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Journal of Special Operations Medicine Keyword Index

This page will help you to find articles based on keywords. Simply click on the keyword in which you are interested, and you will be taken to a list of articles that the author has tagged with that keyword. Please note that this list of keywords is provided by the authors and may contain words that are similar in nature. Please be sure to explore all of the possible synonyms and permutations of the word you are looking for!

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Keyword: (MARCHE)2

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Integrating Chemical Biological, Radiologic, and Nuclear (CBRN) Protocols Into TCCC Introduction of a Conceptual Model - TCCC + CBRN = (MARCHE)2

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

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Keyword: 1,3 Dimethylamylamine

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Atrial Fibrillation with Rapid Ventricular Response following use of Dietary Supplement Containing 1,3 Dimethylamylamine and Caffeine

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

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Keyword: 25-hydroxyvitamin D

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Clinical Relevance of Optimizing Vitamin D Status in Soldiers to Enhance Physical and Cognitive Performance

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

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Keyword: 40-yard dash

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Continuous One-Arm Kettlebell Swing Training on Physiological Parameters in US Air Force Personnel: A Pilot Study

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

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Keyword: 6th Ranger Infantry Battalion

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Medical Operations of the 6th Ranger Infantry Battalion

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

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Keyword: AAT

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Abdominal Aortic Tourniquet™ Use in Afghanistan

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

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

Croushorn J, McLester J, Thomas G, McCord SR. 13(3). 1 - 4. (Journal Article)

Abstract

Junctional hemorrhage, bleeding from the areas at the junction of the trunk and its appendages, is a difficult problem in trauma. These areas are not amenable to regular tourniquets as they cannot fit to give circumferential pressure around the extremity. Junctional arterial injuries can rapidly lead to death by exsanguination, and out-of-hospital control of junctional bleeding can be lifesaving. The present case report describes an offlabel use of the Abdominal Aortic Tourniquet™ in the axilla and demonstrates its safety and effectiveness of stopping hemorrhage from a challenging wound. To our knowledge, the present report is the first human use of a junctional tourniquet to control an upper extremity junctional hemorrhage.

Keywords: AAT; hemorrhage; amputations

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Keyword: Abbreviated Injury Scale

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Interobserver Variability in Injury Severity Scoring After Combat Trauma: Different Perspectives, Different Values?

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

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Keyword: abdominal

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Conceptualized Use of Self-Expanding Foam to Rescue Special Operators From Abdominal Exsanguination: Percutaneous Damage Control for the Forward Deployed

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

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Keyword: Abdominal Aortic and Junctional Tourniquet

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Abdominal Aortic and Junctional Tourniquet Controls Hemorrhage From a Gunshot Wound of the Left Groin

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

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Keyword: Abdominal Aortic Tourniquet ™

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Abdominal Aortic Tourniquet™ Use in Afghanistan

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

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Keyword: abdominal hemorrhage

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Methods for Early Control of Abdominal Hemorrhage: An Assessment of Potential Benefit

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

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Keyword: abdominal pain

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Abdominal Pain

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

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Keyword: abetalipoproteinemia

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

Strain JE, Vigilante JA, DiGeorge NW. 15(4). 1 - 5. (Journal Article)

Abstract

Background: A 19-year-old male military recruit who presented for a screening physical for US Naval Special Warfare Duty was found to have hypolipidemia. Medical history revealed mildly increased frequency of bowel movements, but was otherwise unremarkable. His presentation was most consistent with heterozygous familial hypobetalipoproteinemia (FHBL), and the patient was cleared for Special Operations duty. Methods: A literature search was conducted using PubMed/MEDLINE. Keywords included familial hypobetalipoproteinemia, heterozygous familial hypobetalipoproteinemia, abetalipoproteinemia, hypolipidemia, diving, special operations, and military. Results that included cases of familial hypobetalipoproteinemia were included. Results: Review of the literature reveals that FHBL is a genetic disorder frequently, but not always, due to a mutation in the apolipoprotein B (apoB) gene. Those with the condition should be screened for ophthalmologic, neurologic, and gastrointestinal complications. Analysis of the disease, as well as the absence of reported cases of FHBL in diving and Special Operations, suggest there is minimal increased risk in diving and Special Operations for patients who are likely heterozygous, are asymptomatic, and have a negative workup for potential complications from the disease. Conclusion: Individuals with presumed or proven heterozygous FHBL seeking clearance for Special Operations duty should be given precautions, undergo careful questioning for history of disease-specific complications, and should have a baseline evaluation. If negative, it seems reasonable to clear the patient for Special Operations and diving.

Keywords: hypobetalipoprotteinemia, familial; hypobetalipoprotteinemia, heterozygous familial; abetalipoproteinemia; hypolipidemia; diving; Special Operations; military

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Keyword: ablation

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Treatment of Sea Urchin Injuries

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

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Keyword: abseiling

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Fast-Roping: Potential Consequences of Vibrations for Sensation and Regulation of Movement

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

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Keyword: absorption

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

Sirkin MR, Cook P, Davis KG. 15(4). 54 - 58. (Journal Article)

Abstract

Background: The operative control of noncompressible hemorrhage is the single largest impact that could be addressed in reducing the mortality on the battlefield. Laprotomy pads, traditionally used for hemorrhage evacuation, are made of woven cotton, and, while effective, their use requires a substantial amount of space and adds weight. This poses no concern in traditional operating rooms but is a hindrance for mobile providers and providers in austere environments. We sought to compare different absorptive compunds to ascertain their utility as alternatives for traditional laparotomy pads. Methods: Samples of cotton laparotomy pads, pure rayon sheets, rayon-polypropylene composite sheets, and non-polyester composite "microfiber" sheets were weighed and submerged in heparinized whole bovine blood. After saturation, the favrics were weighed, wrung dry, reweighed, and resubmerged. This process was performed for a total of three sequential submersions. The saturated weights and dry weights of each fabric were used to calculate how much blood each fabric could absorb initially and after multiple repeated uses. The initial densities of the four fabrics was calculated and compared. