = -2.803, p = .005), algorithm progression (z = -2.807, p = .005), and predicting difficulty with airway interventions based on the patient's features (z = -2.809, p = .005). Establishment of ventilation was completed faster after the intervention. More coherent and effective airway management was noted, new knowledge was gained, and implications from psychological research applied. Conclusion: Supplementing the training of Army Reserve Combat Medics with the utilization of anesthesia providers is an effective platform. This exercise imparted confidence in this population of military providers. This is critical for decision-making capabilities, performance, and the prevention of potentially survivable mortality on the battlefield.
Keywords: airway; mortality; military; nurse anesthetist; education
Schauer SG, Naylor JF, Chow AL, Maddry JK, Cunningham CW, Blackburn MB, Nawn CD, April MD. 19(3). 86 - 89. (Journal Article)
Abstract
Background: Airway compromise is the second leading cause of preventable death on the battlefield. Unlike a cricothyrotomy, supraglottic airway (SGA) placement does not require an incision and is less technically challenging. We compare survival of causalities undergoing cricothyrotomy versus SGA placement. Methods: We used a series of emergency department (ED) procedure codes to search within the Department of Defense Trauma Registry (DoDTR) from January 2007 to August 2016. This is a subanalysis of that dataset. Results: During the study period, 194 casualties had a documented cricothyrotomy and 22 had a documented SGA as the sole airway intervention. The two groups had similar proportions of explosive injuries (57.7% versus 63.6%, p = .328), similar composite injury severity scores (25 versus 27.5, p = .168), and similar AIS for the head, face, extremities, and external body regions. The cricothyrotomy group had lower AIS for the thorax (0 versus 3, p = .019) a trend toward lower AIS for the abdomen (0 versus 0, p = .077), more serious injuries to the head (67.5% versus 45.5%, p = .039), and similar rates of serious injuries to the face (4.6% versus 4.6%, p = .984). Glasgow Coma Scale (GCS) scores were similar upon arrival to the ED (3 versus 3, p = .467) as were the proportion of patients surviving to discharge (45.4% versus 40.9%, p = .691). On repeated multivariable analyses, the odds ratios (ORs) for survival were not significantly different between the two groups. Conclusion: We found no difference in short-term outcomes between combat casualties who received an SGA vs cricothyrotomy. Military prehospital personnel rarely used either advanced airway intervention during the recent conflicts in Afghanistan and Iraq.
Keywords: airway; supraglottic; extraglottic; prehospital; cricothyroidotomy; injury; explosive
Schauer SG, Naylor JF, Beaumont DM, April MD, Tanaka K, Baldwin D, Maddry JK, Becker TE, De Lorenzo RA. 20(3). 62 - 66. (Journal Article)
Abstract
Introduction: Airway compromise is the second leading cause of potentially survivable death on the battlefield. Studies show that airway management is a challenge in prehospital combat care with high error and missed opportunity rates. Lacking is user information on the perceived reasons for the challenges. The US military uses several performance improvement and field feedback systems to solicit feedback regarding deployed experiences. We seek to review feedback and after-action reviews (AARs) from end-users with specific regard to airway challenges noted. Methods: We queried the Center for Army Lessons Learned (CALL), the Army Medical Department Lessons Learned (AMEDDLL), and the Joint Lessons Learned Information System (JLLIS).Our queries comprised a series of search terms with a focus on airway management. Three military emergency medicine expert reviewers performed the primary analysis for lessons learned specific to deployment and predeployment training lessons learned. Upon narrowing the scope of entries to those relevant to deployment and predeployment training, a panel of eight experts performed reviews. The varied nature of the sources lent itself to an unstructured qualitative approach with results tabulated into thematic categories. Results: Our initial search yielded 611 nonduplicate entries. The primary reviewers then analyzed these entries to determine relevance to the project-this resulted in 70 deployment- based lessons learned and four training-based lessons learned. The panel of eight experts then reviewed the 74 lessons learned. We categorized 37 AARs as equipment challenges/malfunctions, 28 as training/education challenges, and 9 as other. Several lessons learned specifically stated that units failed to prioritize medic training; multiple comments suggested that units should consider sending their medics to civilian training centers. Other comments highlighted equipment shortages and equipment malfunctions specific to certain mission types (e.g., pediatric casualties, extreme weather). Conclusions: In this review of military lessons learned systems, most of the feedback referenced equipment malfunctions and gaps in initial and maintenance training.This review of AARs provides guidance for targeted research efforts based the needs of the end-users.
Keywords: prehospital; combat; airway; review; lessons
Schauer SG, April MD, Fairley R, Uhaa N, Hudson IL, Johnson MD, Keen DE, De Lorenzo RA. 20(4). 68 - 72. (Journal Article)
Abstract
Background: Airway obstruction is the second leading cause of potentially preventable death on the battlefield. Prior to 2017, the Committee on Tactical Combat Casualty Care (CoTCCC) recommended the surgical cricothyrotomy as the definitive airway of choice. More recently, the CoTCCC has recommended the iGel™ as the supraglottic airway (SGA) of choice. Data comparing these methods in medics are limited. We compared first-pass placement success among combat medics using a synthetic cadaver model. Methods: We conducted a randomized cross-over study of United States Army combat medics using a synthetic cadaver model. Participants performed a surgical cricothyrotomy using a method of their choosing versus placement of the SGA iGel in random order. The primary outcome was first-pass success. Secondary outcomes included time-to-placement, complications, placement failures, and self-reported participant preferences. Results: Of the 68 medics recruited, 63 had sufficient data for inclusion. Most were noncommissioned officers in rank (54%, E6-E7), with 51% reporting previous deployment experience. There was no significant difference in first-pass success (P = .847) or successful cannulation with regard to the two devices. Time-to-placement was faster with the iGel (21.8 seconds vs. 63.8 seconds). Of the 59 medics who finished the survey, we found that 35 (59%) preferred the iGel and 24 (41%) preferred the cricothyrotomy. Conclusions: In our study of active duty Army combat medics, we found no significant difference with regard to first-pass success or overall successful placement between the iGel and cricothyrotomy. Time-to-placement was significantly lower with the iGel. Participants reported preferring the iGel versus the cricothyrotomy on survey. Further research is needed, as limitations in our study highlighted many shortcomings in airway research involving combat medics.
Keywords: combat, medic; airway; cricothyroidotomy; supraglottic; extraglottic
Scheuermann-Poley C, Lieber A. 21(3). 45 - 50. (Journal Article)
Abstract
The use of a nasopharyngeal airway (NPA) as an adjunct airway device can be critically important in emergency medicine. When placed correctly, the device can prevent upper airway obstruction. The goal of our review was to learn whether there is scientific evidence about the correct length and the insertion depth, and also possible facial landmarks, that can predict the appropriate length of the NPA. There has been no real consensus on how to measure the appropriate tube length for the NPA. Several studies have been able to demonstrate correlations between facial landmarks and body dimensions; however, we did not find any scientific evidence on this matter. The reviewed studies do not indicate evidence to support current recommended guidelines. This could potentially lead to both military and civilian emergency training programs not having the most accurate scientific information for training on anatomic structures and also not having a better overall understanding of intraoral dimensions. Emergency personnel should be taught validated scientific knowledge of NPAs so as to quickly determine the correct tube length and how to use anatomic correlations. This might require further studies on the correlations and perhaps radiographic measurements. A further approach includes adjusting the tube to its correct length according to the sufficient assessment and management of the airway problem.
Keywords: airway; nasopharyngeal; tubes; emergency; trauma
Schauer SG, Mendez J, Uhaa N, Hudson IL, Weymouth WL. 21(4). 26 - 29. (Journal Article)
Abstract
Background: Video laryngoscopy (VL) is shown to improve first-pass success rates and decrease complications in intubations, especially in novice proceduralists. However, the currently fielded VL devices are cost-prohibitive for dispersion across the battlespace. The novel i-view VL is a low-cost, disposable VL device that may serve as a potential solution. We sought to perform end-user performance testing and solicit feedback. Methods: We prospectively enrolled Special Operations flight medics with the 160th Special Operations Aviation Regiment at Hunter Army Airfield, Savannah, Georgia. We asked them to perform an intubation using a synthetic cadaver model while in a mobile helicopter simulation setting. We surveyed their feedback afterward. Results: The median age of participants was 30 and all were male. Of those, 60% reported previous combat deployments, with a median of 20 months of deployment time. Of the 10, 90% were successful with intubation, with 60% on first-pass success with an average of 83 seconds time to intubation. Most had a grade 1 view. Most agreed or strongly agreed that it was easy to use (70%), with half (50%) reporting they would use it in the deployed setting. Several made comments about the screen not being bright enough and would prefer one with a rotating display. Conclusions: We found a high proportion of success for intubation in the mobile simulator and a high satisfaction rate for this device by Special Operations Forces medics.
Keywords: i-view; medic; airway; intubation; flight; helicopter; laryngoscopy
Morvan J, Cotte J, des Deserts MD, Worlton T, Menini W, Cathelinaud O, Pasquier P. 22(3). 90 - 93. (Journal Article)
Abstract
In modern and asymmetric conflicts, traumatic airway obstruction caused by penetrating injury to the face and neck anatomy is the second leading cause of preventable mortality. Definitive airway management in the emergency setting is most commonly accomplished by endotracheal intubation. When this fails or is not possible, a surgical airway, usually cricothyrotomy, is indicated. The clinical choice for establishing a definitive airway in the austere setting is impacted by operational factors such as a mass casualty incident or availability and type of casualty evacuation. This is a case report of a patient with severe cervicofacial injuries with imminent airway compromise in the setting of a mass casualty incident, without possibility of sedation and mechanical ventilation during his evacuation. The authors seek to highlight the considerations and lessons learned for emergency cricothyrotomy.
Keywords: Tactical Combat Casualty Care; cricothyrotomy; airway; mass casualties; medical evacuation
Schauer S, Naylor JF, Fisher AD, Becker TE, April MD. 22(4). 18 - 21. (Journal Article)
Abstract
Background: Airway obstruction is the second leading cause of preventable death on the battlefield. Most airway obstruction occurs secondary to traumatic disruptions of the airway anatomical structures. Facial trauma is frequently cited as rationale for maintaining cricothyrotomy in the medics' skill set over the supraglottic airways more commonly used in the civilian setting. Methods: We used a series of emergency department procedure codes to identify patients within the Department of Defense Trauma Registry (DoDTR) from January 2007 to August 2016. This is a sub-group analysis of casualties with documented serious facial trauma based on an abbreviated injury scale of 3 or greater for the facial body region. Results: Our predefined search codes captured 28,222 DoDTR casualties, of which we identified 136 (0.5%) casualties with serious facial trauma, of which 19 of the 136 had documentation of an airway intervention (13.9%). No casualties with serious facial trauma underwent nasopharyngeal airway (NPA) placement, 0.04% underwent cricothyrotomy (n = 10), 0.03% underwent intubation (n = 9), and a single subject underwent supraglottic airway (SGA) placement (<0.01%). We only identified four casualties (0.01% of total dataset) with an isolated injury to the face. Conclusions: Serious injury to the face rarely occurred among trauma casualties within the DoDTR. In this subgroup analysis of casualties with serious facial trauma, the incidence of airway interventions to include cricothyrotomy was exceedingly low. However, within this small subset the mortality rate is high and thus better methods for airway management need to be developed.
Keywords: prehospital; airway; facial; trauma; military
Schauer SG, Hudson IL, Fisher AD, Dion G, Long B, Blackburn MB, De Lorenzo RA, Shaw TA, April MD. 23(1). 23 - 29. (Journal Article)
Abstract
Background: Airway obstruction is the second leading cause of potentially survivable death on the battlefield. Assessing outcomes associated with airway interventions is important, and temporal trends can reflect the influence of training, technology, the system of care, and other factors. We assessed mortality among casualties undergoing prehospital airway intervention occurring over the course of combat operations during 2007-2019. Methods: This is a retrospective analysis of a previously described dataset from the Department of Defense Trauma Registry (DODTR). We included only casualties with documented placement of an endotracheal tube, cricothyrotomy, or supraglottic airway (SGA) in the prehospital setting. Results: Within the DODTR from January 2007 to December 2019, there were 25,849 adult encounters with documentation of any prehospital activity. Within that group, there were 251 documented cricothyrotomies, 1,147 documented intubations, and 35 documented supraglottic airways placed. Cricothyrotomy recipients had a median age of 25. Within this group, the largest proportion were non-North Atlantic Treaty Organization (NATO) military personnel (35%), were injured by explosives (54%), had a median injury severity score (ISS) of 24, and 60% survived to hospital discharge. Intubation recipients had a median age of 24. Within this group, the largest proportion were non-NATO military personnel (37%), were injured by explosives (57%), had a median ISS of 18, and 76% survived to hospital discharge. SGA recipients had a median age of 28. Within this group, the largest proportion were non-NATO military (37%), were injured by firearms (48%), had a median ISS of 25, and 54% survived to hospital discharge. A downward trend existed in the quantity of all procedures performed during the study period. In both unadjusted and adjusted regression models, we identified no year-to-year differences in survival after prehospital cricothyrotomy or SGA placement. In the unadjusted and adjusted models, we noted a decrease in mortality during the 2007-2008 (odds ratio [OR] for death 0.47, 95% CI 0.26-0.86) and an increase from 2012-2013 (OR 2.10, 95% CI 1.09-4.05) for prehospital intubation. Conclusion: Mortality among combat casualties undergoing prehospital or emergency department airway interventions showed no sustained change during the study period. These findings suggest that advances in airway resuscitation are necessary to achieve mortality improvements in potentially survivable airway injuries in the prehospital setting.
Keywords: prehospital; trend; airway; combat; outcome; survival; military
Smith S, Liu M, Ball I, Meunier B, Hilsden R. 23(1). 31 - 37. (Journal Article)
Abstract
Medical leadership must decide how prehospital airways will be managed in a combat environment, and airway skills can be complicated and difficult to learn. Evidence informed airway strategies are essential. A search was conducted in Medline and EMBASE databases for prehospital combat airway use. The primary data of interest was what type of airway was used. Other data reviewed included: who performed the intervention and the success rate of the intervention. The search strategy produced 2,624 results, of which 18 were included in the final analysis. Endotracheal intubation, cricothyroidotomy, supraglottic airways, and nasopharyngeal airways have all been used in the prehospital combat environment. This review summarizes the entirety of the available combat literature such that commanders may make an evidence-based informed decision with respect to their airway management policies.
Keywords: endotracheal intubation; airway; cricothyroidotomy; supraglottic airways; and nasopharyngeal airways
Schauer SG, Damrow T, Martin SM, Hudson IL, De Lorenzo RA, Blackburn MB, Hofmann LJ, April MD. 23(2). 13 - 18. (Journal Article)
Abstract
Background: Airway obstruction is the second leading cause of potentially preventable death on the battlefield. The treatment for airway obstruction is intubation or advanced airway adjunct, which has a known risk of aspiration. We sought to describe the variables associated with aspiration pneumonia after prehospital airway intervention. Methods: This is a sub-analysis of previously described data from the Department of Defense Trauma Registry (DoDTR) from 2007 to 2020. We included casualties that had at least one prehospital airway intervention with documentation of subsequent aspiration pneumonia or pneumonia within three days of the intervention. We used a generalized linear model with Firth bias estimates to test for associations. Results: There were 1,509 casualties that underwent prehospital airway device placement. Of these, 41 (2.7%) met inclusion criteria into the aspiration pneumonia cohort. The demographics had no statistical difference between the groups. The non-aspiration cohort had fewer median ventilator days (2 versus 6, p < 0.001), intensive care unit days (2 versus 7, p < 0.001, and hospital days [3 versus 8, p < 0.001]). Survival was lower in the non-aspiration cohort (74.2% versus 90.2%, p = 0.017). The administration of succinylcholine was higher in the non-aspiration cohort (28.0% versus 12.2%, p = 0.031). In our multivariable model, only the administration of succinylcholine was significant and was associated with lower probability of aspiration pneumonia (odds ratio 0.56). Conclusion: Overall, the incidence of aspiration pneumonia was low in our cohort. The administration of succinylcholine was associated with a lower odds of developing aspiration pneumonia.
Keywords: airway; combat; aspiration; vomit; intubation; prehospital
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
Schauer S, Long B, Fisher AD, Stednick PJ, Bebarta VS, Ginde AA, April MD. 23(4). 110 - 111. (Editorial)
Abstract
Keywords: airway; military; video; laryngoscopy; trauma
Levitan RM. 14(1). 45 - 49. (Journal Article)
Abstract
The author describes a cricothyrotomy system that consists of two devices that, packaged together, are labeled the Control-Cric™ system. The Cric-Key™ was invented to verify tracheal location during surgical airway procedures- without the need for visualization, aspiration of air, or reliance on clinicians' fine motor skills. The Cric-Knife™ combines a scalpel with an overlying sliding hook to facilitate a smooth transition from membrane incision to hook insertion and tracheal control. In a recent test versus a traditional open technique, this system had a higher success rate and was faster to implement.
Keywords: cricothyrotomy; airway device; Cric-Key™; Cric-Knife™
Rodriquez D, Gomaa D, Blakeman T, Petroa M, Dorlac WC, Johannigman J, Branson R. 12(2). 65 - 70. (Journal Article)
Abstract
Mechanical ventilation in an austere environment is difficult owing to logistics, training, and environmental conditions. We evaluated the ability of professional caregivers to provide ventilatory support to a simulated patient using the Simplified Automated Ventilator (SAVe) with a mask hand attended ventilation, mask with single strap unattended ventilation, and supraglottic airway (King LT) ventilation. All three methods were performed using a SAVe with a set tidal volume of 600ml and respiratory rate of 10 breaths per minute. The simulator consisted of a head and upper torso with anatomically correct upper airway structures, trachea, esophagus, and lung which, also measured the delivered tidal volume, respiratory rate, inspiratory flow, and airway pressures. Volunteers used each airway control method to provide ventilation for 10 minutes in random order. Success of each technique was judged as a mean delivered tidal volume of > 500ml. The major finding of this study was that medical professionals using SAVe resuscitator and the manufacturer supplied face mask with single head strap failed to ventilate the airway model in every case.
Keywords: SAVe; ventilation; airway management; prehospital; mask ventilation
Barnard EB, Ervin AT, Mabry RL, Bebarta VS. 14(4). 35 - 39. (Journal Article)
Abstract
Introduction: Airway compromise is the third most common cause of potentially preventable combat death. Surgical cricothyrotomy is an infrequently performed but lifesaving airway intervention. There are limited published data on prehospital cricothyrotomy in civilian or military settings. Our aim was to prospectively describe the survival rate and complications associated with cricothyrotomy performed in the military prehospital and en route setting. Methods: The Life-Saving Intervention (LSI) study is a prospective, institutional review boardapproved, multicenter trial examining LSIs performed in the prehospital combat setting. We prospectively recorded LSIs performed on patients in theater who were transported to six combat hospitals. Trained site investigators evaluated patients on arrival and recorded demographics, vital signs, and LSIs performed. LSIs were predefined and include cricothyrotomies, chest tubes, intubations, tourniquets, and other procedures. From the large dataset, we analyzed patients who had a cricothyrotomy performed. Hospital outcomes were cross-referenced from the Department of Defense Trauma Registry. Descriptive statistics or Wilcoxon test (nonparametric) were used for data comparisons; statistical significance was set at ρ < .05. The primary outcome was success of prehospital and en route cricothyrotomy. Results: Of the 1,927 patients enrolled, 34 patients had a cricothyrotomy performed (1.8%). Median age was 24 years (interquartile range [IQR]: 22.5-25 years), 97% were men. Mechanisms of injury were blast (79%), penetrating (18%), and blunt force (3%), and 83% had major head, face, or neck injuries. Median Glasgow Coma Scale score (GCS) was 3 (IQR: 3-7.5) and four patients had GCS higher than 8. Cricothyrotomy was successful in 82% of cases. Reasons for failure included left main stem intubation (n = 1), subcutaneous passage (n = 1), and unsuccessful attempt (n = 4). Five patients had a prehospital basic airway intervention. Unsuccessful endotracheal intubation preceded 15% of cricothyrotomies. Of the 24 patients who had the provider type recorded, six had a cricothyrotomy by a combat medic (pre-evacuation), and 18 by an evacuation helicopter medic. Combat-hospital outcome data were available for 26 patients, 13 (50%) of whom survived to discharge. The cricothyrotomy patients had more LSIs than noncricothyrotomy patients (four versus two LSIs per patient; ρ < .0011). Conclusion: In our prospective, multicenter study evaluating cricothyrotomy in combat, procedural success was higher than previously reported. In addition, the majority of cricothyrotomies were performed by the evacuation helicopter medic rather than the prehospital combat medic. Prehospital military medics should receive training in decision making and be provided with adjuncts to facilitate this lifesaving procedure.
Keywords: airway management; airway obstruction; military medicine; war; emergency medical services; cricothyrotomy; airway
Rapp J, Hampton K. 17(1). 130 - 130. (Journal Article)
Abstract
Keywords: sonography; airway management
Regner D, Frykholm P. 18(2). 90 - 96. (Journal Article)
Abstract
Background: Airway management is a critical skill that may be essential in the battlefield. The aim of this study was to determine if combat life savers and medics with no or limited clinical experience could provide airway control using the disposable laryngeal suction tube (LTS-D) and the Ambu® AuraOnce ™ disposable laryngeal mask (LMA). Methods: Eight military medics with limited clinical experience and no airway management experience secured the airway on 19 intrahospital anesthetized patients using the LTS-D and the LMA. Each patient was treated with both airway adjuncts in a randomized order. Each medic was studied on at least two and not more than three patients. Success of insertion, number of attempts, and time to correct placement with verified ventilation were recorded. Results: When using the LTS-D, the first-attempt success rate for the medics with the first patient was 50% (four of eight) and 75% (six of eight) on the second attempt. With the second patient, the first-attempt success rate was 87.5% (seven of eight), and on the third patient, it was 100% (three of three). For all patients, the accumulated first-attempt success rate was 73.7% (14 of 19) and 84.2% (16 or 19) for second attempts with the LTS-D. The success rate on first attempt with the LMA was 100% (19 of 19) on the first patient. On the second intervention with the LMA, there was a significant decrease in mean time to verified ventilation, from 56.4 seconds to 27.7 seconds (ρ = .043), and time to verified ventilation with no leakage, from 61.3 seconds to 32.3 seconds (ρ = .029). Insertion attempts for three LTS-Ds and one LMA failed. Conclusion: This study suggests that for the safe use of the laryngeal tube suction by inexperienced airway providers, a clinical training program is required. The LMA proved superior to the LTS-D with a 100% success rate at the first attempt, which suggests that minimal training is needed before clinical use. We therefore recommend the LMA as the primary airway adjunct for military medics, despite a hypothetically inferior protection from aspiration.
Keywords: airway; airway management; combat; education; laryngeal tube; laryngeal tube suction; laryngeal mask; military medicine; supraglottic airway
Farber SJ, Kantar RS, Rodriguez ED. 18(3). 62 - 66. (Journal Article)
Abstract
As the United States continues to increase its use of Special Operations Forces worldwide, treatment of craniomaxillofacial (CMF) trauma must be adapted to meet the needs of the warfighter. The remoteness of Special Operations can result in potentially longer times until definitive treatment may be reached. A significant portion of Servicemembers incur injury to the CMF region (42%). Severe CMF trauma can result in substantial hemorrhage and airway compromise. These can be immediately life threatening and must be addressed expeditiously. Numerous devices and techniques for airway management have been made available to the forward provider. A thorough review of nonsurgical and surgical airway management of the patient with facial injury for the forward provider and providers at receiving facilities is provided in this article. Techniques to address flail segments of the facial skeleton are critical in minimizing airway compromise in these patients. There are many methods to control hemorrhage from the head and neck region. Hemorrhage control is critical to ensure survival in the austere environment and allow for transport to a definitive care facility. Associated injuries to the cervical spine, globe, skull base, carotid artery, and brain must be carefully evaluated and addressed in these patients. Management of vision- threatening orbital compartment syndrome is critical in patients with CMF injuries. Because the head and neck region remains relatively vulnerable in the warfighter, combat CMF trauma will continue to occur. Forward providers will benefit from a review of the acute treatment of CMF traumatic injury. Properly triaging and treating facial injuries is necessary to afford the best chance of survival for patients with a devastating combat CMF injury.
Keywords: craniomaxillofacial trauma; airway management; acute care; hemorrhage; ocular trauma
Cowles CE, Santos RE. 20(1). 29 - 30. (Case Reports)
Abstract
Surgical airway management should be regarded as one of many tools available to forward clinical Operators. The need for that intervention should be determined in a quick and decisive manner consistent with accepted protocols for combat care. The case presented discusses immediate surgical access to the airway required after the initial assessment of the patient and illustrates the clinical urgency of patients requiring surgical intervention in the field setting.
Keywords: wounds; gunshot; airway management; airway obstruction; law enforcement
Naftalovich R, Iskander AJ. 22(1). 102 - 103. (Journal Article)
Abstract
Surgical airway approaches are, at times, last resort options in difficult airway management. In Special Operations these interventions confront distorted anatomy from combat trauma, extreme conditions, and may be performed by non-medically trained personnel. Under these circumstances, needle cricothyroidotomy using a large bore intravenous catheter can be considered. A small syringe connected to the needle can confirm transtracheal placement through air aspiration before passing the angiocatheter over the needle. Button activated retracting needles should be avoided for this when possible. We recommend a 3-mL Luer-lock syringe because a small syringe is better suited for generating pressure and once the catheter is in the trachea, this same syringe can be connected to bag valve ventilation by replacing its plunger with a connector from a 6.5-, 7-, or 7.5-mm endotracheal tube. Adding these small and light high-yield items to the Tactical Combat Casualty Care medic inventory should be considered in future revisions.
Keywords: military medicine; airway management; combat disorders; intubation, intratracheal
Stevens R, Pierce B, Tilley L. 22(4). 72 - 76. (Journal Article)
Abstract
Military medicine has made significant advancements in decreasing mortality by addressing the lethal triad - metabolic acidosis, coagulopathy, and hypothermia. However, casualties are still succumbing to injury. Recent conflict zones have led to the development of remarkable life-saving innovations, including the management of compressible hemorrhage and whole blood transfusions. Nevertheless, hypothermia prevention and treatment techniques remain relatively unchanged. Hypothermia prevention is anticipated to become more critical in future operations due to a predicted increase in evacuation times and reliance on Prolonged Casualty Care (PCC). This is likely secondary to increasingly distanced battlespaces and the mobility challenges of operating in semi-/non-permissive environments. Innovation is essential to combat this threat via active airway rewarming in the vulnerable patient. Thus, we propose the development, fabrication, and efficacy testing of a device in which we estimate being able to control temperature and humidity at physiologic levels in the PCC setting and beyond.
Keywords: Advanced Trauma Life Support care; airway management; critical care; emergency medicine; intellectual property; military medicine; patent; prehospital emergency care; prolonged casualty care; prolonged field care; resuscitation; technological innovations; war-related trauma; wilderness medicine hypothermia
Barnard EB, Ervin AT, Mabry RL, Bebarta VS. 14(4). 35 - 39. (Journal Article)
Abstract
Introduction: Airway compromise is the third most common cause of potentially preventable combat death. Surgical cricothyrotomy is an infrequently performed but lifesaving airway intervention. There are limited published data on prehospital cricothyrotomy in civilian or military settings. Our aim was to prospectively describe the survival rate and complications associated with cricothyrotomy performed in the military prehospital and en route setting. Methods: The Life-Saving Intervention (LSI) study is a prospective, institutional review boardapproved, multicenter trial examining LSIs performed in the prehospital combat setting. We prospectively recorded LSIs performed on patients in theater who were transported to six combat hospitals. Trained site investigators evaluated patients on arrival and recorded demographics, vital signs, and LSIs performed. LSIs were predefined and include cricothyrotomies, chest tubes, intubations, tourniquets, and other procedures. From the large dataset, we analyzed patients who had a cricothyrotomy performed. Hospital outcomes were cross-referenced from the Department of Defense Trauma Registry. Descriptive statistics or Wilcoxon test (nonparametric) were used for data comparisons; statistical significance was set at ρ < .05. The primary outcome was success of prehospital and en route cricothyrotomy. Results: Of the 1,927 patients enrolled, 34 patients had a cricothyrotomy performed (1.8%). Median age was 24 years (interquartile range [IQR]: 22.5-25 years), 97% were men. Mechanisms of injury were blast (79%), penetrating (18%), and blunt force (3%), and 83% had major head, face, or neck injuries. Median Glasgow Coma Scale score (GCS) was 3 (IQR: 3-7.5) and four patients had GCS higher than 8. Cricothyrotomy was successful in 82% of cases. Reasons for failure included left main stem intubation (n = 1), subcutaneous passage (n = 1), and unsuccessful attempt (n = 4). Five patients had a prehospital basic airway intervention. Unsuccessful endotracheal intubation preceded 15% of cricothyrotomies. Of the 24 patients who had the provider type recorded, six had a cricothyrotomy by a combat medic (pre-evacuation), and 18 by an evacuation helicopter medic. Combat-hospital outcome data were available for 26 patients, 13 (50%) of whom survived to discharge. The cricothyrotomy patients had more LSIs than noncricothyrotomy patients (four versus two LSIs per patient; ρ < .0011). Conclusion: In our prospective, multicenter study evaluating cricothyrotomy in combat, procedural success was higher than previously reported. In addition, the majority of cricothyrotomies were performed by the evacuation helicopter medic rather than the prehospital combat medic. Prehospital military medics should receive training in decision making and be provided with adjuncts to facilitate this lifesaving procedure.
Keywords: airway management; airway obstruction; military medicine; war; emergency medical services; cricothyrotomy; airway
Cowles CE, Santos RE. 20(1). 29 - 30. (Case Reports)
Abstract
Surgical airway management should be regarded as one of many tools available to forward clinical Operators. The need for that intervention should be determined in a quick and decisive manner consistent with accepted protocols for combat care. The case presented discusses immediate surgical access to the airway required after the initial assessment of the patient and illustrates the clinical urgency of patients requiring surgical intervention in the field setting.
Keywords: wounds; gunshot; airway management; airway obstruction; law enforcement
Irizarry DJ, Tate C, Bingham MT, Wey P, Batjom E, Nicholas TA, Boedeker BH. 12(1). 24 - 30. (Journal Article)
Abstract
The Medical Civic Assistance Program (MEDCAP) is a military commander's tool developed during the Vietnam War to gain access to and positively influence an indigenous population through the provision of direct medical care provided by military medical personnel, particularly in Counter Insurgency Operations (COIN). An alternative to MEDCAPs is the medical seminar (MEDSEM). The MEDSEM uses a Commander's military medical assets to share culturally appropriate medical information with a defined indigenous population in order to create a sustainable training resource for the local population's health system. At the heart of the MEDSEM is the "train the trainer" concept whereby medical information is passed to indigenous trainers who then pass that information to an indigenous population. The MEDSEM achieves the Commander's objectives of increasing access and influence with the population through a medical training venue rather than direct patient care. Previous MEDSEMS conducted in Afghanistan by military forces focused on improvement of rural healthcare through creation of Village Health Care Workers. This model can also be used to engage host nation (HN) medical personnel and improve medical treatment capabilities in population centers. The authors describe a modification of the MEDSEM, a Medical Mentorship (MM), conducted in November 2010 in Kabul, Afghanistan, at the Afghan National Army (ANA) National Medical Hospital. This training was designed to improve intubation skills in Afghan National Army Hospitals by ANA medical providers, leave residual training capability, and build relationships within the institution that not only assist the institution, but can also be leveraged to foster Commanders' objectives, such as health and reconstruction initiatives and medical partnering for indigenous corps and medical forces described below.
Keywords: Counter-Insurgency; Medical Support; airway training; Afghan National Army
Schauer SG, April MD, Cunningham CW, Long AN, Carter R. 17(3). 18 - 20. (Case Reports)
Abstract
Background: Surgical cricothyrotomy remains the only definitive airway management modality for the tactical setting recommended by Tactical Combat Casualty Care guidelines. Some units have fielded commercial cricothyrotomy kits to assist Combat Medics with surgical cricothyrotomy. To our knowledge, no previous publications report data on the use of these kits in combat settings. This series reports the the use of two kits in four patients in the prehospital combat setting. Methods: Using the Department of Defense Trauma Registry and the Prehospital Trauma Registry, we identified four cases of patients who underwent prehospital cricothyrotomy with the use of commercial kits. In the first two cases, a Medic successfully used a North American Rescue CricKit (NARCK) to obtain a surgical airway in a Servicemember with multiple amputations from an improvised explosive device explosion. In case 3, the Medic unsuccessfully used an H&H Medical kit to attempt placement of a surgical airway in a Servicemember shot in the head by small arms fire. A second attempt to place a surgical airway using a NARCK was successful. In case 4, a Soldier sustained a gunshot wound to the chest. A Medic described fluid in the airway precluding bag-valve-mask ventilation; the Medic attempted to place a surgical airway with the H&H kit without success. Conclusion: Four cases of prehospital surgical airway cannulation on the battlefield demonstrated three successful uses of prehospital cricothyrotomy kits. Further research should focus on determining which kits may be most useful in the combat setting.
Keywords: airway, surgical; cricothyrotomy; cricothyroidotomy; combat; prehospital; Medic, Afghanistan
Clerkin S, Carlson NT, Long B, Taylor DH, Bridwell R. 23(1). 80 - 83. (Case Reports)
Abstract
As arctic warfare becomes a center focus within Special Operations, cold weather injury looms as both a medical and operational threat. While cold weather injury can range from pernio to hemodynamically unstable systemic hypothermia, the more minor injuries are far more common. However, these present a challenge in austere medical care and can drastically impact mission capability. We present a case of a Special Operations crew chief with cold weather digital injury while at the Arctic Isolation Course in Alaska and his subsequent clinical course. Prevention remains the key for mitigating these injuries, while the decision to rewarm must be made with both medical and tactical factors in mind as refreezing incurs significant morbidity. Other components of prehospital treatment include active rewarming, ibuprofen, aloe vera, and pain control.
Keywords: arctic warfare; cold injury; frostbite; rewarm; Alaska; hypothermia; austere
Ahmed A, Peine S. 13(2). 69 - 74. (Journal Article)
Abstract
The intents of this article are to share our experiences during a medical mission in the Dominican Republic and to provide the reader with a cross-sectional view of conditions seen and an overview of interesting and challenging cases encountered. We also discuss treatments and techniques used and share lessons learned.
Keywords: dermatology; albinism; chemdestruction; chromoblastomycosis; lesions; skin dermatoses; ecthyma; intertrigo; folliculitis; fungal; scabies; eczematoid spectrum; atopic dermatitis; xerosis cutis; polymorphous; eruption; mycetoma; leprosy; scarlatina; genoderms
Studer NM, April MD, Bowling F, Danielson PD, Cap AP. 17(2). 82 - 88. (Journal Article)
Abstract
Optimal fluid resuscitation on the battlefield in the absence of blood products remains unclear. Contemporary Combat medics are generally limited to hydroxyethyl starch or crystalloid solutions, both of which present significant drawbacks. Obtaining US Food and Drug Administration (FDA)-approved freeze-dried plasma (FDP) is a top casualty care research priority for the US Military. Interest in this agent reflects a desire to simultaneously expand intravascular volume and address coagulopathy. The history of FDP dates to the Second World War, when American expeditionary forces used this agent frequently. Also fielded was 25% albumin, an agent that lacks coagulation factors but offers impressive volume expansion with minimal weight to carry and requires no reconstitution in the field. The current potential value of 25% albumin is largely overlooked. Although FDP presents an attractive future option for battlefield prehospital fluid resuscitation once FDA approved, this article argues that in the interim, 25% albumin, augmented with fibrinogen concentrate and tranexamic acid to mitigate hemodilution effects on coagulation capacity, offers an effective volume resuscitation alternative that could save lives on the battlefield immediately.
Keywords: albumin; fluid resuscitation; Hextend®; colloid; Tactical Combat Casualty Care; prolonged field care
Bryan CJ, Wolfe AL, Morrow CE, Stephenson JA, Haskell J, Bryan AO. 15(3). 66 - 71. (Journal Article)
Abstract
Background: Caffeine, tobacco, and alcohol are the most widely used substances globally, but the majority of research on the associations among legal substance use and physical health has focused on the general population, not elite military personnel. The purpose of the current study was to describe patterns of tobacco, alcohol, and caffeine use and to examine the relationship of legal substance use with self-reported physical health complaints among US Air Force Pararescuemen (PJs) and Combat Rescue Officers (CROs). Methods: Participants were 196 US PJs and CROs. Participants completed self-report measures of legal drug use and somatic symptoms. Generalized linear modeling with robust maximum likelihood estimation was used for multivariate regression analyses. Chi-square analyses were conducted for univariate comparisons of categorical variables. Results: Reported rates of tobacco use (28.2%), alcohol consumption (83.2%), and regular caffeine consumption (88.8%) were similar to the general population. Daily caffeine intake was significantly higher among participants reporting they were bothered a lot by back pain [Wald χ²(2) = 11.39; ρ = .003] and extremity pain [Wald χ²(2) = 11.39; ρ = .003], even when controlling for age and deployment history. Participants with severe extremity pain also reported drinking approximately twice as many alcoholic beverages per week (mean, 5.46; standard error [SE], 0.91) than participants who were bothered a little (mean, 2.88; SE, 0.54) or not bothered at all (mean, 2.88; SE, 0.52) by extremity pain. Conclusion: Back and extremity pain is associated with greater caffeine and alcohol consumption among PJs.
Keywords: military; caffeine; alcohol; tobacco; pain; Pararescuemen
Gielas A. 24(3). 58 - 61. (Journal Article)
Abstract
Tattooing is an ancient art form widely practiced among Special Operations Forces (SOF) personnel. The ink injected into skin tissue during tattooing often contains various compounds, including impurities and contaminants, which can pose health risks. This article provides an overview of recent research to inform SOF medical personnel about the potential health implications of both new and older tattoos.
Keywords: tattoo; ink pigments; risks; allergies; infection; inflammation; sarcoidosis; lymphoma
Winn AE, Rivard SS, 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® [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
O'Hara R, Sussman LR, Tiede JM, Sheehan R, Keizer B. 22(2). 139 - 148. (Journal Article)
Abstract
Introduction: Special Operations Forces (SOF) Operators (SOs) are exposed to high levels of physiological and cognitive stressors early in their career, starting with the rigors of training, combined with years of recurring deployments. Over time, these stressors may degrade SOs' performance, health, and recovery. Objectives: (1) To evaluate sources identifying and describing physiological and psychological stressors affecting performance, health, and recovery in SOs, and (2) to explore interventions and phenomena of interest, such as the biological mechanisms of overtraining syndrome (OTS). Methods: This review followed the recommendations and methodology of the Joanna Briggs Institute and the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) guidelines. A database search from December 1993 to December 2021 was performed in PubMed, the Cochrane Library, and the Defense Technical Information Center (DTIC). Potential articles were identified using search terms from their titles, abstracts, and full texts. Articles effectively addressing the review questions and objectives were eligible. Results: After 19 articles were excluded for not meeting established inclusion criteria, a total of 92 full-text articles were assessed for eligibility. After the final analysis, 72 articles were included. Conclusions: Allostatic imbalance may occur when supra-maximal demands are prolonged and repeated. Without adequate recovery, health and performance may decline, leading to nonfunctional overreaching (NFO) and OTS, resulting in harmful psychological and hormonal disruptions. The recurring demands placed on SOs may result in a chronically high burden of physical and mental stress known as allostatic overload. Future investigation, especially in the purview of longitudinal implementation, health, and recovery monitoring, is necessary for the health and readiness of the SOF population.
Keywords: humans; cognition; overtraining syndrome; allostatic load; military personnel; sports
Delmonaco BL, Baker A, Clay J, Kilburn J. 16(1). 103 - 108. (Journal Article)
Abstract
An eight-person team of conventional US Air Force (USAF) medical providers deployed to support US Special Operations Forces (SOF) in North and West Africa for the first time in November 2014. The predeployment training, operations while deployed, and lessons learned from the challenges of performing surgery and medical evacuations in the remote desert environment of Chad and Niger on the continent of Africa are described. The vast area of operations and far-forward posture of these teams requires cooperation between partner African nations, the French military, and SOF to make these medical teams effective providers of surgical and critical care in Africa. The continuous deployment of conventional USAF medical providers since 2014 in support of US Special Operations Command Africa is challenging and will benefit from more medical teams and effective air assets to provide casualty evacuation across the vast area of operations.
Keywords: US Special Operations Command North and West Africa; far-forward surgery; conventional US Air Force; Mobile Field Surgical Team; Niamey, Niger; N'Dhamena, Chad; CASEVAC; Boko Haram; al-Qaeda I the Islamic Maghreb; French Military
Berrios I, Carius BM, Vaughn NA, Dobbe L. 24(3). 79 - 83. (Journal Article)
Abstract
Despite advancements in military medical treatment and evacuation, soldiers in austere environments remain vulnerable to disease and non-battle injury and may face prolonged evacuation before receiving definitive care. In particular, arranging care for a soldier presenting with a conditions that has a wide differential diagnosis, such as acute altered mental status (AMS), can be especially challenging. We highlight the case of an otherwise young, healthy U.S. Soldier serving in Indonesia, who presented with acute AMS concerning for undifferentiated infection. Subsequent workup at the receiving hospital following evacuation revealed Salmonella enterica infection, more commonly known as typhoid. However, even with clinical findings of typhoid encephalitis and initiation of empiric treatment, medical care proved challenging in the resource-limited local facilities, despite multiple escalations of care. Ultimately, the patient was evacuated to a tertiary facility in Singapore, where his condition improved, and 4 days after initial presentation the patient had no definitive findings of infections on lumbar puncture. This case not only highlights the threat of typhoid and other infectious diseases in modern operations but also the challenges of suboptimal medical care in both the prehospital and hospital settings when utilizing host nation facilities.
Keywords: altered mental status; prolonged casualty care; MEDEVAC; infectious diseases; optimal medical care, encephalitis; PCC
Martinson J, Park H, Butler FK, Hammesfahr R, DuBose JJ, Scalea TM. 20(2). 116 - 122. (Journal Article)
Abstract
The American College of Surgeons' "Stop the Bleed" (STB) campaign emphasizes how to apply the Combat Application Tourniquet (CAT), a device adopted by the military to control extremity hemorrhage. However, multiple commercially available alternatives to the CAT exist, and it would be helpful for instructors to be knowledgeable about how these other models compare. A PubMed search from January 2012 to January 2020 cross-referenced with a Google search for "tourniquet" was performed for commercially available tourniquets that had been trialed against the CAT. Windlass-type models included the Special Operations Forces Tactical Tourniquet (SOFT-T), the SOFT-T Wide (SOFFT-W), the SAM-XT tourniquet, the Military Emergency Tourniquet (MET), and the Tactical Medical Tourniquet (TMT). Elastic-type tourniquets included were the Stretch, Wrap, And Tuck Tourniquet (SWAT-T), the Israeli Silicone Tourniquet (IST), and the Rapid Activation Tourniquet System (RATS). Ratchet-type tourniquets included were the Ratcheting Medical Tourniquet (RMT) and TX2/TX3 tourniquets, and pneumatic-type tourniquets were the Emergency and Military Tourniquet (EMT) and Tactical Pneumatic Tourniquet (TPT). This review aims to describe the literature surrounding these models so that instructors can help laypeople make more informed purchases, stop the bleed, and save a life.
Keywords: tourniquets; alternate; Stop the Bleed; review
Calvano CJ, Enzenauer RW, Eisnor DL, Mazzoli RA. 17(3). 81 - 83. (Journal Article)
Abstract
Nerve agents are a threat to military and civilian health. The antidote, atropine sulfate, is delivered by autoinjector, which is a limited resource. We propose the use of 1% atropine ophthalmic solution (supplied commercially in 5mL or 15 mL bottles) via oral, ocular, and intranasal administration as an expedient substitute in austere environments.
Keywords: nerve agent; chemical warfare; atropine; antidote; alternative treatment
Kern C, McCoart A, Beltran T, Martoszek M. 18(4). 103 - 105. (Journal Article)
Abstract
Background: Chronic pain is a major cause of disability across the military, especially for the combat Soldier. More than twothirds of Americans with chronic pain are now using complementary medicine. Methods: Patients with chronic pain opting for reflexology as part of their treatment plan received bilateral therapy. Alternating pressure was applied to the individual patient's reflex points corresponding to their pain sites. Following a single treatment session, patients were asked to complete a short survey. Discussion: There is evidence that reflexology is therapeutic for many conditions, to include sleep and anxiety, both of which can be comorbidity in the patient with chronic pain. There is a lack of evidence on the use of reflexology with chronic pain patients receiving multidisciplinary pain care. Results: A total of 311 participants completed the survey. Posttreatment pain scored decreased by a median of 2 points (interquartile range [IQR] 1-3) on a 10-point pain scale. This represents a median 43% (IQR 25%-60%) reduction in pain for males and a 41% (IQR 30%-60%) reduction in pain for females. Conclusion: Currently research is limited on effects of reflexology in treating chronic pain, yet, like acupuncture, this is an inexpensive, reliable, teachable, and simple noninvasive treatment. Further studies are warranted.
Keywords: reflexology; pain; chronic pain; complementary treatments; alternative treatments
Studer NM, Hughes JR, Puskar J. 15(1). 11 - 15. (Case Reports)
Abstract
Decompression sickness (DCS) is one of several dysbarisms (medical conditions resulting from a change in atmospheric pressure) that can be encountered by the Special Operations Forces (SOF) medical provider. DCS can present with several different manifestations. The authors present the case of a 23-year-old Airman who presented with vague neurologic symptoms following altitude-chamber training. They discuss the care of casualties with DCS and its implications for SOF.
Keywords: decompression sickness; Type II DCS; dysbarism; gas embolism; hyperbaric oxygen; altitude chamber; demand value; Oxylator®; hypoxia; hypobaric
Choi JH, Roberts TR, Sieck K, Harea GT, Karaliou V, Wendorff DS, Beely BM, Cancio LC, Sams VG, Batchinsky AI. 20(1). 65 - 70. (Journal Article)
Abstract
Background: We investigated the expression of high mobility group box 1 (HMGB1) protein in a combat-relevant polytrauma/ acute respiratory distress syndrome (ARDS) model. We hypothesized that systemic HMGB1 expression is increased after injury and during aeromedical evacuation (AE) at altitude. Methods: Female Yorkshire swine (n =15) were anesthetized and cannulated with a 23Fr dual-lumen catheter. Venovenous extracorporeal life support (VV ECLS) was initiated via the right jugular vein and carried out with animals uninjured on day 1 and injured by bilateral pulmonary contusion on day 2. On both days, animals underwent transport and simulated AE. Systemic HMGB1 expression was measured in plasma by ELISA. Plasma-free Hb (pfHb) was measured with the use of spectrophotometric methods. Results: Plasma HMGB1 on day 1 was transiently higher at arrival to the AE chambers, increased significantly after injury, reaching highest values at 8,000 ft on day 2, after which levels decreased but remained elevated versus baseline at each time point. pfHb decreased on day 1 at 30,000 ft and significantly increased on day 2 at 8,000 ft and postflight. Conclusions: Systemic HMGB1 demonstrated sustained elevation after trauma and altitude transport and may provide a useful monitoring capability during en route care.
Keywords: acute respiratory distress syndrome; polytrauma; evacuation; altitude physiology; HMGB1
Gattere M, Scaffei N, Gozzetti L, Alessandrini M. 21(1). 120 - 123. (Journal Article)
Abstract
As a result of the increasing use and application of military tourniquets in civilian settings, it is necessary to evaluate the size and effectiveness of the equipment on patients that differ from the military-aged population for whom the devices have been primarily created. This case report describes the application of a tourniquet on a pediatric patient while also profiling a common situation in which the Combat Application Tourniquet GEN 7 (C-A-T Resources) might be used in civilian care systems. The case is that of a 14-month-old child who suffered a limb amputation secondary to a road accident in Italy and the ensuing life-saving treatment. The intervening nurse at the scene had been trained on the use of hemorrhage-control devices through the American College of Surgeons "Stop the Bleed" campaign.
Keywords: tourniquet; hemorrhage; child; pediatric; military personnel; accidents; amputation; Stop the Bleed; NATO Special Operations Combat Medic; NSCOM
Baker RA, Worth K, Pourrajabi N, Martin J, Mitchell S, Baker S. 22(1). 71 - 75. (Journal Article)
Abstract
Background: An austere field amputation can be a life-saving procedure for an entrapped patient when standard equipment is not available or operable. The objective of this study was to use hand tools to perform cadaveric amputations in < 2 minutes. Methods: Timed guillotine amputation of the extremities on three cadavers was attempted using four available hand tools: a multitool, a rescue tool, a hunting knife, and a fixedblade knife. The primary outcome was successful amputation of the extremity in < 2 minutes. Results: Amputation success was different among the tools. The multitool amputated 78% of attempts; the hunting knife, 67%; the rescue knife, 56%; and the fixed-blade knife, 44%. The distal tibia/fibula and radius/ ulna were amputated successfully in 100% of attempts, whereas none of the tools could amputate the femur. The multitool received the best subjective ranking - 1.4 (p = .001) - by amputators, with the fixed-blade knife receiving the worst score. Conclusions: In the rare circumstance that an emergent field amputation requires a hand tool, the multitool is a capable instrument for a distal extremity amputation.
Keywords: amputation; knife; saw; prehospital; field; emergency
Schoenberger T, Foret B, Evans J, Shishido AA. 23(2). 114 - 117. (Journal Article)
Abstract
Prolonged Casualty Care (PCC) has become an essential component to Special Operations Forces (SOF) pre-mission training. However, it has not regularly been required in recent combat operations with the availability of medical evacuation (MEDEVAC) support. Poor weather conditions at an austere SOF outpost created an emergency unreachable by aeromedical evacuation. Herein, we report a case of an emergency bilateral above-the-knee amputation procedure performed by three Special Forces Medical Sergeants (18D(a), 18D(b), and 18D(c)) and supporting Army medics with minimal telemedicine consult and guidance.
Keywords: amputation; austere; MEDEVAC; special operation; Afghanistan; emergency; telemedicine; combat
Patterson J, Bryan RT, Turconi M, Leiner A, Plackett TP, Rhodes LL, Sciulli L, Donnelly S, Reynolds CW, Leanza J, Fisher AD, Kushnir T, Artemenko V, Ward KR, Holcomb JB, Schmitzberger FF. 24(1). 18 - 25. (Journal Article)
Abstract
The use of tourniquets for life-threatening limb hemorrhage is standard of care in military and civilian medicine. The United States (U.S.) Department of Defense (DoD) Committee on Tactical Combat Casualty Care (CoTCCC) guidelines, as part of the Joint Trauma System, support the application of tourniquets within a structured system reliant on highly trained medics and expeditious evacuation. Current practices by entities such as the DoD and North Atlantic Treaty Organization (NATO) are supported by evidence collected in counter-insurgency operations and other conflicts in which transport times to care rarely went beyond one hour, and casualty rates and tactical situations rarely exceeded capabilities. Tourniquets cause complications when misused or utilized for prolonged durations, and in near-peer or peer-peer conflicts, contested airspace and the impact of high-attrition warfare may increase time to definitive care and limit training resources. We present a series of cases from the war in Ukraine that suggest tourniquet practices are contributing to complications such as limb amputation, overall morbidity and mortality, and increased burden on the medical system. We discuss factors that contribute to this phenomenon and propose interventions for use in current and future similar contexts, with the ultimate goal of reducing morbidity and mortality.
Keywords: tourniquets; amputation; traumatic injury; war-related injuries
Anonymous A. 13(2). 1 - 2. (Journal Article)
Abstract
The Abdominal Aortic Tourniquet™ was used recently used in Afghanistan to control severe hemorrhage in a casualty who had traumatic bilateral amputations of the lower extremities. Excerpts from the medical provider's account of the tactical evacuation phase of care are provided.
Keywords: Abdominal Aortic Tourniquet ™; AAT; hemorrhage; amputations
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
Linderman JK, O'Hara R, Ordway J. 20(1). 94 - 100. (Journal Article)
Abstract
Objective: Due to physical demands, Special Operations Forces (SOF) endure changes in body composition, work capacity, and endocrine function. These changes result in energy deficits and sleep deprivation, where sleep averaged 3 hours/ day, independently known to decrease testosterone levels. The use of exogenous testosterone shows increases in lean body mass (LBM) and muscle function in healthy males and reverses cachexia in diseased populations. Therefore, the review's primary purpose is to summarize and contrast literature in both SOF and nonmilitary personnel regarding the correlation between negative energy balance, sleep deprivation, and decreased testosterone. The secondary purpose summarizes the effects of exogenous testosterone therapy in healthy males as well as reversing the effects of muscle wasting diseases. Methods: An online literary search from 1975 to 2015 identified 46 of 71 sources addressing both purposes, and data were summarized into tables providing mean observations. Conclusions: SOF training results in decreased testosterone (-6.3%), LBM (-4.6%), and strength (-11.7%), tied to energy deficits (-3,351 kcal/day) and sleep deprivation (3 hours/ day). Exogenous testosterone therapy increases LBM (6.2%), strength (7.9-14.8%), reverses cachexia (2.0%) and increases strength (12.7%) in those with chronic diseases. Therefore, testosterone supplementation in SOF may attenuate changes in body composition and muscle function during training and sustained Special Operations (SUSOPS).
Keywords: androgenic; anabolic; cachexia; fatigue; Special Operations; military
Schauer SG, Robinson JB, Mabry RL, Howard JT. 15(1). 85 - 89. (Journal Article)
Abstract
Background: Servicemembers injured in combat often experience moderate to severe acute pain. Early and effective pain control in the prehospital setting has been shown to reduce the sequelae of untreated pain. Current data suggest that lack of point-of-injury (POI) analgesia has significant, downstream effects on healthcare quality and associated costs. Methods: This was a process improvement project to determine the current rate of adherence to existing prehospital pain management guidelines. The records of patients who had sustained a major injury and met current Tactical Combat Casualty Care (TCCC) criteria for POI analgesia from July 2013 through March 2014 were reviewed to determine if pain medication was given in accordance with existing guidelines, including medication administration and routes. On 31 October 2013, the new TCCC guidelines were released. The "before" period was from July 2013 through October 2013. The "after" period was from November 2013 through March 2014. Results: During the project period, there were 185 records available for review, with 135 meeting TCCC criteria for POI analgesia (68 pre-, 66 postintervention). Prior to 31 October 2013, 17% of study patients received analgesia within guidelines at the POI compared with 35% in the after period. The most common medication administered preand post-release was oral transmucosal fentanyl citrate. Special Operations Forces had higher adherence rates to TCCC analgesia guidelines than conventional forces, but these still were low. Conclusion: Less than half of all eligible combat casualties receive any analgesia at the POI. Further research is needed to determine the etiology of such poor adherence to current TCCC guidelines.
Keywords: analgesia; point of injury; combat; fentanyl; ketamine; morphine; military
Pamplin JC, Fisher AD, Penny A, Olufs R, Rapp J, Hampton K, Riesberg JC, Powell D, Keenan S, Shackelford S. 17(1). 106 - 120. (Journal Article)
Abstract
Keywords: sedation; analgesia; prolonged field care; guidelines
Lyon RF, Schwan C, Zeal J, Kharod C, Staak BP, Petersen CD, Rush SC. 18(1). 70 - 73. (Journal Article)
Abstract
Effective analgesia is a crucial part of the care and resuscitation of a traumatically injured patient. These secondary effects of pain may increase morbidity and mortality in the acutely injured patient. When ketamine is administered appropriately in the clinical setting, it can provide analgesia, anxiolysis, and amnesia for patients with less respiratory depression and hypotension than equivalent doses of opioid analgesics.
Keywords: ketamine; analgesia; pain; opioids; prehospital analgesic; Pararescuemen; Operation Enduring Freedom
Schauer SG, Fisher AD, April MD, Carter R, Cunningham CW, Aden JK, Fernandez JD, DeLorenzo RA. 19(1). 70 - 74. (Journal Article)
Abstract
Background: Low rates of prehospital analgesia, as recommended by Tactical Combat Casualty Care (TCCC) guidelines, have been demonstrated in the Joint Theaters combat setting. The reasons for this remain unclear. This study expands on previous reports by evaluating a larger prehospital dataset for determinants of analgesia administration. Methods: This was part of an approved quality assurance project evaluating adherence to TCCC guidelines across multiple modalities. Data were from the Prehospital Trauma Registry, which existed from January 2013 through September 2014, and comprises data from TCCC cards, Department of Defense 1380 forms, and after-action reports to provide real-time feedback to units on prehospital medical care. Results: Of 705 total patient encounters, there were 501 documented administrations of analgesic medications given to 397 patients. Of these events, 242 (34.3%) were within TCCC guidelines. Special Operations Command had the highest rate of overall adherence, but rates were still low (68.5%). Medical officers had the highest rates of overall administration. The low rates of administration and adherence persisted across all subgroups. Conclusion: Rates of analgesia administration remained low overall and in subgroup analyses. Medical officers appeared to have higher rates of compliance with TCCC guidelines for analgesia administration, but overall adherence to TCCC guidelines was low. Future research will be aimed at finding methods to improve administration and adherence rates.
Keywords: analgesia; combat; compliance; military; pain; prehospital; Tactical Combat Casualty Care
Schauer SG, April MD, Aden JK, Rowan M, Chung KK. 19(2). 77 - 80. (Journal Article)
Abstract
Background: The military is rapidly moving into a battlespace in which prolonged holding times in the field are probable. Ketamine provides hemodynamic support and has analgesic properties, but the safety of prolonged infusions is unclear. We compare in-hospital mortality between intubated burn intensive care unit (ICU) patients receiving prolonged ketamine infusion lasting =7 days or until death versus controls. Methods: We conducted a before/after cohort study of patients undergoing admission to a burn ICU with intubation within the first 24 hours as part of treatment for thermal burns. In January 2012, this ICU implemented a novel continuous ketamine infusions protocol. We performed a preintervention and postintervention cohort analysis. Results: We identified 2394 patients meeting our inclusion criteria-475 in the ketamine group and 1919 in the control group. Regarding burn total body surface area (TBSA) involvement, there were 1533 in the <10% group, 586 in the 11-30% group, and 281 in the >31% group. The median number of ventilator-free days within the first 30 days did not vary significantly between the ketamine group and the control group: 8.5 days (interquartile range [IQR] 1-16 days) versus 8 days (IQR 3-13 days, p = .442). Subjects receiving ketamine had higher mortality rates: 59.4% (n = 117) versus 40.6% (n = 80, p < .001), with an odds ratio for in-hospital mortality of 7.51 (95% CI 5.53-10.20, p < .001). When controlling for TBSA category, ventilator days and vasopressor administration, there was no association between ketamine and in-hospital mortality (0.66, 0.41-1.05, p = .08). Conclusions: When controlling for confounders, we found no difference in in-hospital mortality between the prolonged ketamine infusion recipients versus non-recipients.
Keywords: ketamine; prolonged; military; trauma; analgesia
Fisher AD, Schwartz DS, Petersen CD, Meyer SE, Thielemann JN, Redman TT, Rush SC. 20(3). 81 - 86. (Journal Article)
Abstract
Background: Opioids can have adverse effects on casualties in hemorrhagic shock. In 2014, the Committee on Tactical Combat Casualty Care (CoTCCC) recommended the use of ketamine at the point of injury (POI). Despite these recommendations the adherence is moderate at best. Poor use may stem from a lack of access to use ketamine during training. The United States Special Operations Command (USSOCOM) is often in a unique position, they maintain narcotics for use during all training events and operations. The goal of this work is to demonstrate that ketamine is safe and effective in both training and operational environments. Methods: This was a retrospective, observational performance improvement project within United States Special Operations Command and Air Combat Command that included the US Army's 75th Ranger Regiment, 160th Special Operations Aviation Regiment, and US Air Force Pararescue. Descriptive statistics were used to calculate the doses per administration to include the interquartile range (IQR), standard deviation (SD) and the range of likely doses using a 95% confidence interval (CI). A Wilcoxon signed-rank test was used to compare the mean pre-ketamine pain scores to the mean post-ketamine on a 0-to-10 pain scale. Results: From July 2010 to October 2017, there was a total of 34 patients; all were male. A total of 22 (64.7%) received intravenous ketamine and 12 (35.3%) received intramuscular ketamine and 8 (23.5%) received intranasal ketamine. The mean number of ketamine doses via all routes administered to patients was 1.88 (SD 1.094) and the mean total dose of all ketamine administration was 90.29mg (95% CI, 70.09-110.49). The mean initial dose of all ketamine administration was 47.35mg (95% CI, 38.52-56.18). The median preketamine pain scale for casualties was noted to be 8.0 (IQR 3) and the median post-ketamine pain scale was 0.0 (IQR 3). Conclusion: Ketamine appears to be safe and effective for use during military training accidents. Military units should consider allowing their medics to carry and use as needed.
Keywords: ketamine; opioids; training; war-related injuries; analgesia
Hall AB, Morrow L, Dixon M. 20(3). 120 - 121. (Journal Article)
Abstract
This case describes the prolonged treatment of a 38-year-old man with a transpelvic gunshot wound requiring a diverting ostomy and cystostomy for damage control procedures with a comminuted acetabular and femoral head fracture. The team used a ketamine drip for prolonged field care over 48 hours. The benefit of using a ketamine drip included low supply requirement, excellent analgesia, and ease of administration, but side-effects included somnolence and atelectasis necessitating oxygen supplementation before evacuation.
Keywords: prolonged field care; trauma; ketamine; analgesia
Fisher AD, DesRosiers TT, Papalski W, Remley MA, Schauer SG, April MD, Blackman V, Brown J, Butler FK, Cunningham CW, Gurney J, Holcomb JB, Montgomery HR, Morgan MM, Motov SM, Shackelford SA, Springer T, Drew B. 22(2). 154 - 165. (Classical Conference)
Abstract
Analgesia in the military prehospital setting is one of the most essential elements of caring for casualties wounded in combat. The goals of casualty care is to expedite the delivery of life-saving interventions, preserve tactical conditions, and prevent morbidity and mortality. The Tactical Combat Casualty Care (TCCC) Triple Option Analgesia guideline provided a simplified approach to analgesia in the prehospital combat setting using the options of combat medication pack, oral transmucosal fentanyl, or ketamine. This review will address the following issues related to analgesia on the battlefield: 1. The development of additional pain management strategies. 2. Recommended changes to dosing strategies of medications such as ketamine. 3. Recognition of the tiers within TCCC and guidelines for higher-level providers to use a wider range of analgesia and sedation techniques. 4. An option for sedation in casualties that require procedures. This review also acknowledges the next step of care: Prolonged Casualty Care (PCC). Specific questions addressed in this update include: 1) What additional analgesic options are appropriate for combat casualties? 2) What is the optimal dose of ketamine? 3) What sedation regimen is appropriate for combat casualties?
Keywords: analgesia; prehospital; casualties; Tactical Combat Casualty Care (TCCC) Triple Option Analgesia guideline; fentanyl; ketamine
Montagnon R, Cungi P, Aoun O, Morand G, Desmottes J, Pasquier P, Travers S, Aigle L, Dubecq C. 23(3). 39 - 43. (Journal Article)
Abstract
Background: Pain management is essential in military medicine, particularly in Tactical Combat Casualty Care (TCCC) during deployments in remote and austere settings. The few previously published studies on intranasal analgesia (INA) focused only on the efficacy and onset of action of the medications used (ketamine, sufentanil, and fentanyl). Side-effects were rarely reported. The aim of our study was to evaluate the use of intranasal analgesia by French military physicians. Methods: We carried out a multicentric survey between 15 January and 14 April 2020. The survey population included all French military physicians in primary-care centers (n = 727) or emergency departments (n = 55) regardless of being stationed in mainland France or French overseas departments and territories. Results: We collected 259 responses (33% responsiveness rate), of which 201 (77.6%) physicians reported being familiar with INA. However, regarding its use, of the 256 physicians with completed surveys, only 47 (18.3%) had already administered it. Emergency medicine physicians supporting highly operational units (e.g., Special Forces) were more familiar with this route of administration and used it more frequently. Ketamine was the most common medication used (n = 32; 57.1%). Finally, 234 (90%) respondents expressed an interest in further education on INA. Conclusion: Although a majority of French military physicians who replied to the survey were familiar with INA, few used it in practice. This route of administration seems to be a promising medication for remote and austere environments. Specific training should, therefore, be recommended to spread and standardize its use.
Keywords: Intranasal route; disaster medicine; emergency medicine; prehospital care; military medicine; analgesia; ketamine; Special Operations
Saint-jean L, Corcostegui S, Galant J, Derkenne C. 23(3). 82 - 84. (Case Reports)
Abstract
We report the case of a patient suffering from a chemical burn caused by white phosphorus, for whom initial management required decontamination using multimodal analgesia. This case report should be familiar to other military emergency physicians and Tactical Emergency Medical Support for two reasons: 1) A phosphorus burn occurs from a chemical agent rarely encountered, with minimal research available in the medical literature, despite the use of this weapon in the recent Ukrainian conflict, and 2) We discuss the use of multimodal analgesia, combining loco-regional anesthesia (LRA) and an intranasal pathway, which can be used in a remote and austere environment.
Keywords: phosphorus burn; analgesia; intranasal
Schauer S, Fisher AD, April MD. 24(1). 81 - 84. (Journal Article)
Abstract
Background: The U.S. Military needs fast-acting, non-opioid solutions for battlefield pain. The U.S. Military recently used morphine auto-injectors, which are now unavailable. Off-label ketamine and oral transmucosal fentanyl citrate use introduces challenges and is therefore uncommon among conventional forces. Sublingual suftentanil is the only recent pain medication acquired to fill this gap. Conversely, methoxyflurane delivered by a handheld inhaler is promising, fast-acting, and available to some partner forces. We describe methoxyflurane use reported in the Department of Defense Trauma Registry (DODTR). Methods: We requested all available DODTR encounters from 2007 to 2023 with a documented intervention or assessment within the first 72 hours of care. We analyzed casualties who received methoxyflurane in the prehospital setting using descriptive statistics. Results: There were 22 encounters with documented methoxyflurane administration. The median patient age was 23 (range 21-31) years. All were men. The largest proportion was partner force (50%), followed by U.S. Military (27%). Most (64%) sustained battle injuries. Explosives were the most common mechanism of injury (46%), followed by firearms (23%). The median injury severity score was 5 (range 1-17). The most frequent injuries were serious injuries to the extremities (27%), and 23% of patients (5) received a tourniquet. One-half of the casualties received concomitant pain medications. Only three casualties had multiple pain scores measured, with a median pain score change of -3 on a scale of 10. Conclusion: Methoxyflurane use in deployed combat shows both feasibility and usability for analgesia.
Keywords: military; combat; trauma; pain; analgesia; methoxy flurane; penthrox
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
Ellis BC, Brown SG. 14(4). 1 - 5. (Case Reports)
Abstract
We present a case report of a Special Operations Soldier who developed anaphylaxis as a consequence of a bee sting, resulting in compromise of the operation. We review the current literature as it relates to the pathophysiology of the disease process, its diagnosis, and its management. An evidence-based field treatment algorithm is suggested.
Keywords: anaphylaxis; anaphylactic shock; epinephrine; epinephrine infusion; review; remote; austere
Ellis BC, Brown SG. 14(4). 1 - 5. (Case Reports)
Abstract
We present a case report of a Special Operations Soldier who developed anaphylaxis as a consequence of a bee sting, resulting in compromise of the operation. We review the current literature as it relates to the pathophysiology of the disease process, its diagnosis, and its management. An evidence-based field treatment algorithm is suggested.
Keywords: anaphylaxis; anaphylactic shock; epinephrine; epinephrine infusion; review; remote; austere
Smith S, Liu M, Ball I, Meunier B, Hilsden R. 23(1). 31 - 37. (Journal Article)
Abstract
Medical leadership must decide how prehospital airways will be managed in a combat environment, and airway skills can be complicated and difficult to learn. Evidence informed airway strategies are essential. A search was conducted in Medline and EMBASE databases for prehospital combat airway use. The primary data of interest was what type of airway was used. Other data reviewed included: who performed the intervention and the success rate of the intervention. The search strategy produced 2,624 results, of which 18 were included in the final analysis. Endotracheal intubation, cricothyroidotomy, supraglottic airways, and nasopharyngeal airways have all been used in the prehospital combat environment. This review summarizes the entirety of the available combat literature such that commanders may make an evidence-based informed decision with respect to their airway management policies.
Keywords: endotracheal intubation; airway; cricothyroidotomy; supraglottic airways; and nasopharyngeal airways
Givens ML, Deuster PA. 15(3). 98 - 104. (Journal Article)
Abstract
Androgen use outside of legitimate medical therapy is a perceived concern that is drawing attention across military and specifically Special Operations Forces (SOF) communities. For leadership and the medical community to properly address the issue and relate to those individuals who are using or considering use, it will be crucial to understand the scope of the problem. Limited data suggest that the prevalence of androgen use may be increasing, and inferences made from the scientific literature suggest that SOF may be a population of concern. While risks of androgen use are well known, there are little data specific to military performance that can be applied to a rigorous risk:benefit analysis, allowing myths and poorly supported theories to perpetuate within the community. Further efforts to define the potential benefits balanced against the short- and longterm risks should be undertaken. Providers within the SOF community should arm themselves with information to engage androgen users and leadership in meaningful discussion regarding androgen use.
Keywords: androgen steroids; protein building
Linderman JK, O'Hara R, Ordway J. 20(1). 94 - 100. (Journal Article)
Abstract
Objective: Due to physical demands, Special Operations Forces (SOF) endure changes in body composition, work capacity, and endocrine function. These changes result in energy deficits and sleep deprivation, where sleep averaged 3 hours/ day, independently known to decrease testosterone levels. The use of exogenous testosterone shows increases in lean body mass (LBM) and muscle function in healthy males and reverses cachexia in diseased populations. Therefore, the review's primary purpose is to summarize and contrast literature in both SOF and nonmilitary personnel regarding the correlation between negative energy balance, sleep deprivation, and decreased testosterone. The secondary purpose summarizes the effects of exogenous testosterone therapy in healthy males as well as reversing the effects of muscle wasting diseases. Methods: An online literary search from 1975 to 2015 identified 46 of 71 sources addressing both purposes, and data were summarized into tables providing mean observations. Conclusions: SOF training results in decreased testosterone (-6.3%), LBM (-4.6%), and strength (-11.7%), tied to energy deficits (-3,351 kcal/day) and sleep deprivation (3 hours/ day). Exogenous testosterone therapy increases LBM (6.2%), strength (7.9-14.8%), reverses cachexia (2.0%) and increases strength (12.7%) in those with chronic diseases. Therefore, testosterone supplementation in SOF may attenuate changes in body composition and muscle function during training and sustained Special Operations (SUSOPS).
Keywords: androgenic; anabolic; cachexia; fatigue; Special Operations; military
Rankin CJ, Fetherston T, Ballentine CD, Adams B, Long B, Carius BM. 22(2). 69 - 74. (Journal Article)
Abstract
The ongoing evolution of prehospital medical care continues to advance beyond immediate triage care. Prehospital care is even more important to consider in theaters with extended evacuation times and limited local medical assets. Although blood loss is often associated with settings of acute traumatic hemorrhage in military medicine, the possibility for other hematologic compromise necessitating urgent action requires medics operating in these environments to have a fundamental knowledge of the pathophysiology, manifestations, and stabilization measures of anemia to aid their patients prior to, or in lieu of, evacuation. Continued development of and access to point-of-care testing in increasingly forward-deployed settings further enable medics to perform these tasks. Here, we provide a brief review of hemoglobin function and composition, and presentation and management considerations of anemia, to assist medics in their treatment efforts. We also address specific concerns for battlefield and atraumatic presentations.
Keywords: hemoglobin; anemia; prehospital care; blood loss, hemorrhage; military; laboratory; malaria; hemolysis; bleeding; transfusion
Fitzgerald BM, Nagy CJ, Goosman EF, Gummerson MC, Wilson JE. 17(4). 56 - 62. (Journal Article)
Abstract
Many anesthesiologists and CRNAs are provided little training in preparing for a humanitarian surgical mission. Furthermore, there is very little published literature that outlines how to plan and prepare for anesthesia support of a humanitarian surgical mission. This article attempts to serve as an in-depth planning guide for anesthesia support of humanitarian surgical missions. Recommendations are provided on planning requirements that most anesthesiologists and CRNAs do not have to consider on routinely, such as key questions to be answered before agreeing to support a mission, ordering and shipping supplies and medications, travel and lodging arrangements, and coordinating translators in a host nation. Detailed considerations are included for all the phases of mission planning: advanced, mission-specific, final, mission-execution, and postmission follow-up planning, as well as a timeline in which to complete each phase. With the proper planning and execution, the anesthetic support of humanitarian surgical missions is a very manageable task that can result in an extremely satisfying sense of accomplishment and a rewarding experience. The authors suggest this article should be used as a reference document by any anesthesia professional tasked with planning and supporting a humanitarian surgical mission.
Keywords: humanitarian surgical mission; anesthesia; planning
Morgans LB, Graham N. 18(2). 142 - 146. (Journal Article)
Abstract
Medical services in the austere and limited environment often require therapeutics and practices uncommon in modern times due to a lack of availability, affordability, or expertise in remote areas. In this setting, diethyl ether, or simply ether anesthesia, still serves a role today as an effective inhalation agent. An understanding of ether as an anesthetic not only illustrates the evolution in surgical anesthesia but also demonstrates ether's surviving function and durable use as a practical agent in developing nations. Although uncommon, it is not unseen, so a working knowledge should be understood if observation and advocacy for patients receiving this method of anesthesia are experienced.
Keywords: austere; primitive; anesthesia; ether; diethyl-ether; inhalation agents; drawover; unconventional medicine
Wickens CD, Delmonaco BL, Pelleg T. 21(4). 71 - 76. (Journal Article)
Abstract
The latest surge of the coronavirus disease 2019 (SARS-CoV-2 virus) pandemic continues to create an unprecedented need for mechanical ventilation in critically ill patients. The U.S. Food and Drug Administration (FDA) recognized that the additional need for ventilators, on March 22, 2020 and issued guidance outlining a policy intended to help increase availability of relevant technologies. The FDA included guidance for healthcare facilities facing shortages of mechanical ventilators to consider alternative devices capable of delivering breaths or pressure support including anesthesia machines. Anesthesia machine manufacturers have published guidelines for the off-label use of anesthesia machines in critical care settings. Capable of providing mechanical ventilation, anesthesia machines do not deliver ventilation modes and flow capabilities commonly used outside the operating room (OR). A paucity of published information exists to describe the operation of anesthesia machines, their technological and practical limitations, and special considerations to prevent harm when re-purposed. We provide technical information and practical guidance for the safe use of anesthesia machines in critically ill patients outside the OR.
Keywords: considerations; critical care; anesthesia
Yost JK, Yates J, Smith B, Workman DJ, Matlick D, Wilson ME, Wilson A. 21(2). 115 - 118. (Journal Article)
Abstract
Background: Medical care provided by Special Operations Forces (SOF) combat medics is vital for establishing communication with local populations. In many of these communities, livestock hold a valuable position within the social, political, and cultural structure. The West Virginia University (WVU) Special Forces Medical Sergeant/Special Operations Independent Duty Corpsman (SFMS/SOIDC) Large Animal Module is designed to provide a foundational experience in livestock husbandry and veterinary procedures to SOF combat medic candidates. This study was conducted to determine the participants' base knowledge of food animal production and to evaluate if the program content was sufficient for increasing their knowledge of the subject matter. Methods: A quasi-experimental design utilizing pre-test and post-test instruments was used. The validity of the testing instruments was established by a panel of subject matter experts and the instruments' reliability was determined by a split-half analysis using SPSS® statistical software. The difference between the pre-test and post-test examinations were compared for 66 candidates who were assigned to WVU Health Sciences Center for the applied medical experience program and 46 counterparts assigned to other institutions by a match pair analysis. Results: Seventy-five percent of the subjects had no previous livestock exposure, and only 7% had previously participated in the 4-H program or Future Farmers of America (FFA). The average improvement in scores, pre-test versus post-test, was significantly greater for those that attended the module (18.5 versus 0.9). Conclusion: Few SFMS/SOIDC candidates have prior knowledge of livestock husbandry practices. The large animal module successfully provides education on livestock husbandry practice to participants. Knowledge of livestock production can assist SOF medics in establishing rapport with indigenous populations while on mission.
Keywords: livestock; husbandry; program evaluations; SFMS; SOIDC; Special Operations; animal; veterinary
Floyd CT, Rothwell SW, Martin R, Risdahl J, Olson CE. 12(1). 49 - 55. (Journal Article)
Abstract
Battlefield hemorrhage remains the primary cause of death in potentially survivable combat injuries with noncompressible hemorrhage. Fibrin dressings have great potential for reducing mortality, however are limited by cost, availability, and disease transmission. Methods: Dressings comprising a soluble dextran dressing with lyophilized salmon thrombin and fibrinogen (STF) were tested against Combat Gauze (CG) as a control in a standard swine femoral artery hemorrhage model. Ten female swine were used in each arm of the study. Results: Survival, blood loss, and time to hemostasis were similar between the two dressings. Two of the CGtreated animals that survived exsanguinated during the simulated walking maneuver. Three CG-treated animals formed a clot within the wound, but the clot did not adhere to the femoral artery injury. All ten of the STFtreated animals formed a clot in the wound that adhered and sealed the arterial injury site, even in three animals that did not survive. None of the STF-treated animals bled following the simulated walking maneuver. Three of five STF-treated animals reestablished blood flow distal to the injury as demonstrated by angiography. Conclusions: The STF dressing is as efficacious as CG in treating hemorrhage in this model of a lethal injury. Further, the STF dressing formed a fibrin sealant over the injury, whereas CG achieved hemostasis by occlusive compression of the artery. The sealant property of the STF dressing allowed reestablishment of antegrade blood flow into the distal limb, demonstrating that this dressing has the potential of limb salvage in addition to control of life-threatening hemorrhage.
Keywords: hemorrhage control; Fibrin dressing; Fibrinogen; Combat Gauze™; animal model
Brisson S, Dekker AH. 17(4). 49 - 51. (Journal Article)
Abstract
Background: Human-animal interactions in the form of animal-assisted therapy (AAT) have become common in both civilian and military health care facilities. Evidence supports AAT as a beneficial therapeutic alternative for patients with physical disabilities and psychological disorders. Few studies have been conducted in the civilian health care setting to evaluate staff attitudes regarding the impact of an AAT program on behavioral health (BH) patients. To our knowledge, no research has examined staff attitudes on the impact and effectiveness of AAT on active-duty Servicemembers in a BH program at a military facility. Methods: At the completion of a year-long AAT dog program and after institutional review board exemption, an anonymous, six-question survey was used to examine staff attitudes (n = 29) regarding the impact and continuation of the program with military BH patients. Results: Most staff members (86%) believed the AAT dog program had a positive impact on the BH patients, including improved patient mood, greater patient relaxation, improved patient attitude toward therapy, and increased social interactions among patients. All the staff reported a desire to continue the program at the military facility. Conclusion: Most BH staff thought the year-long AAT dog program had a positive impact on patients. All staff supported continuation of the program.
Keywords: animal-assisted therapy; therapy dog; military; behavioral health; staff attitudes
Sheean AJ, Owens J, Suttles ST, Crossland BW, Stinner DJ. 15(1). 1 - 6. (Case Reports)
Abstract
Despite the preponderance of evidence demonstrating poor outcomes as a result of combat-related orthopaedic trauma, teams of medical professionals have remained undaunted in their pursuit of innovative techniques to maximize the functional capacity of Servicemembers with devastating extremity injuries. We present the case of an Active Duty Special Forces (SF) qualified senior noncommissioned officer (NCO) with severely injured extremities successfully salvaged with a multidisciplinary program involving cutting-edge prosthetic technology and a novel approach to physical rehabilitation.
Keywords: ankle fusion; outcomes; limb salvage; rehabilitation
Boland M, Mulligan I, Payette J, Serres J, O'Hara R, Maupin G. 12(4). 17 - 23. (Journal Article)
Abstract
Objective: Musculoskeletal injuries related to training and operational missions frequently affect military personnel. A common treatment for these injuries is the PRICE (protection, rest, ice, compression, and elevation) method, which is time consuming and impractical in the field. Therefore, the primary objective of this study was to determine the effectiveness of the cryotherapy wrap compared to a traditional treatment in the management of acute ankle sprains. Methods: A randomized controlled clinical trial was conducted in a university research laboratory with 13 subjects (9 males and 4 females) with the following physical characteristics: age (yr) 20.6 ± 2.2, height (cm) 177.0 ± 14.3, weight (kg) 76.6 ± 20.6, and body mass index (kg/m2) 24.1 ± 3.7. Participants were instructed to perform PRICE with a traditional ice pack and compression wrap (control group) or with an Arctic Ease® cryotherapy wrap (test group) for 48 hours following enrollment in the study. The Numeric Pain Scale, Foot and Ankle Ability Measure, and ankle/foot volumetric measurement were performed at initial presentation and 24-hour, 48-hour, and 7-day follow-up intervals. Results: While the comparison of the Numeric Pain Scale scores, Foot and Ankle Ability Measure scores, and volumetric changes between groups revealed no statistically significant differences (ρ > 0.01), there was an 86% compliance rate for subjects in the cryotherapy wrap group compared to a 17% compliance rate of subjects in the control group. Conclusions: The cryotherapy wraps performed comparably to ice therapy and therefore may be especially applicable to military personnel required to operate in austere and hostile environments where traditional therapies are unrealistic. Although this pilot study did not demonstrate that the cryotherapy wraps produce statistically superior results, trends emerged in the data suggesting that subject compliance rate may be improved by using an alternative form of cryotherapy compression, which could lead to better management of pain, edema, and functional recovery. Future research should include a larger sample size to verify this claim.
Keywords: crytotherapy; ankle sprain; ice; edema; compression
Sola CA, Beute TC. 14(3). 90 - 92. (Journal Article)
Abstract
An active duty male Soldier presents to your clinic with concerns of blister-like lesions on both hands and feet several weeks after receiving immunizations. He is diagnosed with erythema multiforme (EM), a hypersensitivity reaction that is typically self-resolving. This article reviews the etiologies, pathophysiology, course, diagnosis, and treatment of erythema multiforme.
Keywords: erythema multiforme; vaccines; smallpox; typhoid; anthrax
Anderson JL, Kronstedt S, Bergens MA, Johannigman J. 23(1). 103 - 106. (Journal Article)
Abstract
Keywords: Lest We Forget; combat casualty care; war wound therapy; antibiotic therapy; wound care
Schauer SG, Fisher AD, April MD, Stolper KA, Cunningham CW, Carter R, Fernandez JD, Pfaff JA. 18(2). 53 - 56. (Journal Article)
Abstract
Background: Military operations place injured Servicemembers at high risk for open wounds. Austere environments and initial wound contamination increase the risk for infection. Wound infections continue to cause significant morbidity among injured Servicemembers. Limited evidence suggests that early antibiotic therapy for open wounds reduces infection rates. Methods: We obtained data from the Prehospital Trauma Registry (PHTR) from January 2013 through September 2014. This database includes data from Tactical Combat Casualty Care (TCCC) cards, Department of Defense 1380 forms, and after-action reports to provide near-real-time feedback to units on prehospital medical care. We evaluated whether patients with open wounds received antibiotics in accordance with TCCC guidelines. Low adherence was defined at less than 80%. Results: In this data set, overall, prefixed facility providers administered antibiotics to 54.0% of patients with an open combat wound. Of the antibiotics given, 11.1% were within TCCC guidelines. The relatively low administration and adherence rates persisted across subgroup analyses. Conclusion: Overall, relatively few patients with open combat wounds receive antibiotic administration as recommended by TCCC guidelines. In the group that received antibiotics, few received the specific antibiotics recommended by TCCC guidelines. The development of strategies to improve adherence to these TCCC recommendations is a research priority.
Keywords: prehospital; antibiotics; wound; prophylaxis; combat; emergency; tactical; casualty
Schauer SG, Naylor JF, Ahmed YM, Maddry JK, April MD. 20(3). 76 - 80. (Journal Article)
Abstract
Background: The United States (US) military utilizes combat wound medication packs (CWMP) to provide analgesia and wound prophylaxis in casualties who are still able to fight. We compared characteristics of combat casualties receiving CWMP to those not receiving CWMP. We also describe the proportions of casualties with injury patterns consistent with Tactical Combat Casualty Care (TCCC) guideline indications for CWMP use who received this intervention. Methods: This is a secondary analysis of Department of a Defense Trauma Registry (DODTR) dataset of US military personnel from January 2007 to August 2016. We searched for all subjects with documented use of at least one medication from the CWMP (acetaminophen, meloxicam, moxifloxacin). Results: Within our dataset, 11,665 casualties were US military Servicemembers. Overall, <1% (84) of our study population received the CWMP. The median age and mechanism of injuries were similar between CWMP nonrecipients versus recipients. Median composite injury scores were higher for nonrecipients than recipients (6 versus 4, P < .001). Proportions of casualties with injury patterns meeting TCCC guideline CWMP indications who received this intervention were low: gunshot wound, <1% (14 of 1805), tourniquet applied, <1% (11 of 1912), major amputation, <1% (5 of 803), and open fracture, <1% (10 of 2425). Based on serious injuries by body region, we had similar findings for the thorax (<1%; 3 of 1122), abdomen (<1%; 1 of 736), and extremities (<1%; 11 of 2699). Conclusions: Subjects receiving the CWMP were less severely injured compared to those who did not receive this intervention. The CWMP had very infrequent use among those casualties with injury patterns meeting indications specified in the TCCC Guidelines for use of this intervention.
Keywords: combat; pill; pack; military; pain; antibiotics
Sarkisian S, Sletten ZJ, Roberts P, Powell T. 21(2). 80 - 84. (Journal Article)
Abstract
Although skin and soft tissue infections are common in the deployed setting, infectious myositis is relatively uncommon. Bacterial infection of the muscle is the most common infectious etiology and can result in a spectrum of disease, to include abscess formation to necrotizing myositis, toxic shock syndrome, and death. Diagnosis can be elusive, particularly in the early stages. Recognition and proper management are crucial to prevent complications. The authors present a case report of infectious myositis diagnosed and managed in an austere deployed environment, as well as a discussion regarding current recommendations on diagnosis and treatment.
Keywords: infectious myositis; myositis; austere; antibiotics
Koo AY, Rodgers DK, Johnson KA, Gordon LL, Mease LE, Couperus KS. 21(3). 60 - 65. (Journal Article)
Abstract
Objectives: Lab companies developed serology tests for antibody detection of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) with United States Food and Drug Administration (FDA) emergency use authorization. Antibody detection uses purified proteins of SARS-CoV-2 to determine antibody binding via enzyme-linked immunosorbent assay, chemiluminescent immunoassay (CLIA), or colloidal gold-based immunochromatographic assay. With the advent of coronavirus disease 2019 (COVID-19), nucleic acid amplification technology (NAAT) SARS-CoV-2 testing for active infection was not widely available to healthy, active-duty Soldiers. The purpose of this surveillance survey was to determine the prevalence of prior SARS-CoV-2 infection and symptoms of COVID-19 within a mechanized infantry brigade. Materials and Methods: Active-duty military Servicemembers (= 18 years) from a mechanized infantry brigade provided serum samples for testing for the Elecsys® Anti-SARS-CoV-2 qualitative antibody test from June to September 2020 at Joint Base Lewis McChord (JBLM). In addition, participants filled out a questionnaire for symptoms and exposure to COVID-19 from January to September 2020. The surveillance team collected and analyzed antibody testing results and questionnaires from participants for antibody positivity rates and symptom prevalence. Results: A total of 264 participants were tested, with one (0.4%) participant testing positive for the SARS-CoV-2 antibody. On the questionnaire, 144 of 264 (54.5%) endorsed symptoms of COVID-19 from January to September 2020. The most common symptoms were headache (35%), rhinorrhea (34%), cough (35%), and sore throat (31%). A total of 31 respondents (12%) had been quarantined as a trace contact to a COVID-19 positive patient. Conclusions: While there are limitations inherent to SARS-CoV-2 antibody testing and the survey, prevalence of prior SARS-CoV-2 infection is low. In this sample, symptoms for COVID-19 were prevalent with significant days of duty lost. Prevalence of prior SARS-CoV-2 infection in this sample may be generalizable to the larger brigade. Prevalence of symptoms of possible COVID-19 are not generalizable to the larger brigade. There is utility to further studies of SARS-CoV-2 antibody prevalence in military populations for purposes of vaccination triaging and deployment readiness.
Keywords: COVID-19; SARS-CoV-2; antibody; Army Infantry Brigade; vaccines; vaccination; prevalence
Calvano CJ, Enzenauer RW, Eisnor DL, Mazzoli RA. 17(3). 81 - 83. (Journal Article)
Abstract
Nerve agents are a threat to military and civilian health. The antidote, atropine sulfate, is delivered by autoinjector, which is a limited resource. We propose the use of 1% atropine ophthalmic solution (supplied commercially in 5mL or 15 mL bottles) via oral, ocular, and intranasal administration as an expedient substitute in austere environments.
Keywords: nerve agent; chemical warfare; atropine; antidote; alternative treatment
Drew B, Auten JD, Cap AP, Deaton TG, Donham B, Dorlac WC, DuBose JJ, Fisher AD, Ginn AJ, Hancock J, Holcomb JB, Knight J, Koerner AK, Littlejohn LF, Martin MJ, Morey JK, Morrison J, Schreiber MA, Spinella PC, Walrath B, Butler FK. 20(3). 36 - 43. (Journal Article)
Abstract
The literature continues to provide strong support for the early use of tranexamic acid (TXA) in severely injured trauma patients. Questions persist, however, regarding the optimal medical and tactical/logistical use, timing, and dose of this medication, both from the published TXA literature and from the TCCC user community. The use of TXA has been explored outside of trauma, new dosing strategies have been pursued, and expansion of retrospective use data has grown as well. These questions emphasize the need for a reexamination of TXA by the CoTCCC. The most significant updates to the TCCC Guidelines are (i) including significant traumatic brain injury (TBI) as an indication for TXA, (ii) changing the dosing protocol to a single 2g IV/IO administration, and (iii) recommending TXA administration via slow IV/IO push.
Keywords: TXA; tranexamic acid; hemorrhage; hemostatics; antifibrinolytics; hemorrhagic shock; traumatic brain injury; traumatic injuries
Knapik JJ. 14(2). 95 - 97. (Journal Article)
Abstract
Foot blisters are the most common medical problem faced by Soldiers during foot march operations and, if untreated, they can lead to infection. Foot blisters are caused by boots rubbing on the foot (frictional forces), which separates skin layers and allows fluid to seep in. Blisters can be prevented by wearing properly sized boots, conditioning feet through regular road marching, wearing socks that reduce reduce friction and moisture, and possibly applying antiperspirants to the feet.
Keywords: blisters; injury prevention; foot blisters; road marching; footwear; load carriage; socks; antipersprants
Levri JM, Ocon A, Schunk P, Cunningham CW. 17(3). 21 - 23. (Journal Article)
Abstract
Acute ischemic stroke (AIS) treatment guidelines include various recommendations for treatment once the patient arrives at the hospital. Prehospital care recommendations, however, are limited to expeditious transport to a qualified hospital and supportive care. The literature has insufficiently considered prehospital antiplatelet therapy. An otherwise healthy 30-year-old black man presented with headache for about 3 hours, left-sided facial and upper extremity numbness, slurred speech, miosis, lacrimation, and general fatigue and malaise. The presentation occurred at a time and location where appropriate resources to manage potential AIS were limited. The patient received a thorough physical examination and electrocardiogram. Acetylsalicylic acid (ASA) 325mg was administered within 15 minutes of history and examination. A local host-nation ambulance arrived approximately 30 minutes after presentation. The patient's neurologic symptoms had abated by the time the ambulance arrived. The patient did not undergo magnetic resonance imaging (MRI) until 72 hours after being admitted, owing to lack of neurology staff over the weekend. The MRI showed evidence of a left-sided, posteriorinferior cerebellar artery stroke. The patient was then taken to a different hospital, where he received care for his acute stroke. The patient eventually was prescribed a statin, ASA, and an angiotensin-converting enzyme inhibitor. The patient has no lingering symptoms or neurologic deficits.
Keywords: stroke, acute ischemic; prehospital treatment; acetylsalicylic acid; antiplatelet
Nam JJ, Wong AI, Cantong D, Cook JA, Andrews Z, Levy JH. 23(2). 118 - 121. (Journal Article)
Abstract
Coagulopathy can occur in trauma, and it can affect septic patients as a host tries to respond to infection. Sometimes, it can lead to disseminated intravascular coagulopathy (DIC) with a high potential for mortality. New research has delineated risk factors that include neutrophil extracellular traps and endothelial glycocalyx shedding. Managing DIC in septic patients focuses on first treating the underlying cause of sepsis. Further, the International Society on Thrombolysis and Haemostasis (ISTH) has DIC diagnostic criteria. "Sepsis-induced coagulopathy" (SIC) is a new category. Therapy of SIC focuses on treating the underlying infection and the ensuing coagulopathy. Most therapeutic approaches to SIC have focused on anticoagulant therapy. This review will discuss SIC and DIC and how they are relevant to prolonged casualty care (PCC).
Keywords: sepsis; disseminated intravascular coagulation; coagulopathy; antithrombin; prolonged casualty care; PCC; austere critical care
Lynch JH, Verlo AR, Givens ML, Munoz CE. 14(4). 113 - 121. (Journal Article)
Abstract
The natural health threats in Africa pose daunting clinical challenges for any provider, as evidenced by the current Ebola epidemic in West Africa, but the threat is multiplied for the Special Operations provider on the continent who faces these challenges with limited resources and the tyranny of distance. The majority of operationally significant health risks can be mitigated by strict adherence to a comprehensive force health protection plan. The simplest, yet most effective, technique for preventing mosquito-borne diseases is the prevention of mosquito bites with repellent, bed nets, and appropriate clothing in addition to chemoprophylaxis. Some of the more likely or lethal infectious diseases encountered on the continent include malaria, Chikungunya, dengue, human immunodeficiency virus, and Ebola. Venomous snakes pose a particular challenge since the treatment can be as deadly as the injury. Providers supporting African operations should educate themselves on the clinical characteristics of possible envenomations in their area while promoting snake avoidance as the primary mitigation measure. To succeed in Africa, the Special Operations provider must consider how to meet these challenges in an environment where there may not be reliable evacuation, hospitalization, or logistics channels.
Keywords: Africa; tactical medicine; tropical infectious disease; chemoprophylaxis; malaria; dengue; Chikungunya; HIV; Ebola; snake evenomation; antivenin; wilderness medicine
Benjamin JM, Chippaux J, Jackson K, Ashe S, Tamou-Sambo B, Massougbodji A, Akpakpa OC, Abo BN. 19(2). 18 - 22. (Case Reports)
Abstract
A 20-year-old man presented to a rural hospital in Bembéréké, northern Benin, after a witnessed bite from a small, dark snake to his left foot that occurred 3 hours earlier. The description of the snake was consistent with several neurotoxic elapids known to inhabit the area in addition to various species from at least 10 different genera of non-front-fanged colubroid (NFFC) venomous snakes. The presentation was consistent with the early signs of a neurotoxic snakebite as well as a sympathetic nervous system stress response. Diagnosis was further complicated by the presence of a makeshift tourniquet, which either could have been the cause of local signs and symptoms or a mechanical barrier delaying venom distribution and systemic effects until removal. Systemic envenomation did not develop after the removal of the constricting band, but significant local paresthesias persisted for longer than 24 hours and resolved after the administration of a placebo injection of normal saline in place of antivenom therapy. This was an unusual case of snakebite with persistent neuropathy despite an apparent lack of envenomation and a number of snakebite- specific variables that complicated the initial assessment, diagnosis, and treatment of the patient. This case presentation provides clinicians with an opportunity to familiarize themselves with the differential diagnosis and approach to a patient bitten by an unidentified snake, and it illustrates the importance of symptom progression as a pathognomonic sign during the early stages of a truly serious snake envenomation. Treatment should be based on clinical presentation and evolution of symptoms rather than on snake identification alone.
Keywords: snakebite; envenomation; clinical diagnosis; non-front-fanged colubroid; antivenom; dry bite
Mulvaney SW, Lynch JH, Kotwal RS. 15(2). 79 - 85. (Journal Article)
Abstract
Multiple case series published in the peer-reviewed medical literature have demonstrated the safety and efficacy of right-sided stellate ganglion block (SGB) for the treatment of anxiety symptoms associated with posttraumatic stress disorder (PTSD). As this is a new indication for a well-established procedure, there is relatively little information available to assist clinicians in determining the utility of SGB for their patients. Presented are clinical guidelines to assist the provider with patient selection, patient education, and follow-up. Also described is a technique to perform SGB under ultrasoundguidance. Although additional rigorous clinical research is needed to further investigate SGB for the treatment of anxiety symptoms associated with PTSD, these guidelines can also assist clinical investigators in their participant selection, design, and conduct of future research as it pertains to this important topic.
Keywords: posttraumatic stress disorder; stellate ganglion block; ultrasound, guided; anxiety; clinical guidelines
Barczak-Scarboro NE, Cole WR, DeFreese JD, Fredrickson BL, Kiefer AW, Bailar-Heath M, Burke RJ, DeLellis SM, Kane SF, Lynch JH, Means GE, Depenbrock PJ, Mihalik JP. 22(3). 129 - 135. (Journal Article)
Abstract
Purpose: The present study investigated Special Operations Forces (SOF) combat Servicemember mental health at different SOF career stages in association with resilience. Methods: Fifty-eight SOF combat Service Members either entering SOF (career start; n=38) or multiple years with their SOF organization (mid-career; n=20) self-reported mild traumatic brain injury (TBI) history, resilience, subjective well-being, depression, anxiety, and posttraumatic stress. Poisson regression analyses were employed to test SOF career stage differences in each mental health symptom using resilience, while accounting for other pertinent military factors. Results: There were significant interaction effects of SOF career stage and resilience on mental health symptoms. SOF career start combat Servicemembers endorsed lower depression and posttraumatic stress and higher subjective well-being with higher resilience, but these associations between resilience and mental health symptoms were not seen in SOF mid-career Servicemembers. Conclusions: Although preliminary, the adaptive association between resilience and mental health seemed to be blunted in combat Servicemembers having served multiple years in SOF. This information informs research to provide evaluation tools to support prophylactic performance and long-term health preservation in military populations.
Keywords: depression; anxiety; posttraumatic stress; subjective well-being; military; concussion
Kotwal RS, Mazuchowski EL, Howard JT, Hanak JC, Harcke HT, Gurney JM, Shackelford SA. 21(2). 19 - 24. (Journal Article)
Abstract
Background: Autopsy studies of trauma fatalities have provided evidence for the pervasiveness of atherosclerosis in young and middle-aged adults. The objective of this study was to determine the prevalence of atherosclerosis in elite US military forces. Methods: We conducted a retrospective study of all US Special Operations Command (USSOCOM) fatalities from 2001 to 2020 who died from battle injuries. Autopsies were evaluated from Afghanistan- and Iraq-centric combat operations for evidence of coronary and/or aortic atherosclerosis and categorized as minimal (fatty streaking only), moderate (10-49% narrowing of ≥1 vessel), and severe (≥50% narrowing of ≥1 vessel). Prevalence of atherosclerosis was determined for the total population and by subgroup characteristics of age, sex, race/ethnicity, combat operation, service command, occupation, rank, cause of death, manner of death, and body mass index (BMI). Results: From the total of 388 USSOCOM battle injury fatalities, 356 were included in the analysis. The mean age was 31 years (range, 19-57 years), and 98.6% were male. The overall prevalence of coronary and/or aortic atherosclerosis was 17.4%. The prevalence of coronary atherosclerosis alone was 13.8%. Coronary atherosclerosis was categorized as minimal in 1.1%, moderate in 7.6%, and severe in 5.1%. Of those with atherosclerosis, 24.2% were <30 years old, 88.7% were from enlisted ranks, and 95.2% had combatant occupations. When BMI could be calculated, 73.5% of fatalities with atherosclerosis had a BMI =25. Conclusions: Autopsy-determined atherosclerosis is prevalent in elite US military Special Operations Forces despite young age and positive lifestyle benefits of service in an elite military unit.
Keywords: atherosclerosis; elite US military forces; coronary atherosclerosis; aortic atherosclerosis
Borger van der Burg BL, Maayen RC, van Dongen TT, Gerben C, Eric C, DuBose JJ, Horer TM, Bowyer MW, Hoencamp R. 18(4). 70 - 74. (Journal Article)
Abstract
Background: Vascular access is a necessary prerequisite for REBOA placement in patients with severe hemorrhagic shock. Methods: During an EVTM workshop, 10 Special Forces (SOF) medics, five combat nurses, four military nonsurgeon physicians, and four military surgeons participated in our training program. The military surgeons functioned as the control group. A formalized curriculum was constructed including basic anatomy and training in access materials for resuscitative endovascular balloon occlusion of the aorta (REBOA) placement. Key skills were (1) preparation of endovascular toolkit, (2) achieving vascular access in the model, and (3) bleeding control with REBOA. Results: The baseline knowledge of anatomy for SOF medics was significantly less than that for nurses and physicians. Medics had a median time of 3:59 minutes to sheath insertion; nurses, 2:47; physicians, 2:34; and surgeons, 1:39. Military surgeons were significantly faster than medics and military nurses (ρ = .037 resp. 0.034). Medics had a median total time from start to REBOA inflation of 5:05 minutes; nurses, 4:06; military physicians, 3:36; and surgeons, 2:36. Conclusion: This study showed that a comprehensive theoretical and practical training program using a task training model can be used for percutaneous femoral access and REBOA placement training of military medical personnel without prior ultrasound or endovascular experience. Higher levels of training reduce procedure times.
Keywords: vascular access; training; aortic balloon occlusion; military; prehospital
Borger van der Burg BL, Vrancken SM, van Dongen TT, DuBose JJ, Bowyer MW, Hoencamp R. 20(1). 81 - 86. (Journal Article)
Abstract
Background: Early hemorrhage control using resuscitative endovascular balloon occlusion of the aorta (REBOA) can save lives. This study was designed to evaluate the ability to train Quick Response Team Fire Fighters (QRT-FF) to gain percutaneous femoral artery access and place a REBOA catheter in a model, using a comprehensive theoretical and practical training program. Methods: Six QRT-FF participated in the training. SOF medics from a previous training served as the control group. A formalized training curriculum included basic anatomy and endovascular materials for percutaneous access and REBOA placement. Key skills included (1) preparation of an endovascular toolkit, (2) achieving vascular access in the model, and (3) placement and positioning of REBOA. Results: QRT-FF had significantly better scores compared with medics using endovascular materials (P = .003) and performing the procedure without unnecessary attempts (P = .032). Basic surgical anatomy scores for QRT-FF were significantly better than SOF medics (P = .048). QRT-FF subjects demonstrated a significantly higher overall technical skills point score than medics (P = .030). QRT-FF had a median total time from start of the procedure to REBOA inflation of 3:23 minutes, and medics, 5:05 minutes. All six QRT-FF subjects improved their procedure times-as did four of the five medics. Conclusions: Our training program using a task training model can be utilized for percutaneous femoral access and REBOA placement training of QRT-FF without prior ultrasound or endovascular experience. Training the use of advanced bleeding control options such as REBOA, as a secondary occupational task, has the potential to improve outcomes for severely bleeding casualties in the field.
Keywords: vascular access; training; aortic balloon occlusion; firefighters; first responder
Ward H, Downing N, Goller S, Stremick J. 22(4). 93 - 96. (Case Reports)
Abstract
The Role 2 environment presents several challenges in diagnosing and treating complex medical and life-threatening conditions. They are primarily designed to perform damage control resuscitation and surgery in the setting of trauma with less emphasis on complex medical care and limited ability to hold patients for more than 72 hours. Providing care to Soldiers and civilians in the deployed setting is made more difficult by the limited number of personnel, lack of advanced diagnostic equipment such as CT scanners, harsh working conditions, and austere resources. Despite these challenges, deployed physicians have continued to provide high levels of care to injured Soldiers and civilians by using clinical judgment, validated clinical decision-making tools, and adjunct diagnostic tools, such as ultrasound. In this case series we will present three complex medical cases involving pulmonary embolism (PE), ventricular tachycardia (VT), and aortic dissection that were seen in a deployed Role 2 setting. This article will highlight and discuss the challenges faced by deployed providers and ways to mitigate these challenges.
Keywords: Role 2; damage control resuscitation; surgery; pulmonary embolism; ventricular tachycardia; aortic dissection
Gary JL, Kumaravel M, Gates K, Burgess AR, Routt ML, Welch T, Podbielski JM, Beeler AM, Holcomb JB. 14(4). 30 - 34. (Journal Article)
Abstract
Objective: Complex dismounted blast injuries from (improvised) explosive devices have caused amputations of the lower extremities associated with open injuries to the pelvic ring, resulting in life-threatening hemorrhage from disruption of blood vessels near the pelvic ring. Provisional stabilization of the skeletal pelvis by circumferential pelvic compression provides stability for intrapelvic clots and reduces the volume of the pelvis, thereby limiting the amount of hemorrhage. The Junctional Emergency Treatment Tool™ (JETT™; North American Rescue Products, http://www.narescue .com) is a junctional hemorrhage control device developed to treat pelvic and lower extremity injuries sustained in high-energy trauma on the battlefield and in the civilian environment. Our purpose was to evaluate the compressive function of the JETT in the reduction of pelvic ring injuries in a cadaveric model. Methods: Radiographic comparison of pre (intact) and post pelvic ring disruption and injury was compared with radiographic measurements post reduction with the JETT device in two cadavers. The device's ability to reduce pelvic disruption and injury in a human cadaver model was assessed through measurements of the anteroposterior (AP) and transverse diameters obtained at the inlet and outlet of the pelvis. Results: Computed tomography (CT) scans demonstrated that JETT application effectively induced circumferential soft tissue compression that was evoked near anatomic reduction of the sacroiliac joint and symphysis pubis. Conclusions: The JETT is capable of effectively reducing an AP compression type III injury (APC III) pelvic ring disruption and injury by approximating the inlet and outlet dimensions toward predisruption measurements. Such a degree of reduction suggests that the JETT device may be suitable in the acute setting for provisional pelvic stabilization.
Keywords: open book pelvis; pelvic binder; wounds and injuries; hemorrhage, junctional; combat casualty care; pelvic ring disruption and injury; APC III injuries
Banting J, Meriano T. 15(1). 118 - 122. (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 operations medical technicians will be part of the feature.
Keywords: pain; abdominal pain; appendicitis; diagnosis; treatment
Tadlock M, Maves R, Flieger DM, Baldino TJ, Adams D, Riesberg JC, Kitchen LK, Brower JJ, Tripp MS. 24(2). 94 - 102. (Journal Article)
Abstract
During distributed maritime operations, individual components of the naval force are more geographically dispersed. As the U.S. Navy further develops this concept, smaller vessels may be operating at a significant time and distance away from more advanced medical capabilities. Therefore, during both current and future contested Distributed Maritime Operations, Role 1 maritime caregivers such as Independent Duty Corpsman will have to manage patients for prolonged periods of time. This manuscript presents an innovative approach to teaching complex operational medicine concepts (including Prolonged Casualty Care [PCC]) to austere Role 1 maritime caregivers using a hypothetical scenario involving a patient with sepsis and septic shock. The scenario incorporates the Joint Trauma System PCC Clinical Practice Guidelines (CPG) and other standard references. The scenario includes a stem clinical vignette, expected clinical changes for the affected patient at specific time points (e.g., time 0, 1, 2, and 48h), and expected interventions based on the PCC CPG and available shipboard equipment. Epidemiology of sepsis in the deployed environment is also reviewed. This process also identifies opportunities to improve training, clinical skills sustainment, and standard shipboard medical supplies.
Keywords: prolonged casualty care; Tactical Combat Casualty Care; maritime operations; critical care; sepsis; septic shock; appendicitis
Jarvis J. 24(3). 70 - 73. (Journal Article)
Abstract
Biting sandflies are known for transmitting leishmaniasis, but sandflies also transmit sandfly fever viruses that may disrupt military operations. Sandfly fever is caused by serotypes of the Phlebovirus genus (primarily the Naples, Sicilian, or Toscana serotypes). The illness is known colloquially as "three-day fever" and "papataci fever." The clinical course of the disease normally spans about 3 days, with patients exhibiting a prodromal phase consisting of fatigue, chills, abdominal pain, and possibly facial flushing and tachycardia. Disease onset is marked by hyperpyrexia, myalgia, and arthralgia. The incubation period is typically 3-5 days, with viremia in humans lasting typically less than 1 week. This manuscript describes sandfly appearance, behavior, and geographic distribution. It then lists comparable diseases for differential diagnosis. Finally, as no vaccine exists for the sandfly virus, it concludes with steps for preparation and prevention to prevent outbreaks from disrupting military operations.
Keywords: pappataci fever; sandfly fever; phlebovirus; infectious diseases; arbovirus
Samblanet K, Booy M. 22(2). 127 - 128. (Letter)
Abstract
Keywords: Arctic; Tactical Combat Casualty Care; multidomain operations
Kelly K, Pautz CM, Palombo LJ, Jensen AE, Melau J, Turcotte LP, Solberg PA. 23(3). 74 - 81. (Journal Article)
Abstract
Introduction: Little data exist on the effect of extremely cold-water diving on thermo-metabolic hormone secretion. Moreover, the impact of repetitive dives on the stress response is unknown. The purpose of this study was to determine the effects of two daily bouts of cold-water diving on the hormonal and metabolic profile of elite military personnel and to measure the stress response. Methods: Healthy, male, Norwegian Special Forces operators (n = 5) volunteered for this study. Physiological and hormone data were analyzed prior to and following twice-daily Arctic dives (3.3°C). Results: Core temperature was maintained (p > .05), whereas skin temperature was significantly reduced over the course of each dive (p < .01). Pairwise comparisons revealed adrenocorticotropic hormone (ACTH) and cortisol concentration significantly decreased across both dives and days (p < .001). Adrenaline and noradrenaline significantly increased across both time and day (p < .001). Leptin, testosterone, and IGF-1 significantly decreased over time but recovered between days. Conclusion: The main findings of this effort are that there is a rapid sympathetic-adreno-medullary (SAM/SNS) response to cold-water diving and a suppression of the hypothalamic-pituitary-adrenal (HPA) axis and hormones related to repair and recovery. While the sample size was too small to determine the role of SAM/SNS, HPA, and thyroid hormone effect on thermoregulation, it addresses a gap in our understanding of physiological adaptions that occurs in extreme environments.
Keywords: military diving; Arctic; acute stress response; testosterone; leptin
Clerkin S, Carlson NT, Long B, Taylor DH, Bridwell R. 23(1). 80 - 83. (Case Reports)
Abstract
As arctic warfare becomes a center focus within Special Operations, cold weather injury looms as both a medical and operational threat. While cold weather injury can range from pernio to hemodynamically unstable systemic hypothermia, the more minor injuries are far more common. However, these present a challenge in austere medical care and can drastically impact mission capability. We present a case of a Special Operations crew chief with cold weather digital injury while at the Arctic Isolation Course in Alaska and his subsequent clinical course. Prevention remains the key for mitigating these injuries, while the decision to rewarm must be made with both medical and tactical factors in mind as refreezing incurs significant morbidity. Other components of prehospital treatment include active rewarming, ibuprofen, aloe vera, and pain control.
Keywords: arctic warfare; cold injury; frostbite; rewarm; Alaska; hypothermia; austere
Nam JJ, McCravy MS, Haines KL, Thomas SB, Aden JK, Johnston LR, Mason PE, Gurney J, Sams VG. 22(4). 111 - 116. (Journal Article)
Abstract
Background: The purpose of our study was to assess risks/ outcomes of acute respiratory distress syndrome (ARDS) in US combat casualties. We hypothesized that combat trauma patients with ARDS would have worse outcomes based on mechanism of injury (MOI) and labs/vital signs aberrancies. Materials and Methods: We reviewed data on military Servicemembers serving in Iraq and Afghanistan from 1 January 2003 to 31 December 2015 diagnosed with ARDS by ICD-9 code. We extracted patient demographics, injury specifics, and mortality from the Department of Defense Trauma Registry (DoDTR). Results: The most common MOI was an explosion, accounting for 67.6% of all injuries. Nonsurvivors were more likely to have explosion-related injuries, have higher injury severity score (ISS), higher international normalized ratio (INR), lower platelet count, greater base deficit, lower temperature, lower Glasgow Coma Scale (GCS) score, and lower pH. There was no significant difference in deaths across time. Conclusion: By identifying characteristics of patients with higher mortality in trauma ARDS, we can develop treatment guidelines to improve outcomes. Given the high mortality associated with trauma ARDS and relative paucity of clinical data available, we need to improve battlefield data capture to better guide practice and ultimately improve care. The management of ARDS will be increasingly relevant in prolonged casualty care (PCC; formerly prolonged field care) on the modern battlefield.
Keywords: PCC; PFC; prolonged casualty care; prolonged field care; ARDS; acute respiratory distress syndrome; combat casualties; combat trauma; mechanism of injury
Powell E, Betzold R, Kundi R, Anderson D, Haase D, Keville M, Galvagno S. 24(1). 32 - 37. (Journal Article)
Abstract
Background: Veno-venous extracorporeal membrane oxygenation (VV ECMO) is a low-frequency, high-intensity procedure used for severe lung illness or injury to facilitate rapid correction of hypoxemia and respiratory acidosis. This technology is more portable and extracorporeal support is more frequently performed outside of the hospital. Future conflicts may require prolonged causality care and more specialized critical care capabilities including VV ECMO to improve patient outcomes. We used an expert consensus survey based on a developed bifemoral VV ECMO cannulation checklist with an operational focus to establish a standard for training, validation testing, and sustainment. Methods: A 36-item procedural checklist was provided to 14 experts from multiple specialties. Using the modified Delphi method, the checklist was serially modified based on expert feedback. Results: Three rounds of the study were performed, resulting in a final 32-item checklist. Each item on the checklist received at least 70% expert agreement on its inclusion in the final checklist. Conclusion: A procedural performance checklist was created for bifemoral VV ECMO using the modified Delphi method. This is an objective tool to assist procedural training and validation for medical providers performing VV ECMO in austere environments.
Keywords: VVECMO; checklist; prolonged casualty care; ARDS
Colesar MT, Baker JB. 23(3). 24 - 31. (Journal Article)
Abstract
In the most austere combat conditions, Yugoslav guerillas of World War II (WWII) demonstrated an innovative and effective hospitalization system that saved countless lives. Yugoslav Partisans faced extreme medical and logistical challenges that spurred innovation while waging a guerrilla war against the Nazis. Partisans used concealed hospitals ranging between 25 to 215 beds throughout the country with wards that were often subterranean. Concealment and secrecy prevented discovery of many wards, which prototypically contained two bunk levels and held 30 patients in a 3.5 × 10.5-meter space that included storage and ventilation. Backup storage and treatment facilities provided critical redundancy. Intra-theater evacuation relied on pack animals and litter bearers while partisans relied on Allied fixed wing aircraft for inter-theater evacuation.
Keywords: Yugoslavia; warfare; hospital design and construction; military personnel; military health; military medicine; war-related injuries; armed conflicts; World War II
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
Cetin M, Ylidirim M. 23(3). 13 - 17. (Journal Article)
Abstract
Background: Today, asymmetric conflict and terrorism pose a threat to not only soldiers but also civilians, forcing the North Atlantic Treaty Organization (NATO) to confront new threats and rethink its strategy. Various studies have shown that telemedicine is one of these advancements and that it can eventually bring expert advice to the field. Telemedicine, on the other hand, is new in Turkey and has yet to be implemented in the field. The aim of this study is to evaluate the support of health personnel with telemedicine from the perspective of military physicians. Methods: This study was carried out between 20 August 2021 and 5 October 2021 with the participation of 47 military physicians working as research assistants in a training and research hospital. A questionnaire consisting of 17 questions was used to evaluate military physicians' perspectives on telemedicine and their expectations from it. Results: Forty-six of the participants stated that they wanted a healthcare provider/expert opinion to consult about the patient/injured while they were on field and that telemedicine could be used within the scope of field medicine (4.51 ± 0.62). They also stated that telemedicine centers should employ emergency medicine specialists in particular (n = 40, 85.1%). The participants agreed that these centers would be quite useful, particularly for medical evacuations (n = 42, 89.4%). Conclusion: Telemedicine's long-term viability in our country is thought to be contingent upon it covering medical conditions that are practical, require fewer technical intricacies, and appeal to emergency health services. The openness of the personnel to innovation and change is expected to improve harmony and cooperation.
Keywords: military; telemedicine; emergency; Turkey; armed forces
Koo AY, Rodgers DK, Johnson KA, Gordon LL, Mease LE, Couperus KS. 21(3). 60 - 65. (Journal Article)
Abstract
Objectives: Lab companies developed serology tests for antibody detection of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) with United States Food and Drug Administration (FDA) emergency use authorization. Antibody detection uses purified proteins of SARS-CoV-2 to determine antibody binding via enzyme-linked immunosorbent assay, chemiluminescent immunoassay (CLIA), or colloidal gold-based immunochromatographic assay. With the advent of coronavirus disease 2019 (COVID-19), nucleic acid amplification technology (NAAT) SARS-CoV-2 testing for active infection was not widely available to healthy, active-duty Soldiers. The purpose of this surveillance survey was to determine the prevalence of prior SARS-CoV-2 infection and symptoms of COVID-19 within a mechanized infantry brigade. Materials and Methods: Active-duty military Servicemembers (= 18 years) from a mechanized infantry brigade provided serum samples for testing for the Elecsys® Anti-SARS-CoV-2 qualitative antibody test from June to September 2020 at Joint Base Lewis McChord (JBLM). In addition, participants filled out a questionnaire for symptoms and exposure to COVID-19 from January to September 2020. The surveillance team collected and analyzed antibody testing results and questionnaires from participants for antibody positivity rates and symptom prevalence. Results: A total of 264 participants were tested, with one (0.4%) participant testing positive for the SARS-CoV-2 antibody. On the questionnaire, 144 of 264 (54.5%) endorsed symptoms of COVID-19 from January to September 2020. The most common symptoms were headache (35%), rhinorrhea (34%), cough (35%), and sore throat (31%). A total of 31 respondents (12%) had been quarantined as a trace contact to a COVID-19 positive patient. Conclusions: While there are limitations inherent to SARS-CoV-2 antibody testing and the survey, prevalence of prior SARS-CoV-2 infection is low. In this sample, symptoms for COVID-19 were prevalent with significant days of duty lost. Prevalence of prior SARS-CoV-2 infection in this sample may be generalizable to the larger brigade. Prevalence of symptoms of possible COVID-19 are not generalizable to the larger brigade. There is utility to further studies of SARS-CoV-2 antibody prevalence in military populations for purposes of vaccination triaging and deployment readiness.
Keywords: COVID-19; SARS-CoV-2; antibody; Army Infantry Brigade; vaccines; vaccination; prevalence
Osborne K, Wenthe A, Mahowald M, Bridwell R. 24(2). 82 - 84. (Case Reports)
Abstract
Special Operations Servicemembers presenting with palpitations, pre-syncope, or exertional syncope during rigorous physical training are often experiencing a benign condition; however, life-threatening etiologies should be considered. We describe a 43-year-old Special Operator who presented to his medics during selection physical assessment testing with palpitations and lightheadedness, with a subsequent workup revealing arrhythmogenic right ventricular cardiomyopathy (ARVC). His initial electrocardiogram was unremarkable without characteristic ARVC changes. Outpatient evaluation with ambulatory cardiac monitoring recorded numerous episodes of non-sustained ventricular tachycardia. Transthoracic echocardiography demonstrated findings concerning for ARVC, with subsequent cardiac MRI confirming the diagnosis via the 2020 Padua criteria. Management includes activity modification, class III anti-arrhythmic medications, and possible placement of an implantable cardioverter defibrillator to prevent sudden cardiac death. This case demonstrates the importance of maintaining high clinical suspicion for rare diagnoses that present with exertional palpitations, such as arrhythmogenic right ventricular cardiomyopathy, in even our fittest Special Operators.
Keywords: ARVC; sudden cardiac death; arrhythmogenic cardiomyopathy; ventricular tachycardia; arrhythmia
Osborne K, Wenthe A, Mahowald M, Bridwell R. 24(2). 82 - 84. (Case Reports)
Abstract
Special Operations Servicemembers presenting with palpitations, pre-syncope, or exertional syncope during rigorous physical training are often experiencing a benign condition; however, life-threatening etiologies should be considered. We describe a 43-year-old Special Operator who presented to his medics during selection physical assessment testing with palpitations and lightheadedness, with a subsequent workup revealing arrhythmogenic right ventricular cardiomyopathy (ARVC). His initial electrocardiogram was unremarkable without characteristic ARVC changes. Outpatient evaluation with ambulatory cardiac monitoring recorded numerous episodes of non-sustained ventricular tachycardia. Transthoracic echocardiography demonstrated findings concerning for ARVC, with subsequent cardiac MRI confirming the diagnosis via the 2020 Padua criteria. Management includes activity modification, class III anti-arrhythmic medications, and possible placement of an implantable cardioverter defibrillator to prevent sudden cardiac death. This case demonstrates the importance of maintaining high clinical suspicion for rare diagnoses that present with exertional palpitations, such as arrhythmogenic right ventricular cardiomyopathy, in even our fittest Special Operators.
Keywords: ARVC; sudden cardiac death; arrhythmogenic cardiomyopathy; ventricular tachycardia; arrhythmia
Walker S, Agree O, Harris R, DesRosiers TT. 23(2). 49 - 54. (Journal Article)
Abstract
Introduction: Timely vascular access is critical, as hemorrhage is the number one cause of death on the battlefield. Anecdotal evidence in the Military Health System identified an operationally relevant procedural skills gap in vascular access, and data exist in civilian literature showing high rates of iatrogenic injuries when lack of robust procedural opportunity exists. Multiple pre-deployment training courses are available for surgical providers, but no comprehensive pre-deployment vascular access training exists for non-surgical providers. Methods: This mixed-method review aimed to find relevant, operationally focused, vascular access training publications. A literature review was done to identify both relevant military clinical practice guidelines (CPGs) and full text articles. Reviewers also investigated available pre-deployment trainings for both surgeons and non-surgeons in which course administrators were contacted and details regarding the courses were described. Results: We identified seven full-text articles and four CPGs. Two existing surgical training programs and Army, Navy, and Air Force pre-deployment training standards for non-surgeons were evaluated. Conclusion: A cost-effective and accessible pre-deployment curriculum utilizing reviewed literature in a "learn, do, perfect" structure is suggested, building on pre-existing structures while incorporating remotely accessible didactics, hands-on practice with portable simulation models, and live-feedback training.
Keywords: vascular access; military medicine; arterial access; arterial line; central venous access; central line; IV; intravenous; literature review; training, military; deployed medicine; simulation training; austere environments; emergency medical care
Walker S, Agree O, Harris R, DesRosiers TT. 23(2). 49 - 54. (Journal Article)
Abstract
Introduction: Timely vascular access is critical, as hemorrhage is the number one cause of death on the battlefield. Anecdotal evidence in the Military Health System identified an operationally relevant procedural skills gap in vascular access, and data exist in civilian literature showing high rates of iatrogenic injuries when lack of robust procedural opportunity exists. Multiple pre-deployment training courses are available for surgical providers, but no comprehensive pre-deployment vascular access training exists for non-surgical providers. Methods: This mixed-method review aimed to find relevant, operationally focused, vascular access training publications. A literature review was done to identify both relevant military clinical practice guidelines (CPGs) and full text articles. Reviewers also investigated available pre-deployment trainings for both surgeons and non-surgeons in which course administrators were contacted and details regarding the courses were described. Results: We identified seven full-text articles and four CPGs. Two existing surgical training programs and Army, Navy, and Air Force pre-deployment training standards for non-surgeons were evaluated. Conclusion: A cost-effective and accessible pre-deployment curriculum utilizing reviewed literature in a "learn, do, perfect" structure is suggested, building on pre-existing structures while incorporating remotely accessible didactics, hands-on practice with portable simulation models, and live-feedback training.
Keywords: vascular access; military medicine; arterial access; arterial line; central venous access; central line; IV; intravenous; literature review; training, military; deployed medicine; simulation training; austere environments; emergency medical care
Bongiorno MA, Rivard SS, Meyerle JH. 15(2). 12 - 15. (Journal Article)
Abstract
Psoriasis is a chronic immune-mediated disorder that can be triggered by environmental changes, illness, smoking, or medications. This case describes a 25-year-old, activeduty Marine Corps Sergeant with a severe perideployment psoriatic flare, and illustrates treatment limitations, restricted access to specialized care, and the importance of mitigating triggers in the deployed setting.
Keywords: psoriasis; psoriasis, plaque; psoriasis, guttate; arthritis, psoriatic; smoking, cessation; ultraviolet light, exposure; deployment; military provider
Yetto T. 15(2). 132 - 135. (Journal Article)
Abstract
An active duty Sailor has a long history of skin lesions on his scalp, chest, back, and legs. He was evaluated and treated previously but could not recall the specific details. He is diagnosed with plaque psoriasis, an immune-mediated chronic disease. This article reviews the etiology, morphology, diagnosis, and treatment of psoriasis.
Keywords: psoriasis; plaques; pustules; arthritis, psoriatic; nails
Fazekas L, McCown ME, Taylor JB, Ferland KA. 19(1). 27 - 30. (Journal Article)
Abstract
Our intent in presenting this information is to increase the awareness of the Special Operations Forces (SOF) medical community and the overall international medical/military communities about the North Atlantic Treaty Organization (NATO) military medicine's premiere Vigorous Warrior Exercises organized by NATO Centre of Excellence for Military Medicine (MILMED COE). The Vigorous Warrior medical exercise series is conducted biennially, with four successful iterations since 2011. These international medical exercises engage military medical elements that enhance NATO capabilities and ensure that new NATO medical concepts are being exercised and tested across the full capability-requirement spectrum. The primary aims of these exercises are to provide NATO and partner nations a multipurpose platform to collectively train their medical forces and personnel; test and experiment new concepts and doctrines; medically evaluate national or multinational medical treatment facilities in accordance with NATO doctrine; produce medical lessons identified and lessons learned; and provide the participants with multinational experience to enhance the provision of health care in NATO operations. These exercises directly strengthen partnerships, improve military medical interoperability, and demonstrate the Alliance's commitment to improving international military collaboration. More than 1,000 medical personnel from 26 NATO and partner nations successfully conducted the joint, multilevel, multinational, medical live exercise Vigorous Warrior 2017 (VW17) throughout three locations in Germany during 4-22 September 2017. This article details the highly successful VW17 and paves the way for a very bright future for the Alliance's military medicine as well as a Vigorous Warrior 2019.
Keywords: NATO; Vigorous Warrior; NATO Centre of Excellence for Military Medicine; NATO Deployment Health Surveillance Capability; Article 5; joint multinational medical exercise; interoperability; international military collaboration; NATO Concept Development and Experimentation; bioresponsiveness
Knapik JJ, Pope R, Hoedebecke SS, Schram B, Orr R. 19(1). 113 - 124. (Journal Article)
Abstract
Osteoarthritis (OA) is a disorder involving the deterioration of articular cartilage and underlying bone and is associated with symptoms of pain and disability. In military personnel, the incidence of OA has increased between 2000 and 2012 and was the first or second leading cause of medical separations in this period. It has been suggested that consumption of chondroitin sulfate (CS) may reduce the pain and joint deterioration associated with OA. This article reports on a systematic review and meta-analysis of the effectiveness of CS on reducing OA-related pain and joint deterioration. PubMed and Ovid Embase databases and other sources were searched to find randomized, double-blind, placebo-controlled trials on the effects of orally consumed CS on pain and/or joint structure. The outcome measure was the standardized mean difference (SMD) which was the improvement in the placebo groups minus the improvement in the CS groups divided by the pooled standard deviation. There were 18 trials meeting the review criteria for pain with SMD -0.41, 95% confidence interval (95% CI) -0.57 to -0.25 (negative SMD favors CS). Six studies met the review criteria for joint space narrowing with SMD -0.30, 95% CI -0.61 to +0.00. Two studies meet the review criteria for cartilage volume with SMD -0.11, 95% CI -0.48 to +0.26. Larger dosages (1200mg/d) had greater pain reduction efficacy than lower dosages (≤ 1000mg/d). These data suggest that CS has small to moderate effectiveness in reducing OA-related pain but minimal effects on joint space narrowing and no effect on cartilage volume. It is important that clinicians recommend pharmaceutical-grade CS to their patients due to the variability in the amount of CS in dietary supplements purporting to contain CS.
Keywords: osteoarthritis; articular deterioration; bone deterioration; pain; disability; chrondroitin sulfate
Schwartz DS. 14(1). 6 - 8. (Journal Article)
Abstract
An articulating tactical traction splint (REEL™ Tactical Traction Splint), commonly issued to U.S. military per-sonnel, was used to maintain traction in a pulseless fore-arm fracture during a confined space rescue, with good peripheral perfusion maintained through transport. This enabled a single rescuer to focus attention and provide care for other critical aspects of a multisystem trauma patient.
Keywords: articulating tactical traction splint; pulseless forearm fracture; fracture
Melanson V, Hershfield J, Deegan MK, Cho H, Perinon D, Bateman SL, Barnhill JC. 23(3). 63 - 69. (Journal Article)
Abstract
Massive hemorrhaging remains the most common cause of preventable battlefield deaths. Blood used for trauma care requires a robust donation network, capacity for long-term storage, and extensive and accurate testing. Bioengineering technologies could offer a remedy to these constraints in the form of blood substitutes-fluids that could be transfused into patients to provide oxygen, carry away waste, and aid in coagulation-that would be used in prolonged casualty care and in far-forward settings, overcoming the obstacles of distance and time. The different molecular properties of red blood cells (RBCs), blood substitutes, and platelet replacements contribute to their respective utilities, and each type is currently represented in ongoing clinical trials. Hemoglobin oxygen carriers (HBOCs) are the most advanced RBC replacements, many of which are currently being evaluated in clinical trials in the United States and other countries. Despite recent advancements, challenges remaining in the development of blood alternatives include stability, oxygen capacity, and compatibility. The continued research and investment in new technologies has the potential to significantly benefit the treatment of life-threatening emergency injuries, both on the battlefield and in the civilian sector. In this review, we discuss military blood-management practices and military-specific uses of individual blood components, as well as describe and analyze several artificial blood products that could be options for future battlefield use.
Keywords: artificial blood; blood substitutes; red blood cell substitutes; platelet replacements; biomanufacturing
Osborne K, Wenthe A, Mahowald M, Bridwell R. 24(2). 82 - 84. (Case Reports)
Abstract
Special Operations Servicemembers presenting with palpitations, pre-syncope, or exertional syncope during rigorous physical training are often experiencing a benign condition; however, life-threatening etiologies should be considered. We describe a 43-year-old Special Operator who presented to his medics during selection physical assessment testing with palpitations and lightheadedness, with a subsequent workup revealing arrhythmogenic right ventricular cardiomyopathy (ARVC). His initial electrocardiogram was unremarkable without characteristic ARVC changes. Outpatient evaluation with ambulatory cardiac monitoring recorded numerous episodes of non-sustained ventricular tachycardia. Transthoracic echocardiography demonstrated findings concerning for ARVC, with subsequent cardiac MRI confirming the diagnosis via the 2020 Padua criteria. Management includes activity modification, class III anti-arrhythmic medications, and possible placement of an implantable cardioverter defibrillator to prevent sudden cardiac death. This case demonstrates the importance of maintaining high clinical suspicion for rare diagnoses that present with exertional palpitations, such as arrhythmogenic right ventricular cardiomyopathy, in even our fittest Special Operators.
Keywords: ARVC; sudden cardiac death; arrhythmogenic cardiomyopathy; ventricular tachycardia; arrhythmia
Schauer SG, Damrow T, Martin SM, Hudson IL, De Lorenzo RA, Blackburn MB, Hofmann LJ, April MD. 23(2). 13 - 18. (Journal Article)
Abstract
Background: Airway obstruction is the second leading cause of potentially preventable death on the battlefield. The treatment for airway obstruction is intubation or advanced airway adjunct, which has a known risk of aspiration. We sought to describe the variables associated with aspiration pneumonia after prehospital airway intervention. Methods: This is a sub-analysis of previously described data from the Department of Defense Trauma Registry (DoDTR) from 2007 to 2020. We included casualties that had at least one prehospital airway intervention with documentation of subsequent aspiration pneumonia or pneumonia within three days of the intervention. We used a generalized linear model with Firth bias estimates to test for associations. Results: There were 1,509 casualties that underwent prehospital airway device placement. Of these, 41 (2.7%) met inclusion criteria into the aspiration pneumonia cohort. The demographics had no statistical difference between the groups. The non-aspiration cohort had fewer median ventilator days (2 versus 6, p < 0.001), intensive care unit days (2 versus 7, p < 0.001, and hospital days [3 versus 8, p < 0.001]). Survival was lower in the non-aspiration cohort (74.2% versus 90.2%, p = 0.017). The administration of succinylcholine was higher in the non-aspiration cohort (28.0% versus 12.2%, p = 0.031). In our multivariable model, only the administration of succinylcholine was significant and was associated with lower probability of aspiration pneumonia (odds ratio 0.56). Conclusion: Overall, the incidence of aspiration pneumonia was low in our cohort. The administration of succinylcholine was associated with a lower odds of developing aspiration pneumonia.
Keywords: airway; combat; aspiration; vomit; intubation; prehospital
Luk JH, Chang BF, Albus ML, Morgan SA, Szymanski TJ, Hamid OS, Keller L, Daher AF, Sheele JM. 21(4). 66 - 70. (Journal Article)
Abstract
Background: Emergency medical services (EMS) providers are at high risk for occupational violence, and some tactical EMS providers carry weapons. Methods: Anonymous surveys were administered to tactical and nontactical prehospital providers at 180 prehospital agencies in northeast Ohio between September 2018 and March 2019. Demographics were collected, and survey questions asked about workplace violence and comfort level with tactical EMS carrying weapons. Results: Of 432 respondents, 404 EMS providers (94%) reported a history of verbal or physical assault on scene, and 395 (91%) reported working in a setting with a direct active threat at least rarely. Of those reporting a history of assault on scene, 46.5% reported that it occurred at least sometimes. Higher rates of assault on scene were associated with being younger, white, or an emergency medical technician-paramedic, working in an urban environment, having more frequent direct active threats, and having more comfort with tactical EMS carrying firearms (p ≤ .03). Most respondents (306; 71%) reported that they were prepared to defend themselves from someone who originally called for help. Most (303; 70%) reported a comfort level of 8 or higher (from 1, not comfortable to 10, completely comfortable) with tactical EMS providers carrying weapons. Comfort with tactical EMS providers carrying weapons was associated with being white, not having a bachelor's degree, and feeling prepared to defend oneself from a patient (p ≤ .02). Conclusion: EMS providers in the survey report high rates of verbal and physical violence while on scene and are comfortable with tactical EMS providers carrying weapons.
Keywords: assault; emergency medical services; EMS; firearm; safety; Special Weapons and Tactics; SWAT; tactical EMS; weapon
Hart D, McNeil M, Hegarty C, Rush RM, 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
Barry DM, DeVries M. 19(4). 66 - 73. (Journal Article)
Abstract
Background: Performance enhancement coaching poses significant benefits to individuals and organizations, such as improved job satisfaction and goal achievement. Given their training and experience in assessment and feedback, operational psychologists assigned to Special Operations units are uniquely positioned to provide performance enhancement coaching tailored to Operators and enablers. A preliminary program evaluation was conducted of the Performance Enhancement Assessment and Coaching (PEAC) Program. Methods: A sample of 32 Operators and enablers assigned to a US Army Special Operations Forces (ARSOF) unit voluntarily participated in the PEAC Program and completed one 90-minute coaching session. Following their coaching session, Soldiers provided qualitative and quantitative feedback on their coaching experience. Results: Soldiers overwhelmingly agreed that the PEAC Program was worth their time and helpful towards achieving their goals. Results indicate the PEAC Program enhanced Soldiers' perceived self-awareness, self-efficacy, and job performance. Results also suggest performance enhancement coaching may improve pass rates on interpersonally demanding Special Operations courses. Conclusion: Performance enhancement coaching delivers considerable value for Special Operations personnel and their organizations in relatively minimal time. Operational psychologist coaches (OPCs) assigned to Special Operations units can leverage their assessment skills to provide targeted, tailored performance enhancement coaching and increase value to their organizations.
Keywords: coaching; performance enhancement; operational psychology; assessment
Biggs A, Heller T, Colvin K, Wood D, Jewell JA, Littlejohn LF. 23(3). 18 - 23. (Journal Article)
Abstract
Special Operations organizations have recently demonstrated their commitment to enhanced cognitive functioning and improving brain health through the development of a Cognitive Domain. However, as this new enterprise becomes supported by more resources and personnel, a critical question involves what cognitive assessments should be conducted to evaluate cognitive functions. The assessment itself forms a crux in the Cognitive Domain that could mislead cognitive practitioners if not properly applied. Here, the discussion addresses the most important criteria to satisfy in the development of a Special Operations cognitive assessment, including operational relevance, optimization, and speed. Cognitive assessments in this domain must incorporate the following: (1) a task with clear operational relevance to ensure meaningful results, (2) no ceiling effects so that performance can support cognitive enhancement initiatives, and (3) the task itself should impose a minimal time requirement to avoid creating a substantial logistical burden. A dynamic threat assessment task supported by drift diffusion modeling can meet all requisite criteria, while also providing more insight into decision parameters of Special Operations personnel than any currently used test. The discussion concludes with a detailed description of this recommended cognitive assessment task, as well as the research and development steps needed to support its application.
Keywords: cognitive; assessment; Special Operations; drift diffusion; decisions
Johnson AK, Royer SD, Ross JA, Poploski KM, Sheppard RL, Heebner NR, Abt JP, Winters JD. 21(4). 30 - 35. (Journal Article)
Abstract
Background: Servicemembers are required to operate at high levels despite experiencing common injuries such as chronic low back pain. Continuing high levels of activity while compensating for pain may increase the risk of musculoskeletal injuries. As such, the purpose of this project was to determine if servicemembers with chronic low back pain have reduced lower extremity performance, and if they use alternate strategies to complete a functional performance task as compared to healthy servicemembers. Methods: Of a total of 46 male United States Marine Corps Forces Special Operations Command (MARSOC) personnel, 23 individuals who suffered from chronic low back pain (age = 28.6 ± 4.4 years, weight = 84.2 ± 6.8 kg) and 23 healthy controls (age = 27.9 ± 3.8 years, weight = 83.8 ± 7.7 kg) completed a stop jump task. In this task, three-dimensional biomechanics were measured, and lower extremity and trunk strength were assessed. Results: The low back pain group exhibited higher vertical ground reaction force impulse on the dominant limb (0.26% body weight [BW]/s), compared to the nondominant limb (0.25% BW/s, p = .036). The control group demonstrated relationships between jump height and strength in both limbs (dominant: r = 0.436, p = .043; nondominant: r = 0.571, p = .006), whereas the low back pain group demonstrated relationships between jump height and dominant limb knee work (r = 0.470, p = .027) and ankle work (r = 0.447, p = .037). Conclusions: This study demonstrates that active-duty MARSOC personnel with a history of low back pain reach similar levels of jump height during a counter movement jump, as compared to those without a history of low back pain. However, the asymmetries displayed by the low back pain group suggest an alternate strategy to reaching similar jump heights as compared to healthy individuals.
Keywords: biomechanics; low back pain; asymmetries; jump height
Knapp JG, Tang N. 24(2). 91 - 93. (Journal Article)
Abstract
Separate evidence-based, best practice guidelines and recommendations exist for the prehospital management of traumatic injuries sustained in combat settings and those encountered during high-threat civilian operational incidents. The Bureau of Alcohol, Tobacco, Firearms and Explosives (ATF) Tactical Medic Program is a mature operational medicine asset supporting high-threat federal law enforcement operations. The ATF conducted an audit of its agency-issued tactical medic bags with regards to completeness, as defined by authorized medical protocols, which are aligned with current Tactical Combat Casualty Care and Tactical Emergency Casualty Care guidelines.
Keywords: TCCC; TECC; tactical medic bags; ATF
Kotwal RS, Mazuchowski EL, Howard JT, Hanak JC, Harcke HT, Gurney JM, Shackelford SA. 21(2). 19 - 24. (Journal Article)
Abstract
Background: Autopsy studies of trauma fatalities have provided evidence for the pervasiveness of atherosclerosis in young and middle-aged adults. The objective of this study was to determine the prevalence of atherosclerosis in elite US military forces. Methods: We conducted a retrospective study of all US Special Operations Command (USSOCOM) fatalities from 2001 to 2020 who died from battle injuries. Autopsies were evaluated from Afghanistan- and Iraq-centric combat operations for evidence of coronary and/or aortic atherosclerosis and categorized as minimal (fatty streaking only), moderate (10-49% narrowing of ≥1 vessel), and severe (≥50% narrowing of ≥1 vessel). Prevalence of atherosclerosis was determined for the total population and by subgroup characteristics of age, sex, race/ethnicity, combat operation, service command, occupation, rank, cause of death, manner of death, and body mass index (BMI). Results: From the total of 388 USSOCOM battle injury fatalities, 356 were included in the analysis. The mean age was 31 years (range, 19-57 years), and 98.6% were male. The overall prevalence of coronary and/or aortic atherosclerosis was 17.4%. The prevalence of coronary atherosclerosis alone was 13.8%. Coronary atherosclerosis was categorized as minimal in 1.1%, moderate in 7.6%, and severe in 5.1%. Of those with atherosclerosis, 24.2% were <30 years old, 88.7% were from enlisted ranks, and 95.2% had combatant occupations. When BMI could be calculated, 73.5% of fatalities with atherosclerosis had a BMI =25. Conclusions: Autopsy-determined atherosclerosis is prevalent in elite US military Special Operations Forces despite young age and positive lifestyle benefits of service in an elite military unit.
Keywords: atherosclerosis; elite US military forces; coronary atherosclerosis; aortic atherosclerosis
Thomas A, Pagenhardt J, Balcik B. 20(1). 37 - 39. (Case Reports)
Abstract
Atrial flutter and atrial fibrillation are among the most commonly encountered cardiac arrhythmias; however, there is a dearth of clinical trials or case studies regarding its occurrence in the setting of stimulants such as caffeine and nicotine in otherwise healthy young patients. Described here is a case of a 29-year-old physically fit white man without significant past medical history who presented in stable condition complaining only of palpitations. He was found to have atrial flutter without rapid ventricular response on cardiac monitoring, most likely due to concomitant presence of high levels of nicotine and caffeine via chewing tobacco and energy drinks. He was treated conservatively with vagal maneuvers and intravenous fluids with complete resolution of symptoms and electrocardiographic abnormalities within 14 hours. This demonstrates an alternate conservative treatment strategy in appropriately risk stratified patients who present in an austere field setting with limited resources.
Keywords: atrial flutter; caffeine; nicotine; vagal maneuver; athlete
Avilla J, Rerucha C, Hu C. 23(2). 99 - 101. (Journal Article)
Abstract
The presentation of Type 3c diabetes is atypical, accounting for 0.5-1% of all types of diabetes. Combining this with the healthy Special Operations community is even more profound. A 38-year-old active-duty male in Special Operations developed acute abdominal pain and vomiting while deployed. He was diagnosed with severe acute necrotizing pancreatitis secondary to Type 3c diabetes, and the management of his condition became increasingly difficult. This case highlights Type 3c diabetes and the complexity of formulating a comprehensive treatment plan for a tactical athlete.
Keywords: tactical; type 3c diabetes; abdominal pain; pancreatitis; athlete; Special Operations
O'Hara R, Sussman LR, Sheehan R, Keizer B, Tiede JM. 22(4). 65 - 69. (Journal Article)
Abstract
The flotation-restriction environmental stimulation technique (FR) may have utility as a recovery tool for improving performance in elite competitive athletes and Special Operations Forces Operators (SOs). Studies suggest that FR may ameliorate various neurophysiological disorders and improve performance in recreational and elite athletic populations. We sought to understand whether there is evidence to support the use of FR to enhance physiological and psychological performance parameters in the SO population and to provide postulations as to the mechanisms of action of FR therapy. We performed an online literary search of publications dating from 1982 to 2021 and identified 34 sources addressing the aims, depending on population and condition or conditions, being treated. The reported physiological and psychological benefits of FR range from immediate to lasting 4 months. Overall, eight to twelve FR treatment sessions of from 40 to 90 minutes each may provide variable long-term benefits. The associated synergistic benefits of FR may be attributed to its thermal, chemical, and mechanical effects but deserve further exploration. Based on the current evidence, FR may serve as an effective performance-recovery therapy for improving pain, sleep, and performance measures (e.g., marksmanship and physical performance) in trained, untrained, and healthy adults. Future research focusing on FR as a unimodal recovery intervention is warranted in a specialized group of SOs.
Keywords: adult; humans; pain; sleep; exercise; athletes; physical functional performance
Grier T, Anderson MK, Depenbrock P, Eiserman R, Nindl BC, Jones BH. 18(2). 42 - 48. (Journal Article)
Abstract
Background: We sought to assess the rehabilitation process, training, performance, and injury rates among those participating and not participating in the Tactical Human Optimization, Rapid Rehabilitation, and Reconditioning (THOR3) program and determine injury risk factors. Methods: A survey inquiring about personal characteristics, injuries, physical performance, and THOR3 participation during the previous 12 months was administered to Army Special Operations Forces (SOF) Soldiers. Based on responses to physical training, Soldiers were categorized into three groups: a traditional physical training (TPT) group, a cross-training (CT) group, and a THOR3 group. To identify potential injury risk factors, risk ratios and 95% confidence intervals (95% CIs) were calculated. Backward- stepping multivariable logistic regression models were used to assess key factors associated with injury risk. Results: The survey was completed by 328 male Soldiers. Most of the Soldiers (62%) who scheduled an appointment with the physical therapist were seen within 1 day. Self-reported injury rates for the TPT, CT, and THOR3 groups were 70%, 52%, and 48%, respectively. When controlling for personal characteristics, unit training, and fitness, the TPT group had a marginally higher risk of being injured than the THOR3 group (odds ratio [OR], 2.72; 95% CI, 0.86-8.59; p = .09). Soldiers who did not perform any unit resistance training (ORnone/90-160 min, 3.62; 95% CI, 1.05-12.53; p = .04) or the greatest amount of resistance training (OR>160 min/90-160 min, 3.44; 95% CI, 1.64-7.20; p < .01) were more likely to experience an injury than the moderate-resistance training group. Conclusion: THOR3 appears to offer human performance optimization/injury prevention advantages over other SOF human performance programs.
Keywords: THOR3; physical fitness; physical training; musculoskeletal; athletic performance; injury
Kroshus E, Cameron KL, Coatsworth JD, D'Lauro C, Kim NJ, Lee KM, Register-Mihalik J, Milroy JJ, Roetert EP, Schmidt JD, Silverman RD, Warmath D, Wayment HA, Hainline B. 20(3). 88 - 95. (Journal Article)
Abstract
Early disclosure of possible concussive symptoms has the potential to improve concussion-related clinical outcomes. The objective of the present consensus process was to provide useful and feasible recommendations for collegiate athletic departments and military service academy leaders about how to increase concussion symptom disclosure in their setting. Consensus was obtained using a modified Delphi process. Participants in the consensus process were grant awardees from the National Collegiate Athletic Association and Department of Defense Mind Matters Research & Education Grand Challenge and a multidisciplinary group of stakeholders from collegiate athletics and military service academies. The process included a combination of in-person meetings and anonymous online voting on iteratively modified recommendations for approaches to improve concussion symptom disclosure. Recommendations were rated in terms of their utility and feasibility in collegiate athletic and MSA settings with a priori thresholds for retaining, discarding, and revising statements. A total of 17 recommendations met thresholds for utility and feasibility and are grouped for discussion in five domains: (1) content of concussion education for athletes and MSA cadets, (2) dissemination and implementation of concussion education for athletes and military service academy cadets, (3) other stakeholder concussion education, (4) team and unit-level processes, and (5) organizational processes. Collectively, these recommendations provide a path forward for athletics departments and military service academies in terms of the behavioral health supports and institutional processes that are needed to increase early and honest disclosure of concussion symptoms and ultimately to improve clinical care outcomes.
Keywords: concussion; athletics departments; military service academies; clinical care outcomes
Sarkar D, Martinez J. 19(2). 23 - 28. (Case Reports)
Abstract
There is a growing body of literature on the safe, effective use of tranexamic acid (TXA) for hemostasis in a variety of clinical settings. We present a case series of three patients with difficult-to-treat epistaxis where standard treatment methods were not effective. Using atomized intranasal TXA (ATXA) as part of a stepwise treatment approach, we were able to achieve hemostasis and manage all three cases independently, and we did so without major complications in our emergency department (ED). Given recent literature showing the underuse of TXA in combat casualties, ATXA, if formulated and delivered properly, may be of benefit for epistaxis and other significant hemorrhage cases. Further work must be done to elucidate the mechanism of action, specific dose, delivery method, use indications, and safety profile of ATXA.
Keywords: epistaxis; atomized; tranexamic acid; TXA; atomized intranasal TXA; intranasal
Sarkar D, Martinez J. 19(2). 23 - 28. (Case Reports)
Abstract
There is a growing body of literature on the safe, effective use of tranexamic acid (TXA) for hemostasis in a variety of clinical settings. We present a case series of three patients with difficult-to-treat epistaxis where standard treatment methods were not effective. Using atomized intranasal TXA (ATXA) as part of a stepwise treatment approach, we were able to achieve hemostasis and manage all three cases independently, and we did so without major complications in our emergency department (ED). Given recent literature showing the underuse of TXA in combat casualties, ATXA, if formulated and delivered properly, may be of benefit for epistaxis and other significant hemorrhage cases. Further work must be done to elucidate the mechanism of action, specific dose, delivery method, use indications, and safety profile of ATXA.
Keywords: epistaxis; atomized; tranexamic acid; TXA; atomized intranasal TXA; intranasal
Ahmed A, Peine S. 13(2). 69 - 74. (Journal Article)
Abstract
The intents of this article are to share our experiences during a medical mission in the Dominican Republic and to provide the reader with a cross-sectional view of conditions seen and an overview of interesting and challenging cases encountered. We also discuss treatments and techniques used and share lessons learned.
Keywords: dermatology; albinism; chemdestruction; chromoblastomycosis; lesions; skin dermatoses; ecthyma; intertrigo; folliculitis; fungal; scabies; eczematoid spectrum; atopic dermatitis; xerosis cutis; polymorphous; eruption; mycetoma; leprosy; scarlatina; genoderms
Conlon EG, Wright KT. 19(1). 125 - 127. (Journal Article)
Abstract
Atopic dermatitis (eczema) and psoriasis are two common chronic skin diseases that affect many people, including active- duty military Servicemembers and their families. Both conditions have significant psychosocial impacts and can lead to substantial morbidity if undiagnosed and left untreated. We compare and contrast atopic dermatitis and psoriasis in terms of epidemiology, etiology, presentation, diagnosis, and treatment. The goal is to help military medical providers distinguish between the two diseases and provide practical steps for treatment and long-term management.
Keywords: atopic dermatitis; dermatology; diagnostics; eczema; psoriasis; skin conditions; treatment
Armstrong M. 12(4). 1 - 4. (Journal Article)
Abstract
Our nation's servicemembers commonly use dietary supplements to enhance their performance. Despite this prolific use, many of these products have detrimental side-effects that compromise servicemembers' health and could, by proxy, compromise a mission. This paper presents the case of a 32-year old Navy Special Operations Forces (SOF) Sailor who, prior to physical training, used a supplement containing 1,3 Dimethylamylamine (DMAA), and then developed atrial fibrillation with rapid ventricular response. He required intravenous calcium channel blocker administration, followed by beta blockers, for rate control. As military providers, we routinely ask our patients about their use of supplements and while the regulation of these products is beyond the scope of practice for most of us, it is our duty to become better educated about the risks and benefits of these supplements. We must educate our patients and our commands on the potential harm that these supplements may pose.
Keywords: atrial fibriliation; supplement; DMAA; Special Operations; 1,3 Dimethylamylamine
Thomas A, Pagenhardt J, Balcik B. 20(1). 37 - 39. (Case Reports)
Abstract
Atrial flutter and atrial fibrillation are among the most commonly encountered cardiac arrhythmias; however, there is a dearth of clinical trials or case studies regarding its occurrence in the setting of stimulants such as caffeine and nicotine in otherwise healthy young patients. Described here is a case of a 29-year-old physically fit white man without significant past medical history who presented in stable condition complaining only of palpitations. He was found to have atrial flutter without rapid ventricular response on cardiac monitoring, most likely due to concomitant presence of high levels of nicotine and caffeine via chewing tobacco and energy drinks. He was treated conservatively with vagal maneuvers and intravenous fluids with complete resolution of symptoms and electrocardiographic abnormalities within 14 hours. This demonstrates an alternate conservative treatment strategy in appropriately risk stratified patients who present in an austere field setting with limited resources.
Keywords: atrial flutter; caffeine; nicotine; vagal maneuver; athlete
Calvano CJ, Enzenauer RW, Eisnor DL, Mazzoli RA. 17(3). 81 - 83. (Journal Article)
Abstract
Nerve agents are a threat to military and civilian health. The antidote, atropine sulfate, is delivered by autoinjector, which is a limited resource. We propose the use of 1% atropine ophthalmic solution (supplied commercially in 5mL or 15 mL bottles) via oral, ocular, and intranasal administration as an expedient substitute in austere environments.
Keywords: nerve agent; chemical warfare; atropine; antidote; alternative treatment
Tekmal S, Lockett C, Long B, Schauer S. 22(4). 83 - 86. (Journal Article)
Abstract
Background: The Department of State has the primary responsibility of diplomatic operations in foreign countries. The US military often supports these missions and, when needed, may be called upon to provide security in the event of changes in the host nation's government stability. The US military was requested to help evacuate the consulate in Benghazi after the attack on September 11, 2012. The medical requirements to support such a mission remain unclear, and data are lacking. We sought to describe the medical care required during this evacuation mission. Methods: This is a secondary analysis of a previously described dataset from the United States Transportation Command (TRANSCOM) Regulating Command & Control and Evacuation System (TRAC2ES) from 2008 to 2018, with a focus on cases involving the evacuation after the Libyan consulate attack in September 2012. Within our dataset, we isolated all cases of evacuation from the attack on US government facilities in Benghazi. We describe the available data within TRAC2ES, including the free text information placed by the initiating medical personnel. Results: We identified three cases of evacuations within TRAC2ES associated with the Benghazi consulate attack. All cases were evacuated from host nation hospitals to Landstuhl Regional Medical Center (LRMC) by military aircraft under urgent status. Case 1 was an adult male injured by an undocumented mechanism. He was found to be in severe shock, received four units of blood prior to transport, and was intubated. Case 2 was an adult male injured by an undocumented mechanism. He had documented smoke inhalation injury and was found to be coughing up black sputum. Case 3 was an adult male injured by an undocumented mechanism. He had a compound radial fracture with an external fixator in place and subsequently developed compartment syndrome. He was intubated prior to transport. Conclusions: Our case series focuses on the unique aspects of military support of diplomatic missions in countries lacking a stable government-specifically, what transpired in Benghazi. Such events showcase areas of potential collaboration between the Department of State and the Department of Defense in coordinating medical evacuations for casualties sustained during diplomatic missions.
Keywords: Libya; Benghazi; embassy; attack; military; evacuation
Wessels LE, Roper MT, Ignacio RC, Davis KL, Ambrosio AA. 21(3). 93 - 95. (Journal Article)
Abstract
Background: Virtual health (VH) may enhance mentorship to remote first responders. We evaluated the feasibility of synchronous bidirectional VH to mentor life-saving procedures performed by deployed novice providers. Methods: Video teleconferencing (VTC) was established between the USNS Mercy (T-AH 19) underway in the Pacific Ocean to Naval Medical Center San Diego using surgeon teleconsultation. The adult simulated clinical vignette included injuries following a shipboard explosion with subsequent fire. The pediatric simulated vignette included injuries that resulted from an improvised explosive device (IED) blast. Using VTC, augmented reality (AR) goggles, and airway simulation equipment, corpsmen (HMs) received visual cues to perform advanced life-saving procedures. Results: In adult scenarios, 100% of novice hospital HMs performed tasks on first attempt (n = 12). Mean time for tourniquet placement was 46 seconds (standard deviation [SD], 19 seconds); needle thoracostomy, 70 seconds (SD, 67 seconds); tube thoracostomy, 313 seconds (SD, 152 seconds); and cricothyroidotomy, 274 seconds (SD, 82 seconds). In pediatric scenarios, 100% of novice HMs performed tasks on first attempt (n = 5). Mean time for tube thoracostomy completion was 532 seconds (SD, 109 seconds). Conclusion: VH can enhance the training and delivery of trauma care during prolonged field care in resource-limited settings.
Keywords: Tactical Combat Casualty Care; thoracostomy, tube; cricothyroidotomy; augmented reality; tourniquet
Ellis BC, Brown SG. 14(4). 1 - 5. (Case Reports)
Abstract
We present a case report of a Special Operations Soldier who developed anaphylaxis as a consequence of a bee sting, resulting in compromise of the operation. We review the current literature as it relates to the pathophysiology of the disease process, its diagnosis, and its management. An evidence-based field treatment algorithm is suggested.
Keywords: anaphylaxis; anaphylactic shock; epinephrine; epinephrine infusion; review; remote; austere
Rago AP, Sharma U, Sims K, King DR. 15(3). 39 - 45. (Journal Article)
Abstract
Background: Noncompressible hemorrhage is the leading cause of potentially survivable death on the battlefield. In Special Operations Forces (SOF), 50% of potentially survivable deaths have been related to noncompressible hemorrhage. Currently, there are no widely available presurgical interventions that can slow abdominal bleeding. Consequently, many of the preventable deaths occur en route to definitive care as a failure to rescue from exsanguination. A self-expanding polyurethane foam has been developed as a percutaneous damage control intervention to rescue casualties who would otherwise die of noncompressible hemorrhage, and allow them to survive long enough to reach surgical intervention. The purpose of this paper is to summarize the existing preclinical data, describe the role of SOF personnel in foam delivery-system development, and to integrate these together to conceptualize how foam could be incorporated into SOF medical care. Methods: All existing publications on self-expanding foam are reviewed. Additionally, eight SOF medical providers with combat experience provided end-user input to delivery-device design through an interactive human-factors testing process. Results: Ten preclinical publications described efficacy, safety, dose translation, and risk-benefit analysis of exsanguination rescue with percutaneous-foam damage control. SOF medical providers guided weight, cubic, operational requirements, and limits for the foam delivery device. Conclusion: Presurgical exsanguination rescue with percutaneous foam damage control is safe and effective with a favorable risk-benefit profile in preclinical studies. Battlefield, presurgical use by SOF medical providers is conceptually possible. Adoption of the technology on the battlefield should proceed with SOF medical provider input.
Keywords: hemorrhage; noncompressable; bleeding; foam; advanced medic; abdominal; austere; ResQFoam
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
Monti JD. 17(1). 22 - 25. (Journal Article)
Abstract
Ultrasound represents an ideal diagnostic adjunct for medical personnel operating in austere environments, because of its increasing portability and expanding number of point-of-care applications. However, these machines cannot be used without a transmission medium that allows for propagation of ultrasound waves from transducer to patient. This article describes a novel ultrasound gel alternative that may be better suited for resource-constrained environments than standard ultrasound gel, without compromising image quality.
Keywords: ultrasound; austere; ultrasound gel; military; POCUS
Sherman RA, Hetzler MR. 17(2). 154 - 162. (Journal Article)
Abstract
The past 25 years have seen an increase in use of maggot therapy for wound care. Maggot therapy is very effective in wound debridement; it is simple to apply and requires very little in the way of resources, costs, or skilled personnel. These characteristics make it well suited for use in austere environments. The use of medical-grade maggots makes maggot therapy nearly risk free, but medical grade maggots may not always be available, especially in the wilderness or in resource-limited communities. By understanding myiasis and fly biology, it should be possible even for the nonentomologist to obtain maggots from the wild and apply them therapeutically, with minimal risks.
Keywords: maggot; maggot therapy; wound; wound care; austere; field hospital
Hetzler MR. 17(4). 130 - 132. (Journal Article)
Abstract
Radiographs, bones scans, and even ultrasound may be rare in the austere or acute environment for the evaluation of suspected musculoskeletal fractures. Having an easy, simple, and confident means of objective evaluation used in conjunction with the patient presentation, history, and physical findings may provide a more efficient and economical means of treatment. This introduction and review of selected literature are meant to provide a fuller understanding and consideration for the methods of using a tuning fork in fracture assessment.
Keywords: tuning fork; fracture; austere; operational medicine; primitive medicine
Christensen PA. 18(1). 150 - 154. (Journal Article)
Abstract
Austere care of the wounded is challenging for all Western medical professionals-nurse, medic, or physician. There can be no doubt that working for the first time, either for a nongovernment organization or in the Special Forces, you will be taking care of wounded patients outside your training and experience. You must have the ability to adapt to and overcome lack of resources and equipment, and accept standards of treatment often very different and lower than that common in western hospitals. The International Committee of the Red Cross (ICRC) was asked to provide relief for the Pakistan Red Crescent in 1982 and set up the ICRC Hospital for Afghan War Wounded in Peshawar on the border to Afghanistan. This article relates how a western-trained young anesthetist on a ICRC surgical team experienced this, at the time, austere environment.
Keywords: austere; ICRC; Pakistan; Afghanistan; nongovernment organization
Morgans LB, Graham N. 18(2). 142 - 146. (Journal Article)
Abstract
Medical services in the austere and limited environment often require therapeutics and practices uncommon in modern times due to a lack of availability, affordability, or expertise in remote areas. In this setting, diethyl ether, or simply ether anesthesia, still serves a role today as an effective inhalation agent. An understanding of ether as an anesthetic not only illustrates the evolution in surgical anesthesia but also demonstrates ether's surviving function and durable use as a practical agent in developing nations. Although uncommon, it is not unseen, so a working knowledge should be understood if observation and advocacy for patients receiving this method of anesthesia are experienced.
Keywords: austere; primitive; anesthesia; ether; diethyl-ether; inhalation agents; drawover; unconventional medicine
Antosh IJ, McGrane OL, Capan EJ, Dominguez JD, Hofmann LJ. 19(1). 48 - 51. (Journal Article)
Abstract
There are no established ground medical-evacuation systems within Special Operations Command Africa (SOCAFRICA), given the austere and varied environments. Transporting the injured casualty requires ingenuity and modification of existing vehicles. The Expeditionary Resuscitative Surgical Team (ERST) assigned to SOCAFRICA used four unconventional means for ground evacuation. This is a retrospective review of the various modes of ground transportation used by the ERST-3 during deployment with SOCAFRICA. All handcarried litter and air evacuation platforms were excluded. Over 9 months, four different ground casualty platforms were used after they were modified: (1) Mine-Resistant Ambush-Protected All-Terrain Vehicle (MAT-V; Oshkosh Defense); (2) MRZR-4 ("Razor"; Polaris Industries); (3) nonstandard tactical vehicles, (NSTVs; Toyota HiLux); and (4) John Deere TH 6x4 ("Gator"). Use of all vehicle platforms was initially rehearsed and then they were used on missions for transport of casualties. Each of the four methods of ground evacuation includes a description of the talon litter setup, the necessary modifications, the litter capacity, the strengths and weaknesses, and any summary recommendations for that platform. Understanding and planning for ground casualty evacuation is necessary in the austere environment. Although each modified vehicle was used successfully to transfer the combat casualty with an ERST team member, consideration should be given to acquisition of the MAT-V medical-specific vehicle. Understanding the currently available modes of ground casualty evacuation transport promotes successful transfer of the battlefield casualty to the next echelon of care.
Keywords: patient transport; ground evacuation; Special Operations; austere; prolonged field care
Nicholson B, Neskey J, Stanfield R, Fetterolf B, Ersando J, Cohen J, Kue R. 19(1). 66 - 69. (Journal Article)
Abstract
Current prolonged field care (PFC) training routinely occurs in simulated physical locations that force providers to continue care until evacuation to definitive care, as based on the staged Ruck-Truck-House-Plane model. As PFC-capable teams move further forward into austere environments in support of the fight, they are in physical locations that do not fit this staged model and may require teams to execute their own casualty evacuation through rough terrain. The physical constraints that come specifically with austere, mountainous terrain can challenge PFC providers to initiate resuscitative interventions and challenge their ability to sustain these interventions during lengthy, dismounted movement over unimproved terrain. In this brief report, we describe our experience with a novel training course designed for PFC-capable medical teams to integrate their level of advanced resuscitative care within a mountainous, rough terrain evacuation-training program. Our goals were to identify training gaps for Special Operations Forces medical units tasked to operate in a cold-weather, mountain environment with limited evacuation resources and the challenges related to maintaining PFC interventions during dismounted casualty movement.
Keywords: prolonged field care; evacuation; rough terrain; austere; mountain warfare
Kerr W, Hubbard B, Anderson B, Montgomery HR, Glassberg E, King DR, Hardin RD, Knight RM, Cunningham CW. 19(2). 128 - 133. (Journal Article)
Abstract
Effectively and rapidly controlling significant junctional hemorrhage is an important effort of Tactical Combat Casualty Care (TCCC) and can potentially contribute to greater survival on the battlefield. Although the US Food and Drug Administration (FDA) has approved labeling of four devices for use as junctional tourniquets, many Special Operations Forces (SOF) medics do not carry commercially marketed junctional tourniquets. As part of ongoing educational improvement during Special Operations Combat Medical Skills Sustainment Courses (SOCMSSC), the authors surveyed medics to determine why they do not carry commercial tourniquets and present principles and methods of improvised junctional tourniquet (IJT) application. The authors describe the construction and application of IJTs, including the use of available pressure delivery devices and emphasizing that successful application requires sufficient and repetitive training.
Keywords: tourniquets; tourniquets, improvised; hemorrhage, junctional; training; austere
Hampton K, Van Humbeeck L. 20(2). 148 - 148. (Journal Article)
Abstract
Keywords: ultrasound; testicles; austere
Hall AB, Dixon M, Dennis AJ, Wilson RL. 20(4). 92 - 94. (Journal Article)
Abstract
Background: The COVID-19 pandemic has been a struggle for medical systems throughout the world. In austere locations in which testing, resupply, and evacuation have been limited or impossible, unique challenges exist. This case series demonstrates the importance of population isolation in preventing disease from overwhelming medical assets. Methods: This is a case series describing the outbreak of COVID-19 in an isolated population in Africa. The population consists of a main population with a Role 2 capability, with several supported satellite populations with a Role 1 capability. Outbreaks in five satellite population centers occurred over the course of the COVID-19 pandemic from its start on approximately 1 March 2020 until 28 April 2020, when a more robust medical asset became available at the central evacuation hub within the main population. Results: Population movement controls and the use of telehealth prevented the spread within the main population at risk and enabled the setup of medical assets to prepare for anticipated widespread disease. Conclusion: Isolation of disease in the satellite populations and treating in place, rather than immediately moving to the larger population center's medical facilities, prevented widespread exposure. Isolation also protected critical patient transport capabilities for use for high-risk patients. In addition, this strategy provided time and resources to develop infrastructure to handle anticipated larger outbreaks.
Keywords: COVID-19; Coronavirus; austere; military
Carlton DM, Lowery D, Woodard C, Lugo-Robles R, Charny G. 21(2). 54 - 60. (Journal Article)
Abstract
Background: While the US military has relied on the "Golden Hour" for casualty evacuation in Iraq and Afghanistan during most of the last two decades, Special Operations Forces (SOF) personnel have found themselves operating further outside of this established medical infrastructure. This has required prolonged casualty care beyond doctrinal timelines. Telemedicine is increasingly used by medical personnel to bridge this gap, augmenting the local staff with the expertise of a distant consultant. This pilot study was launched to establish a baseline of current SOF telemedical capabilities. Methods: This is a cross-sectional study of a 292 Department of Defense (DoD) SOF medical personnel via an online questionnaire during the period of October 2018-May 2019. Results: Approximately 16.1% of the 292 respondents stated they received telemedicine equipment, 51.1% of respondents who received telemedicine equipment reported also receiving training on their equipment. Overall, 40.6% of respondents were "actively looking to add telemedicine to their practice," with prolonged field care as the primary intended use. Ideal characteristics of telemedicine equipment were described as a device weighing 6 lb or less, with real-time video and ultrasound transmission capabilities. Discussion: The data demonstrated a gap between provider demand for telemedicine capabilities and their comfort to employ these capabilities downrange. Conclusions: This study suggests a need to increase the self-reported telemedicine competency of deployed local providers. Authors believe that this is best accomplished through incorporation of early integration of teleconsulting systems into mission rehearsals and unit exercises. Further study should be considered to investigate the efficacy of ongoing acquisition and training programs, along with how telemedicine is being incorporated in the unit during the predeployment training period.
Keywords: telemedicine; telehealth; communication; military; prolonged field care; Special Operations Force; austere; project research
Sarkisian S, Sletten ZJ, Roberts P, Powell T. 21(2). 80 - 84. (Journal Article)
Abstract
Although skin and soft tissue infections are common in the deployed setting, infectious myositis is relatively uncommon. Bacterial infection of the muscle is the most common infectious etiology and can result in a spectrum of disease, to include abscess formation to necrotizing myositis, toxic shock syndrome, and death. Diagnosis can be elusive, particularly in the early stages. Recognition and proper management are crucial to prevent complications. The authors present a case report of infectious myositis diagnosed and managed in an austere deployed environment, as well as a discussion regarding current recommendations on diagnosis and treatment.
Keywords: infectious myositis; myositis; austere; antibiotics
Boyer NL, Mazarella JA, Thronson EE, Brillhart DB. 21(4). 99 - 103. (Journal Article)
Abstract
In a rapidly changing operational environment, in which there has been an emphasis on prolonged field care and limited evacuation platforms, military providers must practice to the full scope of their training to maximize outcomes. In addition to pushing military providers further into combat zones, the Department of Defense has relied on contracted personnel to help treat and evacuate servicemembers. This article is a retrospective review on the interoperability of the expeditionary resuscitative surgical team (ERST) and a contracted personnel recovery (CPR) team in a far-forward austere environment and will discuss actual patient transport case reviews that used multiple evacuation platforms across thousands of miles of terrain. To effectively incorporate CPR personnel into a military transport team model, we recommend including cross-training on equipment and formularies, familiarization with CPR evacuation platforms, and mass casualty (MASCAL) exercises that incorporate the different platforms available.
Keywords: patient transport; air evacuation; prolonged field care; Special Operations; Expeditionary Resuscitative Surgical Team; contract personnel recovery; austere
Lundy JB, Sparkman BK, Sleeter JJ, Steinberger Z, Remick KN. 21(4). 118 - 123. (Journal Article)
Abstract
The authors describe an equipment list for an ultramobile, surgeon-carried equipment set that is specifically designed for missions that require the extremes of constraints on personnel and resources conducted outside the ring of golden hour access to damage control surgery (DCS) capabilities.
Keywords: damage control surgery; damage control resuscitation; surgical equipment; austere; packing; pack; backpack; trauma; surgeon; surgery
Williams NC. 22(2). 120 - 125. (Journal Article)
Abstract
Septic children are among the most challenging and resource-intensive patients that clinicians see around the world daily. These patients often require a broad range of therapies and assessment techniques, frequently relying on expertise across multiple specialties such as radiology and laboratory services. In developed nations, these resources are readily available or in close proximity, as transport is often logistically feasible to coordinate transfer to definitive care. In developing nations and areas of conflict, this is not the case. Most of the world's population lives in developing nations, resulting in inadequate access to specialized pediatric intensive care resources. As a result, many clinicians globally face the unique challenge of caring for septic children in resource-deprived and austere settings. Areas recovering from natural disasters, remote villages, and conflict zones are examples of austere environments where children have an increased risk of sepsis while having the fewest medical resources available. This creates a unique challenge that prehospital clinicians are specifically tasked with managing, sometimes lasting for multiple days pending the possibility of a transport option. Clinicians in these environments must be aggressive in identifying and treating critically-ill children in resource limited environments, but also nuanced in their care plan due to the limitations of the environment.
Keywords: sepsis; austere; pediatric; prehospital; child; critical care; resources; limited
Clerkin S, Carlson NT, Long B, Taylor DH, Bridwell R. 23(1). 80 - 83. (Case Reports)
Abstract
As arctic warfare becomes a center focus within Special Operations, cold weather injury looms as both a medical and operational threat. While cold weather injury can range from pernio to hemodynamically unstable systemic hypothermia, the more minor injuries are far more common. However, these present a challenge in austere medical care and can drastically impact mission capability. We present a case of a Special Operations crew chief with cold weather digital injury while at the Arctic Isolation Course in Alaska and his subsequent clinical course. Prevention remains the key for mitigating these injuries, while the decision to rewarm must be made with both medical and tactical factors in mind as refreezing incurs significant morbidity. Other components of prehospital treatment include active rewarming, ibuprofen, aloe vera, and pain control.
Keywords: arctic warfare; cold injury; frostbite; rewarm; Alaska; hypothermia; austere
Schoenberger T, Foret B, Evans J, Shishido AA. 23(2). 114 - 117. (Journal Article)
Abstract
Prolonged Casualty Care (PCC) has become an essential component to Special Operations Forces (SOF) pre-mission training. However, it has not regularly been required in recent combat operations with the availability of medical evacuation (MEDEVAC) support. Poor weather conditions at an austere SOF outpost created an emergency unreachable by aeromedical evacuation. Herein, we report a case of an emergency bilateral above-the-knee amputation procedure performed by three Special Forces Medical Sergeants (18D(a), 18D(b), and 18D(c)) and supporting Army medics with minimal telemedicine consult and guidance.
Keywords: amputation; austere; MEDEVAC; special operation; Afghanistan; emergency; telemedicine; combat
Moore A, Aden JK, Curtis R, Umar M. 19(3). 71 - 75. (Journal Article)
Abstract
Background: The laryngeal handshake method (LHM) may be a reliable standardized method to quickly and accurately identify the cricothyroid membrane (CTM) when performing an emergency surgical airway (ESA). However, there is currently minimal available literature evaluating the method. Furthermore, no previous CTM localization studies have focused on success rates of military prehospital providers. This study was conducted with the goal of answering the question: Which method is superior, the LHM or the traditional method (TM), for identifying anatomical landmarks in a timely manner when performed by US Army combat medic trainees? Methods: This prospective randomized crossover study was conducted at Ft Sam Houston, TX, in September 2018. Two Army medic trainees with similar body habitus volunteered as subjects, and the upper and lower borders and midline of their CTMs were identified by ultrasound (US). The participants were also recruited from the medic trainee population. After receiving initial training on the LHM and refresher training on the TM, participants were asked to localize the CTMs of each subject with one method per subject. Success was defined as a marking within the borders and 5mm of midline within 2 minutes. Results: Thirty-two combat medic trainees participated; 78% (n = 25) successfully localized the CTM using the TM versus 41% (n = 13) using the LHM (p = .002). Conclusion: Findings of this study support that at present the TM is a superior method for successful localization of the CTM when performed by Army combat medic trainees.
Keywords: laryngeal handshake method; cricothyrotomy landmarks; cricothyroidotomy palpation; austere cricothyroidotomy
Nam JJ, Wong AI, Cantong D, Cook JA, Andrews Z, Levy JH. 23(2). 118 - 121. (Journal Article)
Abstract
Coagulopathy can occur in trauma, and it can affect septic patients as a host tries to respond to infection. Sometimes, it can lead to disseminated intravascular coagulopathy (DIC) with a high potential for mortality. New research has delineated risk factors that include neutrophil extracellular traps and endothelial glycocalyx shedding. Managing DIC in septic patients focuses on first treating the underlying cause of sepsis. Further, the International Society on Thrombolysis and Haemostasis (ISTH) has DIC diagnostic criteria. "Sepsis-induced coagulopathy" (SIC) is a new category. Therapy of SIC focuses on treating the underlying infection and the ensuing coagulopathy. Most therapeutic approaches to SIC have focused on anticoagulant therapy. This review will discuss SIC and DIC and how they are relevant to prolonged casualty care (PCC).
Keywords: sepsis; disseminated intravascular coagulation; coagulopathy; antithrombin; prolonged casualty care; PCC; austere critical care
O'Dochartaigh D, Picard CT, Brindley PG, Douma MJ. 20(2). 110 - 114. (Journal Article)
Abstract
Introduction: Abdominal-pelvic hemorrhage (i.e., originates below the diaphragm and above the inguinal ligaments) is a major cause of death. It has diverse etiology but is typically associated with gunshot or stab wounds, high force or velocity blunt trauma, aortic rupture, and peripartum bleeds. Because there are few immediately deployable, temporizing measures, and the standard approaches such as direct pressure, hemostatics, and tourniquets are less reliable than they are with compressible extremity injuries, risk for death resulting from abdominal-pelvic hemorrhage is high. This review concerns the exciting potential of proximal external aortic compression (PEAC) as a temporizing technique for life-threatening lower abdominal-pelvic hemorrhage. PEAC can be accomplished by means of a device, two locked arms (manual), or a single knee (genicular) to press over the midline supra-umbilical abdomen. The goal is to compress the descending aorta and slow or halt downstream hemorrhage while not delaying more definitive measures such as hemostatic packing, tourniquets, endovascular balloons, and ultimately operative repair. Methods: Clinical review of the Ovid MEDLINE, In-Process, & Other Non-Indexed, and Google Scholar databases was performed for the period ranging from 1946 to 3 May 2019 for studies that included the following search terms: [proximal] external aortic compression OR vena cava compression AND (abdomen or pelvis) OR (hemorrhage) OR (emergency or trauma). In addition, references from included studies were assessed. Conclusion: Sixteen studies met the inclusion criteria. Evidence was grouped and summarized from the specialties of trauma, aortic surgery, and obstetrics to help prehospital responders and guide much-needed additional research, with the goal of decreasing the high risk for death after life-threatening abdominal-pelvic hemorrhage.
Keywords: hemorrhage; trauma; shock; junctional trauma; noncompressible hemorrhage; prehospital care; austere environment; proximal external aortic compression; PEAC
Rapp J, Keenan S, Taylor D, Rapp A, Turconi M, Maves R, Kavanaugh M, Makati D, Powell D, Loos PE, Sarkisian S, Sakhuja A, Mosely DS, Shackelford SA. 20(4). 27 - 39. (Journal Article)
Abstract
This Role 1 prolonged field care (PFC) guideline is intended for use in the austere environment when evacuation to higher level of care is not immediately possible. A provider must first be an expert in Tactical Combat Casualty Care (TCCC). The intent of this guideline is to provide a functional, evidence-based and experience-based solution to those individuals who must manage patients suspected of having or diagnosed with sepsis in an austere environment. Emphasis is placed on the basics of diagnosis and treatment using the tools most familiar to a Role 1 provider. Ideal hospital techniques are adapted to meet the limitations of austere environments while still maintaining the highest standards of care possible. Sepsis and septic shock are medical emergencies. Patients suspected of having either of these conditions should be immediately evacuated out of the austere environment to higher echelons of care. These patients are often complex, requiring 24-hour monitoring, critical care skills, and a great deal of resources to treat. Obtaining evacuation is the highest treatment priority for these patients. This Clinical Practice Guideline (CPG) uses the minimum, better, best paradigm familiar to PFC and gives medics of varying capabilities and resources options for treatment.
Keywords: prolonged field care; Tactical Combat Casualty Care; sepsis; austere environment
Peters AM, Yu I, Menguito M, Morrow S, Barnhill JC, Washington MA. 21(2). 85 - 88. (Journal Article)
Abstract
Background: Female Servicemembers are increasingly being incorporated into the combat arms and Special Operations communities. Female urinary diversion devices (FUDDs) have been used to facilitate urination in the austere environments that are encountered by Servicemembers. Importantly, the potential for the bacterial contamination of these devices has not been evaluated. The goals of this study were to determine whether microorganisms adhere to the surfaces of FUDDs in the field environment and to demonstrate the presence of potential pathogens on the used devices. Materials and Methods: A total of 15 devices that were used in a comprehensive 18-24-hour military field exercise were tested for the presence of microorganisms. Briefly, each device was swabbed, and the swabs were used to inoculate blood agar plates to encourage bacterial growth. The resulting bacterial colonies were identified, and the surface topography of the devices was investigated with electron microscopy. Results: Although microscopy revealed few surface features capable of facilitating bacterial attachment, several species were recovered. Significantly, a biofilm-forming strain of Proteus mirabilis (P. mirabilis) was detected on two of the devices. P. mirabilis is a mobile urinary pathogen that can potentially migrate from the surface of the device into the urinary tract of the user. Conclusion: Commercial FUDDs can support bacterial growth and harbor potential pathogens. Care should be taken to ensure that Servicemembers are aware of the importance of the proper care and cleaning of these devices in the field environment. To this end, standard operating procedures should be developed and distributed.
Keywords: female Servicemembers; female urinary diversion devices; urination; austere environment; Proteus mirabilis
Lanham N, Belyea CM, Marcello D, Wataka AB, Musila L. 24(1). 77 - 80. (Journal Article)
Abstract
Background: Recommendations for optimal temperature and humidity for sterile instrument storage vary according to different sources. Furthermore, there are limited data comparing methods of packing smaller, lightweight, low-profile instruments. The purpose of this study was to compare sterile peel packaging and sterile cellulose wrapping for sterile instrument storage in an austere environment characterized by elevated temperature and humidity. Methods: Stainless steel screws were sterilized and stored in either sterile peel packaging, sterile cellulose wrapping, or no packaging. Four groups were evaluated. Group 1 consisted of four screws in a sterile peelpack envelope and served as a time-zero control. Group 2 consisted of two groups of five screws, each packaged with blue sterilization cellulose wrap. Group 3 consisted of two groups of five screws, each packaged in sterile peel-pack envelopes. Group 4 consisted of 10 non-sterile unpackaged screws, which served as controls. Screws from groups 2, 3, and 4 were then cultured for 6 and 12 weeks. Temperature and humidity values were recorded in the instrument storage area. Results: Average temperature was 21.3°C (SD 1.2°C; range 18.9°C-27.2°C) and average humidity was 51.7% (SD 3.9%; range 39%- 70%). Groups 1 (time-zero control) and 2 (sterile cellulose wrapping) demonstrated no growth. After 6 and 12 weeks, groups 3 (sterile peel packaging) and 4 (control) demonstrated bacterial growth. Conclusion: The most common culture isolates were gram-positive rods and two common nosocomial Staphylococcius species. Sterile peel packaging was not found to be equivalent to sterile cellulose wrapping in austere environmental conditions.
Keywords: instrument sterility; austere environment; peel packing; cellulose wrapping; sterile instrument storage
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
Amodt ZT. 13(4). 6 - 11. (Journal Article)
Abstract
Military forces have missions that send them all over the globe. With the reemergence of bed bugs worldwide, the possibility of Servicemembers encountering them has increased. Special Operations Forces are often sent to locations that may not have integrated pest management support. Knowing how to identify and manage a bed bug infestation, with and without proper equipment and supplies, may become necessary in the very near future. It is also important that Servicemembers are aware of how bed bugs travel, to prevent their dispersal back to the United States and into their barracks and homes.
Keywords: bed bugs; bat bugs; infestations; austere environments; pest management
Manley JD, Mitchell BJ, DuBose JJ, Rasmussen TE. 17(1). 1 - 8. (Case Reports)
Abstract
Background: Resuscitative endovascular balloon occlusion of the aorta (REBOA) is used to mitigate bleeding and sustain central aortic pressure in the setting of shock. The ER-REBOA™ catheter is a new REBOA technology, previously reported only in the setting of civilian trauma and injury care. The use of REBOA in an out-of-hospital setting has not been reported, to our knowledge. Methods: We present a case series of wartime injured patients cared for by a US Air Force Special Operations Surgical Team at an austere location fewer than 3km (5-10 minutes' transport) from point of injury and 2 hours from the next highest environment of care-a Role 2 equivalent. Results: In a 2-month period, four patients presented with torso gunshot or fragmentation wounds, hemoperitoneum, and class IV shock. Hand-held ultrasound was used to diagnose hemoperitoneum and facilitate 7Fr femoral sheath access. ER-REBOA balloons were positioned and inflated in the aorta (zone 1 [n = 3] and zone 3 [n = 1]) without radiography. In all cases, REBOA resulted in immediate normalization of blood pressure and allowed induction of anesthesia, initiation of whole-blood transfusion, damage control laparotomy, and attainment of surgical hemostasis (range of inflation time, 18-65 minutes). There were no access- or REBOArelated complications and all patients survived to achieve transport to the next echelon of care in stable condition. Conclusion: To our knowledge, this is the first series to demonstrate the feasibility and effectiveness of REBOA in modern combat casualty care and the first to describe use of the ER-REBOA catheter. Use of this device by nonsurgeons and surgeons not specially trained in vascular surgery in the out-of-hospital setting is useful as a stabilizing and damage control adjunct, allowing time for resuscitation, laparotomy, and surgical hemostasis.
Keywords: REBOA; endovascular balloon occulsion; shock, hemorrhagic; austere environments
Corso P, Mandry C, Reynolds S. 17(2). 74 - 81. (Journal Article)
Abstract
The combat focus of the US Military over the past 15 years has primarily centered on the Iraq and Afghanistan areas of operation (AOs). Thus, much human and financial capital has been dedicated to the creation of a robust medical infrastructure to support those operations. However, Special Operation Forces (SOF) are often called upon to deploy in much more medically austere AOs. SOF medical providers operating in such environments face significant challenges due to the diversity of medical threats, extremely limited access to medical resupply, a material shortage of casualty evacuation platforms, lack of medical facilities, and limited access to higher-level care providers. This article highlights the challenges faced during a recent Special Forces deployment to such an austere environment. Many of these challenges can be mitigated with a specific approach to premission training and preparation.
Keywords: prolonged field care; austere environments; deployed preparation
Ross EM, Redman TT. 18(1). 37 - 43. (Case Reports)
Abstract
Background: Noncompressible junctional and truncal hemorrhage remains a significant cause of combat casualty death. Resuscitative endovascular balloon occlusion of the aorta (REBOA) is an effective treatment for many junctional and noncompressible hemorrhages. The current hospital standard for time of placement of REBOA is approximately 6 minutes. This study examined the training process and the ability of nonsurgical physicians to apply REBOA therapy in an austere field environment. Methods: This was a skill acquisition and feasibility study. The participants for this experiment were two board-certified military emergency medicine physicians with no prior endovascular surgery exposure. Both providers attended two nationally recognized REBOA courses for training. A perfused cadaver model was developed for the study. Each provider then performed REBOA during different phases of prehospital care. Time points were recorded for each procedure. Results: There were 28 REBOA catheter placement attempts in 14 perfused cadaver models in the nonhospital setting: eight placements in a field setting, eight placements in a static ambulance, four placements in a moving ambulance, and eight placements inflight on a UH-60 aircraft. No statistically significant differences with regard to balloon inflation time were found between the two providers, the side where the catheter was placed, or individual cadaver models. Successful placement was accomplished in 85.7% of the models. Percutaneous access was successful 53.6% of the time. The overall average time for REBOA placement was 543 seconds (i.e., approximately 9 minutes; median, 439 seconds; 95% confidence interval [CI], 429-657) and the average placement time for percutaneous catheters was 376 seconds (i.e., 6.3 minutes; 95% CI, 311-44 seconds) versus those requiring vascular cutdown (821 seconds; 95% CI, 655-986). Importantly, the time from the decision to convert to open cutdown until REBOA placement was 455 seconds (95% CI, 285-625). Conclusion: This study demonstrated that, with proper training, nonsurgical providers can properly place REBOA catheters in austere prehospital settings at speeds
Keywords: austere environments; noncompressable hemorrhage; resuscitative endovascular balloon occlusion of the aorta; battlefield REBOA; combat resuscitation team; prehospital REBOA; damage control resuscitation; helicopter REBOA; en route care REBOA
Blaine C, Abbott M, Jacobson E. 18(3). 120 - 123. (Journal Article)
Abstract
The authors present their experience in emergency and longterm medical care by Special Operations Forces (SOF) medical providers in an austere environment. In this case, a Special Forces Operational Detachment-Alpha (SFOD-A) was deployed in support of Operation Inherent Resolve, partnered with indigenous combat forces.
Keywords: prolonged field care; indigenous combat forces; austere environments
Mesar T, Lessig A, King DR. 18(4). 34 - 35. (Journal Article)
Abstract
Background: Care of trauma casualties in an austere environment presents many challenges, particularly when evacuation is not immediately available. Man-packable medical supplies may be consumed by a single casualty, and resupply may not be possible before evacuation, particularly during prolonged field care scenarios. We hypothesized that unmanned aerial drones could successfully deliver life-sustaining medical supplies to a remote, denied environment where vehicle or foot traffic is impossible or impractical. Methods: Using an unmanned, rotary- wing drone, we simulated delivery of a customizable, 4.5kg load of medical equipment, including tourniquets, dressings, analgesics, and blood products. A simulated casualty was positioned in a remote area. The flight was preprogrammed on the basis of grid coordinates and flew on autopilot beyond visual range; data (altitude, flight time, route) were recorded live by high-altitude Shadow drone. Delivery time was compared to the known US military standards for traversing uneven topography by foot or wheeled vehicle. Results: Four flights were performed. Data are given as mean (± standard deviation). Time from launch to delivery was 20.77 ± 0.05 minutes (cruise speed, 34.03 ± 0.15 km/h; mean range, 12.27 ± 0.07 km). Medical supplies were delivered successfully within 1m of the target. The drone successfully returned to the starting point every flight. Resupply by foot would take 5.1 hours with an average speed of 2.4km/h and 61.35 minutes, with an average speed of 12 km/h for a wheeled vehicle, if a rudimentary road existed. Conclusion: Use of unmanned drones is feasible for delivery of life-saving medical supplies in austere environments. Drones repeatedly and accurately delivered medical supplies faster than other methods without additional risk to personnel or manned airframe. This technology may have benefit for austere care of military and civilian casualties.
Keywords: drone; prolonged field care; medical supplies; delivery; austere environments
Avila CO, Sayson SC, Bennett B. 22(3). 19 - 21. (Journal Article)
Abstract
Introduction: Military medical research has affirmed that early administration of blood products and timely treatment save lives. The US Navy's Expeditionary Resuscitative Surgical System (ERSS) is a Role 2 Light Maneuver team that functions close to the point of injury, administering blood products and providing damage-control resuscitation and surgery. However, information is lacking on the logistical constraints regarding provisions for and the stability of blood products in austere environments. Methods: ERSS conducted a study on the United States Central Command (USCENTCOM) area of responsibility. Expired but properly stored units of stored whole blood (SWB) were subjected to five different storage conditions, including combinations of passive and active refrigeration. The SWB was monitored continuously, including for external ambient temperatures. The time for the SWB to rise above the threshold temperature was recorded. Results: The main outcome of the study was the time for the SWB to rise above the recommended storage temperature. Average ambient temperature during the experiment involving conditions 1 through 4 was 25.6°C (78.08°F). Average ambient temperature during the experiment involving condition 5 was 34.8°C (94.64°F). Blood temperature reached the 6°C (42.8°F) threshold within 90 minutes in conditions 1 and 2, which included control and chemically activated ice packs in the thermal insulated chamber (TIC). Condition 2 included prechilling the TIC in a standard refrigerator to 4°C (39.2°F), which kept the units of SWB below the threshold temperature for 490 minutes (approximately 8 hours). Condition 4 entailed prechilling the TIC in a standard freezer to 0.4°C (32.72°F), thus keeping the units of SWB below threshold for 2,160 minutes (i.e., 36 hours). Condition 5 consisted of prechilling the TIC to 3.9°C (39.02°F) in the combat blood refrigerator, which kept the SWB units below the threshold for 780 minutes (i.e., 13 hours), despite a higher average ambient temperature of almost +10°C (50°F). Conclusion: Combining active and passive refrigeration methods will increase the time before SWB rises above the threshold temperature. We demonstrate an adaptable approach of preserving blood product temperature despite refrigeration power failure in austere settings, thereby maintaining mission readiness to increase the survival of potential casualties.
Keywords: stored whole blood; forward deployed surgical team; austere environments; walking blood bank; fresh whole blood; Role 2 care; blood transfusion; Golden Hour Offset Surgical Team
Walker S, Agree O, Harris R, DesRosiers TT. 23(2). 49 - 54. (Journal Article)
Abstract
Introduction: Timely vascular access is critical, as hemorrhage is the number one cause of death on the battlefield. Anecdotal evidence in the Military Health System identified an operationally relevant procedural skills gap in vascular access, and data exist in civilian literature showing high rates of iatrogenic injuries when lack of robust procedural opportunity exists. Multiple pre-deployment training courses are available for surgical providers, but no comprehensive pre-deployment vascular access training exists for non-surgical providers. Methods: This mixed-method review aimed to find relevant, operationally focused, vascular access training publications. A literature review was done to identify both relevant military clinical practice guidelines (CPGs) and full text articles. Reviewers also investigated available pre-deployment trainings for both surgeons and non-surgeons in which course administrators were contacted and details regarding the courses were described. Results: We identified seven full-text articles and four CPGs. Two existing surgical training programs and Army, Navy, and Air Force pre-deployment training standards for non-surgeons were evaluated. Conclusion: A cost-effective and accessible pre-deployment curriculum utilizing reviewed literature in a "learn, do, perfect" structure is suggested, building on pre-existing structures while incorporating remotely accessible didactics, hands-on practice with portable simulation models, and live-feedback training.
Keywords: vascular access; military medicine; arterial access; arterial line; central venous access; central line; IV; intravenous; literature review; training, military; deployed medicine; simulation training; austere environments; emergency medical care
Nam JJ, Milia DJ, Diamond SR, Gourlay DM. 19(3). 117 - 121. (Journal Article)
Abstract
Theater Special Operations Force (SOF) medical planners have been using Army forward surgical teams (FSTs) to maintain a golden hour for US SOF during Operation Freedom's Sentinel in the form of Golden Hour Offset Surgical Treatment Teams (GHOST-Ts) in Afghanistan. Recently, the Special Operations Resuscitation Team (SORT) was designed to decompress and augment a GHOST-T to help extend a golden hour ring in key strategic locations. This article describes both teams working together in Operation Freedom's Sentinel while deployed in support of SOF in central Afghanistan during the summer fighting season.
Keywords: prolonged field care; austere medicine; military medicine; damage control resuscitation; damage control surgery
Staak BP, DeSoucy ES, Petersen CD, Smith J, Hartman M, Rush SC. 20(3). 135 - 140. (Journal Article)
Abstract
Best practices and training for prolonged field care (PFC) are evolving. The New York Pararescue Team has used part task training, cadaver labs, clinical rotations, and a complicated sim lab to prepare for PFC missions including critical care. This report details an Atlantic Ocean nighttime parachute insertion to provide advanced burn care to two sailors with 50% and 60% body surface area burns. Medical mission planning included pack-out of ventilators, video laryngoscopes, medications, and 50 L of lactated Ringer's (LR). Over the course of 37 hours, the patients required high-volume resuscitation, analgesia, wound care, escharotomies, advanced airway and ventilator management, continuous sedation, telemedicine consultation, and complicated patient movement during evacuation. A debrief survey was obtained from the Operators highlighting recommendation for more clinical rotations and labs, missionspecific pack-outs, and tactical adjustments. This historic mission represents the most sophisticated PFC ever performed by PJs and serves to validate and share our approach to PFC.
Keywords: prolonged field care; military medicine; austere medicine; burns; critical care
DeSoucy ES, Hewitt CW, Bolleter S. 22(1). 81 - 86. (Journal Article)
Abstract
Background: Acute compartment syndrome (ACS) following extremity trauma requires rapid fasciotomy to avoid significant morbidity and limb loss. Four-compartment fasciotomy of the leg is a surgical procedure typically performed in the operating room; however, casualties who cannot be rapidly transported may need fasciotomies in the prehospital setting. In the absence of traditional operating instruments (e.g., scalpel, long Metzenbaum scissors, electrocautery), alternative means of fasciotomy may be needed. We undertook a proof-of-concept study using cadaver models to determine whether leg fasciotomies could be performed with alternative devices compared with the surgical standard. Methods: Two-incision, four-compartment fasciotomies were performed on fresh, never-frozen, non-embalmed cadaver legs using a scalpel for the initial skin incision, followed by release of the fascia using one of the following instruments: 5.5-in curved Mayo scissors; Benchmade rescue hook (model BM-5BLKW); rescue hook on the Leatherman Raptor multitool (model 831741-FFP); Leatherman Z-Rex multitool rescue hook (model LM93408); or No. 10 PenBlade (model PB-M-10- CAS). The procedures were performed by a surgeon. Skin and fascia incisional lengths were recorded along with a subjective impression of the performance for each device. Post-procedural dissection was performed to identify associated injuries to the muscle, superficial peroneal nerve, and the greater saphenous vein (GSV). Results: All devices were able to adequately release the fascia in all four compartments. All rescue hooks (Benchmade, Raptor, and Z-Rex) required a "pull technique" and a skin incision of equal length to the fascia incision. The PenBlade was used in a "push technique," similar to the standard scissor fasciotomy through a smaller skin incision. There was one superficial peroneal nerve transection with the rescue hooks, but there were no GSV injuries or significant muscle damage with any instrument. Conclusion: Four-compartment fasciotomy can be performed with readily available alternative equipment such as rescue hooks and the PenBlade. Hook-type devices require longer skin incisions compared with scissors and the PenBlade. In contested environments, patients with ACS may require fasciotomy prior to evacuation to surgical teams; training combat medics in the use of these alternative instruments in the field may preserve life and limb.
Keywords: fasciotomy; austere medicine; compartment syndrome; combat casualty care
True NA, Siler S, Manning JE. 13(2). 33 - 37. (Journal Article)
Abstract
Novel aortic catheter-based resuscitation interventions aimed at control of noncompressible torso hemorrhage and resuscitative perfusion are undergoing active research and development. These methods have been reported as resuscitative endovascular balloon occlusion of the aorta, selective aortic arch perfusion, and profound hypothermia (emergency preservation and resuscitation). These interventions are advanced options to treat noncompressible torso hemorrhage and hemorrhage-induced traumatic cardiac arrest in the presurgical environment. However, to achieve maximum potential benefit, such interventions need to be initiated as soon as possible. This means that these advanced interventions should be adapted for use in austere military treatment facilities and, when feasible, initiated at the point of injury. This report argues for the feasibility of advanced endovascular resuscitation interventions in the austere military theater.
Keywords: resuscitation; traumatic hemorrhage; noncompressible torso hemorrhage; traumatic cardiac arrest; technology; austere setting; hemorrhagic shock
Hale DF, Sexton JC, Benavides LC, Benavides JM, Lundy JB. 17(3). 40 - 45. (Journal Article)
Abstract
Background: The deployment of surgical assets has been driven by mission demands throughout years of military operations in Iraq and Afghanistan. The transition to the highly expeditious Golden Hour Offset Surgical Transport Team (GHOST- T) now offers highly mobile surgical assets in nontraditional operating rooms; the content of the surgical instrument sets has also transformed to accommodate this change. Methods: The 102nd Forward Surgical Team (FST) was attached to Special Operations assigned to southern Afghanistan from June 2015 to March 2016. The focus was to decrease overall size and weight of FST instrument sets without decreasing surgical capability of the GHOST-T. Each instrument set was evaluated and modified to include essential instruments to perform damage control surgery. Results: The overall number of main instrument sets was decreased from eight to four; simplified augmentation sets have been added, which expand the capabilities of any main set. The overall size was decreased by 40% and overall weight decreased by 58%. The cardiothoracic, thoracotomy, and emergency thoracotomy trays were condensed to thoracic set. The orthopedic and amputation sets were replaced with an augmentation set of a prepackaged orthopedic external fixator set). An augmentation set to the major or minor basic sets, specifically for vascular injuries, was created. Conclusion: Through the reorganization of conventional FST surgical instrument sets to maintain damage control capabilities and mobility, the 102nd GHOST-T reduced surgical equipment volume and weight, providing a lesson learned for future surgical teams operating in austere environments.
Keywords: austere surgery; forward surgical team; Golden Hour Offset Surgical Treatment Team (GHOST-T)
Benavides JM, Benavides LC, Hale DF, Lundy JB. 17(3). 46 - 50. (Journal Article)
Abstract
Theater Special Operations Force (SOF) medical planners have begun using Army Forward Surgical Teams (FSTs) to maintain a golden hour for U.S. SOF during Operation Freedom's Sentinel required adaptation in FST training, configuration, personnel, equipment, and employment to form Golden Hour Offset Surgical Treatment Teams (GHOST-Ts). This article describes one such FST's experience in Operation Freedom's Sentinel while deployed for 9 months in support of SOF in southern Afghanistan.
Keywords: Golden Hour Offset Surgical Treatment Team (GHOST-T); austere surgery
Bowman M, Ashbaucher J, Cohee B, Fisher MS, Jennette JB, Huse JD, Copeland C, Muir KB. 19(4). 85 - 87. (Journal Article)
Abstract
US Special Operations Forces work by, with, and through partner forces (PFs) to accomplish mutual objectives. Surgical teams support these forces directly and may assist in treating injuries sustained by PF, based on established medical rules of engagement. These surgical operations are often conducted in austere conditions, with limited access to blood products. Limited blood product availability decreases US medical capacity to resuscitate injured PFs and augment the local trauma system. We present an innovative solution used by an expeditionary resuscitative surgical team (ERST) and Special Operations civil affairs team to partner with host nation (HN) medical personnel to improve PF access to damage control resuscitation and surgery. Whole blood obtained through a local HN hospital was provided to the ERST to allow for increased capacity to resuscitate PF casualties and augment the local trauma system. The ERST subsequently used this blood to resuscitate two PF surgical casualties.
Keywords: walking blood bank; stored whole blood; austere surgical team; US military
Dilday J, Sirkin MR, Wertin T, Bradley F, Hiles J. 18(1). 29 - 31. (Case Reports)
Abstract
The current forward surgical team (FST) operating table is heavy and burdensome and hinders essential movement flexibility. A novel attachable rail system, the Shrail, has been developed to overcome these obstacles. The Shrail turns a North Atlantic Treaty Organization litter into a functional operating table. A local FST compared the assembly of the FST operating table with assembling the Shrail. Device weight, storage space, and assembly space were directly measured and compared. The mean assembly time required for the Shrail was significantly less compared with the operating table (23.36 versus 151.6 seconds; p ≤ .01). The Shrail weighs less (6.80kg versus 73.03kg) and requires less storage space (0.019m3 versus 0.323m3) compared with the current FST operating table. The Shrail provides an FST with a faster, lighter surgical table assembly. For these reasons, it is better suited for the demands of an FST and the implementation of prolonged field care.
Keywords: Shrail; litter; operating table; prolonged field care; austere, military
Donham B, Barbee GA, Deaton TG, Kerr W, Wier RP, Fisher AD. 19(3). 24 - 25. (Journal Article)
Abstract
Fresh whole blood (FWB) is increasingly being recognized as the ideal resuscitative fluid for hemorrhagic shock. Because of this, military units are working to establish the capability to give FWB from a walking blood bank donor in environments that are unsupported by conventional blood bank services. Therefore, many military units are performing autologous blood transfusion training. In this training, a volunteer has a unit of blood collected and then transfused back into the same donor. The authors report their experience performing an estimated 3408 autologous transfusions in training and report no instances of hemolytic transfusion reactions or other major complications. With appropriate control measures in place, autologous FWB training is low-risk training.
Keywords: military personnel; blood transfusion; autologous; simulation training
Calvano CJ, Enzenauer RW, Wenkel JW, Henke JL, Rohrbough CK, Miller SL, Howerton PH, Schreffler JP. 14(2). 9 - 13. (Journal Article)
Abstract
Eye injuries are common in forward areas of operations. Definitive diagnosis and care may be limited not by provider skill but rather by available equipment. The ability to treat simple trauma such as corneal foreign bodies at the Role 1 level has advantages including rapid return to duty, decreased cost of treatment, and, most important, decreased risk of delayed care. We propose the device such as a hand-held portable slit lamp should be made available for appropriate Special Operations Medical Forces (SOFMED) or aviation providers.
Keywords: ocular; trauma; slit lamp; Role 1; aviation; Special Forces medicine
McIntire S, Boujie L, Leasiolagi J. 16(3). 11 - 14. (Journal Article)
Abstract
Injuries involving rupture of the pectoralis major are relatively rare. When they do occur, it is mostly frequently in a young, athletic man. The most common cause is weight lifting that results in eccentric muscle contraction (muscle contraction against an overbearing force, leading to muscle lengthening)-specifically, the bench press. Other mechanisms for this injury include forceful abduction and external rotation of the arm. Injury can occur anywhere along the pectoralis major from its medial origin on the sternum and clavicle to its lateral tendinous insertion on the humerus. At the time of injury, patients may report feeling a tearing sensation or hearing a pop, with immediate onset of pain. Physical examination findings can include a deformed appearance of the chest, ecchymosis of the chest and upper arm, pain and weakness with arm adduction and internal rotation, or noticeable asymmetry of the anterior axilla with arm abduction. Magnetic resonance imaging is the imaging study of choice to aid diagnosis. In a young and active population, such as the Special Operations community, appropriate and timely diagnosis is important because surgical intervention often is recommended. This report presents the case of an active-duty Servicemember who sustained a pectoralis major injury while exiting an aircraft during the Basic Airborne Course.
Keywords: pectoralis major; rupture; avulsion; tear; airborne; parachute; static line
Sardianos D, Boland J. 19(2). 118 - 121. (Journal Article)
Abstract
Technology has become a necessity in modern society, providing capabilities that have never been experienced before. The integration of such capabilities arms today's Special Operations medic with abilities that can make a vast difference to the survivability rate of an ill or injured patient. Taking advantage of new technological capabilities such as advanced monitoring and diagnostics and portable ultrasound also plays a key role; together with the evolution in modern communication.
Keywords: technology; awareness; ultrasound; telemedicine; NATO; Special Operations Combat Medic; NSOCM
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
Gyo M. 17(3). 95 - 99. (Journal Article)
Abstract
The Back Pack Health Worker Team (BPHWT), a community- based health organization, provides primary health care to ethnic people in conflict, remote, and internally displaced areas, in Burma (aka Myanmar), controlled by ethnic armed organizations fighting against the Burma government. Its services include both curative and preventative health care through a network of 1,425 health personnel including community health workers and village-embedded traditional birth attendants and village health workers. The BPHWT organizational and program model may prove useful to Special Operations medical actions in support of insurgent movements and conversely with a host nation's counterinsurgency strategies, which include the extension of its health services into areas that may be remote and/or inhabited by indigenous people and have insurgency potential. In the former respect, special attention is directed toward "humanitarian struggle" that uses health care as a weapon against the counterinsurgency strategies of a country's oppressive military.
Keywords: Back Pack Health Worker Team; Burma; health care; humanitarianism
Wagner C, Davis G, Donato M, Bedard P, Bridwell R. 24(2). 73 - 77. (Case Reports)
Abstract
Lumbar paraspinal muscle compartment syndrome is an uncommon, rapidly progressive, and potentially devastating injury with fewer than 40 cases reported in the literature. It initially mimics nonemergent causes of low back pain, disproportionately affects young men, and is most often secondary to acute physical exertion. The disease process is commonly associated with rhabdomyolysis. Diagnostic tools include physical examination, measurement of lactate and creatine kinase levels, MRI, and direct compartment pressure measurement. While medical and nonoperative management strategies have been explored, the gold standard for treatment is emergent lumbar fasciotomy. Opioid and non-steroidal pain management, as well as physical therapy, are the mainstays of post-treatment recovery, with many surgical patients reporting complete symptom resolution at long-term follow-up. This article discusses the case of a 27-year-old, male, active-duty, Special Operations Aviation Soldier who presented to the emergency department and was found to have lumbar paraspinal muscle compartment syndrome.
Keywords: lumbar; paraspinal; compartment syndrome; back pain; rhabdomyolysis; fasciotomy
Lundy JB, Sparkman BK, Sleeter JJ, Steinberger Z, Remick KN. 21(4). 118 - 123. (Journal Article)
Abstract
The authors describe an equipment list for an ultramobile, surgeon-carried equipment set that is specifically designed for missions that require the extremes of constraints on personnel and resources conducted outside the ring of golden hour access to damage control surgery (DCS) capabilities.
Keywords: damage control surgery; damage control resuscitation; surgical equipment; austere; packing; pack; backpack; trauma; surgeon; surgery
Bridwell RE, Carius BM, Oliver JJ. 19(4). 19 - 21. (Case Reports)
Abstract
Shewanella algae is a unique bacterium largely documented in skin and soft tissue infections (SSTIs) with a wide range of presentations from gas-producing necrotizing fasciitis to osteomyelitis. Seawater exposure to lower extremity ulcers and wounds is most often correlated with infection, which has been documented in causing complications of bacteremia, sepsis, and infective endocarditis. Further complicating treatment is poor response to most empiric regimens prior to definitive diagnosis and an uneven response to antibiotics, including documented resistance to carbapenem. This case documents the presentation of a Basic Underwater Demolition SEAL (BUD/S) training candidate who presented acutely for complaints of severe lower body swelling and abrasions during "Hell Week" and was found to have polymicrobial bacteremia with Staphylococcus aureus, Enterococcus, and S algae.
Keywords: Shewanella algae; bacteremia; military training; underwater
Washington M, 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
Anonymous A. 21(4). 104 - 105. (Journal Article)
Abstract
The Centers for Disease Control and Prevention warned that two people are dead and two have recovered after being infected with the bacterial disease melioidosis - a disease that had never before been detected on contiguous US soil. The cases occurred between March and July 2021 in Georgia, Kansas, Texas, and Minnesota. Melioidosis, also called Whitmore's disease, is an infectious disease that can infect humans or animals. The disease is caused by the bacterium Burkholderia pseudomallei. It is predominately a disease of tropical climates, especially in Southeast Asia and northern Australia where it is widespread.
Keywords: bacteria; melioidosis; contaminated source; Whitmore's disease; Burkholderia pseudomallei
Washington M, Kajiura L, Leong MK, Agee W, Barnhill JC. 15(1). 100 - 104. (Journal Article)
Abstract
Staphylococcus sciuri is an emerging gram-positive bacterial pathogen that is infrequently isolated from cases of human disease. This organism is capable of rapid conversion from a state of methicillin sensitivity to a state of methicillin resistance and has been shown to express a set of highly effective virulence factors. The antibioticresistance breakpoints of S. sciuri differ significantly from the more common Staphylococcus species. Therefore, the rapid identification of S. sciuri in clinical material is a prerequisite for the proper determination of the antibiotic- resistance profile and the rapid initiation of antimicrobial therapy. Here, we present a brief literature review of S. sciuri and an entomological case study in which we describe the colonization of an American cockroach with this agent. In addition, we discuss potential implications for the distribution and evolution of antibiotic- resistant members of the genus Staphylococcus.
Keywords: bacteriology; entomology; operating environment; preventive medicine
Washington MA, Farrell J, Meany J, Chow W. 21(4). 22 - 24. (Journal Article)
Abstract
Processionary caterpillars are well-described threats to human and animal health. They are found throughout Central Asia, Northern Africa, and Southern Europe. However, US military personnel may not be familiar with the threat that these organisms pose in Australia. The larval form of the bag-shelter moth (Ochrogaster lunifer) is a processionary caterpillar that has been found throughout inland and coastal Australia. These organisms are habitually associated with Acacia and Eucalyptus trees and they tend to form long chains known as "processions" as they travel between nesting and pupating sites. They are covered with numerous hairs that can detach, become airborne, and cause potentially life-threatening inflammatory reactions and ocular trauma in susceptible personnel. They can also cause severe inflammatory reactions in military working animals. It is important that military and preventive medical personnel become aware of the presence of processionary caterpillars in Australia, and that they can identify aerial or ground-based nests so that these dangerous organisms can be avoided by both humans and animals. Early identification is important so that prompt medical treatment can be rendered in the event of an accidental exposure.
Keywords: entomology; military animals; bag-shelter moth; Ochrogaster lunifer; processionary caterpillar
Costello JT, Allen PB, Levesque R. 17(3). 59 - 63. (Journal Article)
Abstract
Background: Excessive ventilation of sick and injured patients is associated with increased morbidity and mortality. Combat Medical Systems® (CMS) is developing a new bag-valve-mask (BVM) designed to limit ventilation rates. The purpose of this study was to compare ventilation rates between a standard BVM device and the CMS device. Methods: This was a prospective, observational, semirandomized, crossover study using Army Medics. Data were collected during Brigade Combat Team Trauma Training classes at Camp Bullis, Texas. Subjects were observed during manikin simulation training in classroom and field environments, with total duration of manual ventilation and number of breaths given recorded for each device. Analysis was performed on overall ventilation rate in breaths per minute (BPM) and also by grouping the subjects by ventilation rates in low, correct, and high groups based on an ideal rate of 10-12 BPM. Results: A total of 89 Medics were enrolled and completed the classroom portion of the study, with a subset of 36 evaluated in the field. A small but statistically significant difference in overall BPM between devices was seen in the classroom (ρ < .001) but not in the field (ρ > .05). The study device significantly decreased the incidence of high ventilation rates when compared by groups in both the classroom (ρ < .001) and the field (ρ = .044), but it also increased the rate of low ventilation rates. Conclusion: The study device effectively reduced rates of excessive ventilation in the classroom and the field.
Keywords: bag-valve-mask; BVM; hyperventilation; hemorrhage; traumatic brain injury; TBI; prehospital trauma
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
Stopyra JP, Bozeman WP, Callaway DW, Winslow J, McGinnis HD, Sempsrott J, Evans-Taylor L, Alson RL. 16(3). 36 - 40. (Journal Article)
Abstract
There is some controversy about whether ballistic protective equipment (body armor) is required for medical responders who may be called to respond to active shooter mass casualty incidents. In this article, we describe the ongoing evolution of recommendations to optimize medical care to injured victims at such an incident. We propose that body armor is not mandatory for medical responders participating in a rapid-response capacity, in keeping with the Hartford Consensus and Arlington Rescue Task Force models. However, we acknowledge that the development and implementation of these programs may benefit from the availability of such equipment as one component of risk mitigation. Many police agencies regularly retire body armor on a defined time schedule before the end of its effective service life. Coordination with law enforcement may allow such retired body armor to be available to other public safety agencies, such as fire and emergency medical services, providing some degree of ballistic protection to medical responders at little or no cost during the rare mass casualty incident. To provide visual demonstration of this concept, we tested three "retired" ballistic vests with ages ranging from 6 to 27 years. The vests were shot at close range using police-issue 9mm, .40 caliber, .45 caliber, and 12-gauge shotgun rounds. Photographs demonstrate that the vests maintained their ballistic protection and defeated all of these rounds.
Keywords: body armor; ballistics; active shooter; active assailant; mass-casualty event
Cantle PM, Hurley MJ, Swartz MD, Holcomb JB. 18(2). 98 - 104. (Journal Article)
Abstract
Background: Noncompressible truncal hemorrhage (NCTH) after injury is associated with a mortality increase that is unchanged during the past 20 years. Current treatment consists of rapid transport and emergent intervention. Three early hemorrhage control interventions that may improve survival are placement of a resuscitative endovascular balloon occlusion of the aorta (REBOA), injection of intracavitary self-expanding foam, and application of the Abdominal Aortic Junctional Tourniquet (AAJT™). The goal of this work was to ascertain whether patients with uncontrolled abdominal or pelvic hemorrhage might benefit by the early or prehospital use of one of these interventions. Methods: This was a single-center retrospective study of patients who received a trauma laparotomy from 2013 to 2015. Operative reports were reviewed. The probable benefit of each hemorrhage control method was evaluated for each patient based on the location(s) of injury and the severity of their physiologic derangement. The potential scope of applicability of each control method was then directly compared. Results: During the study period, 9,608 patients were admitted; 402 patients required an emergent trauma laparotomy. REBOA was potentially beneficial for hemorrhage control in 384 (96%) of patients, foam in 351 (87%), and AAJT in 35 (9%). There was no statistically significant difference in the potential scope of applicability between REBOA and foam (ρ = .022). There was a significant difference between REBOA and AAJT (ρ < .001) and foam and AAJT™ (ρ < .001). The external surface location of signs of injury did not correlate with the internal injury location identified during laparotomy. Conclusion: Early use of REBOA and foam potentially benefits the largest number of patients with abdominal or pelvic bleeding and may have widespread applicability for patients in the preoperative, and potentially the prehospital, setting. AAJT may be useful with specific types of injury. The site of bleeding must be considered before the use of any of these tools.
Keywords: trauma; resuscitation; abdominal hemorrhage; foam; baloon aortic occlusion; junctional tourniquet
Hillis GR, Yi CJ, Amrani DL, Akers TW, Schwartz RB, Wedmore I, McManus JG. 14(4). 41 - 47. (Journal Article)
Abstract
Background: Uncontrolled hemorrhage remains one of the most challenging problems facing emergency medical professionals and a leading cause of traumatic death in both battlefield and civilian environments. Survival is determined by the ability to rapidly control hemorrhage. Several commercially available topical adjunct agents have been shown to be effective in controlling hemorrhage, and one, Combat Gauze™ (CG), is used regularly on the battlefield and for civilian applications. However, recent literature reviews have concluded that no ideal topical agent exists for all injuries and scenarios. The authors compared a novel nonimpregnated dressing composed of cellulose and silica, NuStat® (NS), to CG in a lethal hemorrhagic groin injury. These dressings were selected for their commercial availability and design intended for control of massive hemorrhage. Methods: A complex penetrating femoral artery groin injury was made using a 5.5mm vascular punch followed by 45 seconds of uncontrolled hemorrhage in 15 swine. The hemostatic dressings were randomized using a random sequence generator and then assigned to the animals. Three minutes of manual pressure was applied with each agent after the free bleed. Hextend™ bolus (500mL) was subsequently rapidly infused using a standard pressure bag along with the addition of maintenance fluids to maintain blood pressure. Hemodynamic parameters were recorded every 10 minutes and additionally at critical time points defined in the protocol. Primary end points included immediate hemostasis upon release of manual pressure (T0), hemostasis at 60 minutes, and rebleeding during the 60-minute observation period. Results: NS was statistically superior to CG in a 5.5mm traumatic hemorrhage model at T0 for immediate hemostasis (ρ = .0475), duration of application time (ρ = .0093), use of resuscitative fluids (ρ = .0042) and additional blood loss after application (ρ = .0385). NS and CG were statistically equivalent for hemostasis at 60 minutes, rebleeding during the study, and the additional secondary metrics, although the trend indicated that in a larger sample size, NS could prove statistical superiority in selected categories. Conclusions: In this porcine model of uncontrolled hemorrhage, NS improved immediate hemorrhage control, stability, and use of fluid in a 60-minute severe porcine hemorrhage model. In this study, NS demonstrated equivalence to CG at achieving long-term hemostasis and the prevention of rebleed after application. NS was shown to be an efficacious choice for hemorrhage control in combat and civilian emergency medical service environments.
Keywords: EMS; hemostatic dressing; hemorrhage, uncontrolled; hemorrhage, severe; traumatic injuries; NuStat; NS; CG; silica; bamboo; cellulose; Combat Gauze™; kaolin
Bennett BL, Littlejohn LF, Kheirabadi BS, Butler FK, Kotwal RS, Dubick MA, Bailey HH. 14(3). 40 - 57. (Journal Article)
Abstract
Hemorrhage remains the leading cause of combat death and a major cause of death from potentially survivable injuries. Great strides have been made in controlling extremity hemorrhage with tourniquets, but not all injuries are amenable to tourniquet application. Topical hemostatic agents and dressings have also contributed to success in controlling extremity and compressible junctional hemorrhage, and their efficacy continues to increase as enhanced products are developed. Since the addition of Combat Gauze™ (Z-Medica Corporation, Wallingford, CT, USA; http://www.z-medica.com/) in April 2008 to the Tactical Combat Casualty Care (TCCC) Guidelines, there are consistent data from animal studies of severe hemorrhage that chitosan-based hemostatic gauze dressings developed for battlefield application are, at least, equally efficacious as Combat Gauze. Successful outcomes are also reported using newer chitosan-based dressings in civilian hospitalbased surgical case reports and prehospital (battlefield) case reports and series. Additionally, there have been no noted complications or safety concerns in these cases or across many years of chitosan-based hemostatic dressing use in both the military and civilian prehospital sectors. Consequently, after a decade of clinical use, there is added benefit and a good safety record for using chitosan- based gauze dressings. For these reasons, many specific US military Special Operations Forces, NATO militaries, and emergency medical services (EMS) and law enforcement agencies have already implemented the widespread use of these new recommended chitosanbased hemostatic dressings. Based on the past battlefield success, this report proposes to keep Combat Gauze as the hemostatic dressing of choice along with the new addition of Celox™ Gauze (Medtrade Products Ltd., Crewe, UK; http://www.celoxmedical.com/usa/products /celox-gauze/) and ChitoGauze® (HemCon Medical Technologies, Portland, OR, USA; http://www.hemcon.com/) to the TCCC Guidelines.
Keywords: hemorrhage; hemostasis; hemostatic agents; topical; dressing; bandage
Kragh JF, Aden JK, Dubick MA. 20(3). 44 - 51. (Journal Article)
Abstract
Background: Given little data to assess guidelines, we sought a way to exchange one type of intervention, field tourniquet use, for another, use of a pressure dressing. The study purpose was to test performance of controlling simulated bleeding with a stepwise procedure of tourniquet conversion. Methods: An experiment was designed to assess 15 tests of a caregiver making tourniquet-dressing conversions. Tests were divided into trials: tourniquet use and its conversion. In laboratory conditions, the tourniquet trial was care under gunfire; then, the conversion trial was emergency healthcare. A HapMed Leg Tourniquet Trainer simulated a limb amputation. An investigator provided healthcare. Results: Mean (± standard deviation [SD]) test time and blood loss were 9 ± 3.6 minutes and 334 ± 353.9mL, respectively. The first test took 17 minutes. By test number, times decreased; the last six took ≤7 minutes. All tourniquet trials controlled bleeding. Mean (±SD) tourniquet pressure and blood loss were 222 ± 18.0mmHg and 146 ± 40.9mL, respectively. Bleeding remained uncontrolled in one conversion. Initial attempts to wrap a dressing were effective in 73% of tries (n = 11 of 15). Four of 15 wrap attempts (27%) were repeated to troubleshoot bleeding recurrence, and the first three tests required a repetition. Mean (±SD) dressing pressures and blood losses were 141 ± 17.6mmHg and 188 ± 327.4mL, respectively. Unsatisfactory conversion trials had a dressing pressure <137mmHg. Dressings and wraps hid the wound to impair assessment of bleeding. Conclusions: In testing a method of converting a limb tourniquet to a pressure dressing, the caregiver performed faster with experience accrual. The tourniquet results were uniformly good, but conversion results were worse and more varied. Simulating conversion was disappointing on a manikin and indicated that its redesign might be needed to suit this method. The procedural method constituted a start for further development.
Keywords: bleeding control and prevention; bandage; dressing, emergency; skill; tourniquet
George T, Jordan M, Bianchi W, Boboc M, Zarow GJ, Natarajan R, Walchak AC, Roszko PJ. 19(1). 89 - 94. (Journal Article)
Abstract
Background: Military forces render emergency care in marine environments, where care for exsanguination is challenging. However, the effect of saltwater on the functionality of hemostatic agents is unknown. In this study, we used thromboelastography (TEG) to quantify the effect of saltwater on the efficacy of five gauze products. Methods: Blood from 24 healthy adult men was diluted by 30% with hetastarch to mimic hemodilution. Dry and saltwater-soaked Kerlix™, ChitoGauze®, Combat Gauze®, NuStat™, and WoundClot™ were contrasted in terms of the TEG parameters of speed of clot initiation (R), clot amplification (K), α angle (i.e., clot formation rate), and maximum amplitude of clot (MA), using repeated-measures analysis of variance at the p < .05 statistical significance threshold. Results: Compared with untreated dilute blood, R was significantly faster when any dry or wet gauze was added, with the fastest R values recorded for Combat Gauze. K and α angle findings were mixed. MA was greater than diluted blood for dry hemostatic gauze, but in the wet condition, only the MA for Combat Gauze was significantly greater than that of diluted blood. Conclusion: Gauze products, wet or dry, improved clotting compared to diluted blood without gauze. Saltwater exposure did not significantly detract from this benefit. Our findings suggest that Combat Gauze may be the choice hemostatic gauze for maritime environments.
Keywords: thromboelastography; hemostatic agents; gauze; kaolin; chitosan; trauma; exsanguination; cellulose; hemodilution; military; hemostatics; bandages; hemorrhage; marine; seawater; coagulation; TEG
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
Rivard SS, Crandall ML, Gibbs NF. 14(1). 99 - 102. (Journal Article)
Abstract
Servicemembers are often exposed to extreme environments with sun exposure, often laying the foundation for future skin cancer. Basal cell carcinoma (BCC) is the most common of skin cancers. We present the case of a 36-year-old male active duty Seabee who presents with a left shoulder plaque that initially started as an erythematous papule but has now increased to greater than 6cm in the past 10 years and is diagnosed as giant basal cell carcinoma (GBCC). Although only 0.5% to 1% of BCCs develop into GBCCs, there is the potential for metastasis and even death. This article addresses the concerning and potentially fatal diagnosis of GBCC, including your initial impressions and differential diagnoses, available treatment options, and ways to prevent it from ever occurring in our military population.
Keywords: basal cell carcinoma; giant basal cell carcinoma; enlarging plaque; electrodessication and curettage; UV damage; sun exposure; Seabee; military provider
Amodt ZT. 13(4). 6 - 11. (Journal Article)
Abstract
Military forces have missions that send them all over the globe. With the reemergence of bed bugs worldwide, the possibility of Servicemembers encountering them has increased. Special Operations Forces are often sent to locations that may not have integrated pest management support. Knowing how to identify and manage a bed bug infestation, with and without proper equipment and supplies, may become necessary in the very near future. It is also important that Servicemembers are aware of how bed bugs travel, to prevent their dispersal back to the United States and into their barracks and homes.
Keywords: bed bugs; bat bugs; infestations; austere environments; pest management
Janak J, Kotwal RS, Howard JT, Gurney J, Eastridge BJ, Holcomb JB, Shackelford SA, De Lorenzo RA, Stewart IJ, Mazuchowski EL. 24(2). 11 - 16. (Journal Article)
Abstract
Aggregate statistics can provide intra-conflict and inter-conflict mortality comparisons and trends within and between U.S. combat operations. However, capturing individual-level data to evaluate medical and non-medical factors that influence combat casualty mortality has historically proven difficult. The Department of Defense (DoD) Trauma Registry, developed as an integral component of the Joint Trauma System during recent conflicts in Afghanistan and Iraq, has amassed individual-level data that have afforded greater opportunity for a variety of analyses and comparisons. Although aggregate statistics are easily calculated and commonly used across the DoD, other issues that require consideration include the impact of individual medical interventions, non-medical factors, non-battle-injured casualties, and incomplete or missing medical data, especially for prehospital care and forward surgical team care. Needed are novel methods to address these issues in order to provide a clearer interpretation of aggregate statistics and to highlight solutions that will ultimately increase survival and eliminate preventable death on the battlefield. Although many U.S. military combat fatalities sustain injuries deemed non-survivable, survival among these casualties might be improved using primary and secondary prevention strategies that prevent injury or reduce injury severity. The current commentary proposes adjustments to traditional aggregate combat casualty care statistics by integrating statistics from the DoD Military Trauma Mortality Review process as conducted by the Joint Trauma System and Armed Forces Medical Examiner System.
Keywords: combat casualty care statics; injury survivability mortality; trauma; battle injury; disease, non-battle injury
Johnson D, Dial J, Ard J, Yourk T, Burke E, Paine C, Gegel B, Burgert J. 14(1). 79 - 85. (Journal Article)
Abstract
Introduction: The military recommends that a 500mL bolus of Hextend® be administered via an intravenous (IV) 18-gauge needle or via an intraosseous (IO) needle for patients in hypovolemic shock. Purposes: The purposes of this study were to compare the time of administration of Hextend and the hemodynamics of IV and IO routes in a Class II hemorrhage swine model. Methods: This was an experimental study using 27 swine. After 30% of their blood volume was exsanguinated, 500mL of Hextend was administered IV or IO, but not to the control group. Hemodynamic data were collected every 2 minutes until administration was complete. Results: Time for administration was not significant (p = .78). No significant differences existed between the IO and IV groups relative to hemodynamics (p > .05), but both were significantly different than the control group (p < .05). Conclusions: The IO route is an effective method of administering Hextend.
Keywords: hemorrhage; shock; Hextend®; hetastarch; battlefield
Reva VA, Pochtarnik AA, Shelukhin DA, Skvortzov AE, Semenov EA, Emelyanov AA, Nosov AM, Demchenko KN, Reznik ON, Samokhvalov IM, DuBose JJ. 20(4). 77 - 83. (Journal Article)
Abstract
Purpose: To evaluate the feasibility of prehospital extracorporeal cardiopulmonary resuscitation (E-CPR) in the military exercise setting. Methods: Three 40kg Sus scrofa (wild swine) underwent controlled 35% blood loss and administration of potassium chloride to achieve cardiac arrest (CA). During CPR, initiated 1 minute after CA, the animals were transported to Role 1. Femoral vessels were cannulated, followed by E-CPR using a portable perfusion device. Crystalloid and blood transfusions were initiated, followed by tactical evacuation to Role 2 and 4-hour observation. Results: All animals developed sustained asystole. Chest compressions supported effective but gradually deteriorating blood circulation. Two animals underwent successful E-CPR, with restoration of perfusion pressure to 80mmHg (70-90mmHg) 25 and 23 minutes after the induction of CA. After transportation to Role 2, one animal developed abdominal compartment syndrome as a result of extensive (9L) fluid replacement. The other animal received a lower volume of crystalloids (4L), and no complications occurred. In the third animal, multiple attempts to cannulate arteries were unsuccessful because of spasm and hypotension. Open aortic cannulation enabled the circuit to commence. No return of spontaneous circulation was ultimately achieved in either of the remaining animals. Conclusion: Our study demonstrates both the potential feasibility of battlefield E-CPR and the evolving capability in the care of severey injured combat casualties.
Keywords: conbat trauma; extracorporeal membrane oxygenation; endovascular; battlefield; cardiac arrest; cardiopulmonary resuscitation
Butler FK, Kotwal RS, Buckenmaier CC, Edgar EP, O'Connor KC, Montgomery HR, Shackelford SA, Gandy JV, Wedmore I, Timby JW, Gross K, Bailey JA. 14(1). 13 - 25. (Journal Article)
Abstract
Although the majority of potentially preventable fatalities among U.S. combat forces serving in Afghanistan and Iraq have died from hemorrhagic shock, the majority of U.S. medics carry morphine autoinjectors for prehospital battlefield analgesia. Morphine given intramuscularly has a delayed onset of action and, like all opioids, may worsen hemorrhagic shock. Additionally, on a recent assessment of prehospital care in Afghanistan, combat medical personnel noted that Tactical Combat Casualty Care (TCCC) battlefield analgesia recommendations need to be simplified-there are too many options and not enough clear guidance on which medication to use in specific situations. They also reported that ketamine is presently being used as a battlefield analgesic by some medics in theater with good results. This report proposes that battlefield analgesia be achieved using one or more of three options: (1) the meloxicam and Tylenol in the TCCC Combat Pill Pack for casualties with relatively minor pain who are still able to function as effective combatants; (2) oral transmucosal fentanyl citrate (OTFC) for casualties who have moderate to severe pain, but who are not in hemorrhagic shock or respiratory distress and are not at significant risk for developing either condition; or (3) ketamine for casualties who have moderate to severe pain but who are in hemorrhagic shock or respiratory distress or are at significant risk for developing either condition. Ketamine may also be used to increase analgesic effect for casualties who have previously been given opioids (morphine or fentanyl.)
Keywords: battlefield analgesia; fentanyl; ketamine; morphine
Ross EM, Redman TT. 18(1). 37 - 43. (Case Reports)
Abstract
Background: Noncompressible junctional and truncal hemorrhage remains a significant cause of combat casualty death. Resuscitative endovascular balloon occlusion of the aorta (REBOA) is an effective treatment for many junctional and noncompressible hemorrhages. The current hospital standard for time of placement of REBOA is approximately 6 minutes. This study examined the training process and the ability of nonsurgical physicians to apply REBOA therapy in an austere field environment. Methods: This was a skill acquisition and feasibility study. The participants for this experiment were two board-certified military emergency medicine physicians with no prior endovascular surgery exposure. Both providers attended two nationally recognized REBOA courses for training. A perfused cadaver model was developed for the study. Each provider then performed REBOA during different phases of prehospital care. Time points were recorded for each procedure. Results: There were 28 REBOA catheter placement attempts in 14 perfused cadaver models in the nonhospital setting: eight placements in a field setting, eight placements in a static ambulance, four placements in a moving ambulance, and eight placements inflight on a UH-60 aircraft. No statistically significant differences with regard to balloon inflation time were found between the two providers, the side where the catheter was placed, or individual cadaver models. Successful placement was accomplished in 85.7% of the models. Percutaneous access was successful 53.6% of the time. The overall average time for REBOA placement was 543 seconds (i.e., approximately 9 minutes; median, 439 seconds; 95% confidence interval [CI], 429-657) and the average placement time for percutaneous catheters was 376 seconds (i.e., 6.3 minutes; 95% CI, 311-44 seconds) versus those requiring vascular cutdown (821 seconds; 95% CI, 655-986). Importantly, the time from the decision to convert to open cutdown until REBOA placement was 455 seconds (95% CI, 285-625). Conclusion: This study demonstrated that, with proper training, nonsurgical providers can properly place REBOA catheters in austere prehospital settings at speeds
Keywords: austere environments; noncompressable hemorrhage; resuscitative endovascular balloon occlusion of the aorta; battlefield REBOA; combat resuscitation team; prehospital REBOA; damage control resuscitation; helicopter REBOA; en route care REBOA
Gray J, Linklater DR, Johnston J, Donham B. 17(1). 46 - 53. (Journal Article)
Abstract
Pediatric trauma represents a notable proportion of casualties encountered by Combat medics, physician assistants, and physicians while in the deployed setting. Most of these resuscitation teams receive limited pediatric- specific training and suffer subsequent emotional stress due the perceived high-stakes nature of caring for gravely wounded children. Even when children survive long enough to arrive at combat support hospitals, there remain high risks for morbidity and mortality for many of them. There are numerous reports of the epidemiological characteristics of these pediatric patients, the common mechanisms of injury, the hospital lengths of stay, and calls for pediatric-specific equipment and specialist presence in-theatre. There is scant literature, however, on child-specific battlefield resuscitation and training for initial providers, and we believe that, with appropriately tailored pediatric resuscitation education and training strategies, there is some potential for a reduction in the morbidity and mortality associated with childhood combat injury.
Keywords: pediatrics; combat injury; battlefield resuscitation
Knight RM. 17(1). 72 - 75. (Journal Article)
Abstract
Resuscitative endovascular balloon occlusion of the aorta (REBOA) has a place in civilian trauma centers in the United States, and British physicians performed the first prehospital REBOA, proving the concept viable for civilian emergency medical service. Can this translate into battlefield REBOA to stop junctional hemorrhage and extend "golden hour" rings in combat? If yes, at what level is this procedure best suited and what does it entail? This author's perspective, after treating patients on the battlefield and during rotary wing evacuation, is that REBOA may have a place in prehospital resuscitation but patient and provider selection are paramount. The procedure, although simple in description, is quite complicated and can cause major physiologic changes best dealt with by experienced providers. REBOA is incapable of extending the golden hour limiting the procedure's utility.
Keywords: REBOA; resuscitative endovascular balloon occlusion of the aorta; battlefield resuscitation; junctional hemorrhage
Thompson P, Ciaraglia A, Handspiker E, Bjerkvig C, Bynum JA, Glassberg E, Gurney J, Hudson AJ, Jenkins DH, Nicholson SE, Strandenes G, Braverman MA. 23(2). 9 - 12. (Journal Article)
Abstract
Introduction: Tension pneumothorax (TPX) is the third most common cause of preventable death in trauma. Needle decompression at the fifth intercostal space at anterior axillary line (5th ICS AAL) is recommended by Tactical Combat Casualty Care (TCCC) with an 83-mm needle catheter unit (NCU). We sought to determine the risk of cardiac injury at this site. Methods: Institutional data sets from two trauma centers were queried for 200 patients with CT chest. Inclusion criteria include body mass index of =30 and age 18-40 years. Measurements were taken at 2nd ICS mid clavicular line (MCL), 5th ICS AAL and distance from the skin to pericardium at 5th ICS AAL. Groups were compared using Mann-Whitney U and chi-squared tests. Results: The median age was 27 years with median BMI of 23.8 kg/m2. The cohort was 69.5% male. Mean chest wall thickness at 2nd ICS MCL was 38-mm (interquartile range (IQR) 32-45). At 5th ICS AAL, the median chest wall thickness was 30-mm (IQR 21-40) and the distance from skin to pericardium was 66-mm (IQR 54-79). Conclusion: The distance from skin to pericardium for 75% of patients falls within the length of the recommended needle catheter unit (83-mm). The current TCCC recommendation to "hub" the 83mm needle catheter unit has potential risk of cardiac injury.
Keywords: pneumothorax; needle thoracentesis; battlefield trauma
Montgomery HR, Butler FK, Kerr W, Conklin CC, Morissette DM, Remley MA, Shaw TA, Rich TA. 17(2). 21 - 38. (Classical Conference)
Abstract
Based on careful review of the Tactical Combat Casualty Care (TCCC) Guidelines, the authors developed a list of proposed changes for inclusion in a comprehensive change proposal. To be included in the proposal, individual changes had to meet at least one of three criteria: (1) The change was primarily tactical rather than clinical; (2) the change was a minor modification to the language of an existing TCCC Guideline; and (3) the change, though clinical, was straightforward and noncontentious. The authors presented their list to the TCCC Working Group for review and approval at the 7 September 2016 meeting of the Committee on Tactical Combat Casualty Care (CoTCCC). Twenty-three items met with general agreement and were retained in this change proposal.
Keywords: Tactical Combat Casualty Care; TCCC; T3; Tactical Combat Casualty Care guidelines; TCCC Guidelines Comprehensive Review and Update; battlefield trauma care; Role 1 Care
Greydanus DJ, Hassmann LL, Butler FK. 20(2). 95 - 103. (Journal Article)
Abstract
At present, however, there is no systematic, comprehensive quality assurance program for TCCC training throughout the DoD. Individual courses and instructors may or may not use all of the materials in the JTS-approved curriculum; they may or may not add content that is not part of the JTS curriculum; and they may or may not add additional training in the form of advanced simulation, hands-on training with moulaged casualties, graded trauma lanes, or live-tissue training. A recent pilot appraisal of four Tactical Combat Casualty Care for Medical Personnel (TCCC-MP) training courses found that TCCC-MP courses are not presenting all of the course material recommended by the Joint Trauma System (JTS), despite TCCC training having been mandated by the Department of Defense (DoD) for all US military personnel. Some of the omitted material is essential to ensuring that students are fully prepared to perform TCCC on the battlefield. Further, there was incorrect messaging presented in the TCCC-MP courses that were appraised, some of which, if actually reflected in the care provided on the battlefield, would likely result in adverse casualty outcomes. Other aspects of the TCCC messaging presented in the appraised courses that is not at present part of the JTS-approved curriculum might, however, be appropriate for inclusion into the TCCC Guidelines and the course curriculum. Examples of material that should be considered for incorporation into the TCCC curriculum include modifying the method of tranexamic acid (TXA) administration (slow IV push vs the currently recommended 10-minute infusion) and a better technique for securing of the new CAT Generation 7 tourniquets after application. The course appraiser also noted that there were a number of excellent videos of actual TCCC interventions being performed that are not part of the current JTS-approved TCCC-MP curriculum. These videos should be forwarded to CoTCCC staff and the Joint Trauma Education and Training (JTET) branch of the JTS for consideration as potential additions to the TCCC-MP curriculum. Consideration should also be given to the inclusion of additional TCCC training modalities such as advanced simulators, moulaged casualties, graded trauma lanes, autologous blood transfusion training, and the use of live-tissue training (when logistically feasible) for selected course items such as surgical airways. Further, the 16-hour training time currently allotted for TCCC-MP training was found to be insufficient to present all of academic material and testing contained in the existing TCCC-MP curriculum. A 5-day course should be considered to include the entire JTS-recommended curriculum and to add graded trauma lanes and autologous blood transfusion training to the core JTS TCCC-MP curriculum. The post-course written testing also needs to use the standardized TCCC fund of knowledge questions and the TCCC Critical Decision Case Study questions developed by the JTS. Finally, there is a need to establish a systematic and standardized quality assurance program to ensure that TCCC training programs are carried out in accordance with the JTS-recommended TCCC curriculum. This program would best be performed as a new function of the CoTCCC with dedicated TCCC course appraisers.
Keywords: Tactical Combat Casualty Care; TCCC; training; simulators; live tissue training; battlefield trauma care
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
Riesberg JC, Gurney JM, Morgan M, Northern DM, Onifer DJ, Gephart WJ, Remley MA, Eickhoff E, Miller C, Eastridge BJ, Montgomery HR, Butler FK, Drew B. 21(4). 138 - 142. (Classical Conference)
Abstract
Historically, about 20% of hospitalized combat injured patients have an abdominal injury. Abdominal evisceration may be expected to complicate as many as one-third of battle-related abdominal wounds. The outcomes for casualties with eviscerating injuries may be significantly improved with appropriate prehospital management. While not as extensively studied as other forms of combat injury, abdominal evisceration management recommendations extend back to at least World War I, when it was recognized as a significant cause of morbidity and was especially associated with bayonet injury. More recently, abdominal evisceration has been noted as a frequent result of penetrating, ballistic trauma. Initial management of abdominal evisceration for prehospital providers consists of assessing for and controlling associated hemorrhage, assessing for bowel content leakage, covering the eviscerated abdominal contents with a moist, sterile barrier, and carefully reassessing the patient. Mortality in abdominal evisceration is more likely to be secondary to associated injuries than to the evisceration itself. Attempting to establish education, training, and a standard of care for nonmedical and medical first responders and to leverage current wound management technologies, the Committee on Tactical Combat Casualty Care (CoTCCC) conducted a systematic review of historical Service guidelines and recent medical studies that include abdominal evisceration. For abdominal evisceration injuries, the following principles of management apply: (1) Control any associated bleeding visible in the wound. (2) If there is no evidence of spinal cord injury, allow the patient to take the position of most comfort. (3) Rinse the eviscerated bowel with clean fluid to reduce gross contamination. (4) Cover exposed bowel with a moist, sterile dressing or a sterile water-impermeable covering. It is important to keep the wound moist; irrigate the dressing with warm water if available. (4) For reduction in wounds that do not have a substantial loss of abdominal wall, a brief attempt may be made to replace/reduce the eviscerated abdominal contents. If the external contents do not easily go back into the abdominal cavity, do not force or spend more than 60 seconds attempting to reduce contents. If reduction of eviscerated contents is successful, reapproximate the skin using available material, preferably an adhesive dressing like a chest seal (other examples include safety pins, suture, staples, wound closure devices, etc.). Do not attempt to reduce bowel that is actively bleeding or leaking enteric contents. (6) If unable to reduce, cover the eviscerated organs with water-impermeable, nonadhesive material (transparent preferred to allow ability to reassess for ongoing bleeding; examples include a bowel bag, IV bag, clear food wrap, etc.), and then secure the impermeable dressing to the patient using an adhesive dressing (e.g., Ioban, chest seal). (7) Do NOT FORCE contents back into abdomen or actively bleeding viscera. (8) Death in the abdominally eviscerated patient is typically from associated injuries, such as concomitant solid organ or vascular injury, rather than from the evisceration itself. (9) Antibiotics should be administered for any open wounds, including abdominal eviscerating injuries. Parenteral ertapenem is the preferred antibiotic for these injuries.
Keywords: abdominal injury; abdominal evisceration; battle-related abdominal wounds; prehospital management
Knapik JJ, Hoedebecke SS. 21(2). 100 - 107. (Journal Article)
Abstract
Vitamin A is a generic term for compounds that have biological activity similar to that of retinol and includes carotenoids like β-carotene and α-carotene. Some studies suggest high dietary intake of vitamin A can increase bone fracture risk. This investigation involved a systematic review and meta-analysis examining the association between vitamin A and fracture risk. Published literature was searched to find studies that (1) involved human participants, (2) had prospective cohort or case-control study designs, (3) contained original quantitative data on associations between dietary intake of vitamin A and fractures, and (4) provided either risk ratios (RRs), odds ratios (ORs), or hazard ratios (HRs) with 95% confidence intervals (95% CIs) comparing various levels of vitamin A consumption to fracture risk. Thirteen studies met the review criteria. Meta-analyses indicated that risk of hip fracture was increased by high dietary intake of total vitamin A (RR = 1.29; 95% CI = 1.07-1.57) or retinol (RR = 1.23; 95% CI = 1.02-1.48). Hip fracture risk was reduced by high dietary intake of total carotene (RR = 0.62; 95% CI = 0.42-0.93), β-carotene (RR = 0.72; 95% CI = 0.58-0.89), or α-carotene (RR = 0.81; 95% CI = 0.67-0.97). Total fracture risk was not associated with any vitamin A compound. High intake of total vitamin A or retinol increased hip fracture risk, while high intake of some carotenoids reduced hip fracture risk.
Keywords: retinol; β-carotine; α-carotene; B-cryptoxanthin; hip fracture; total fracture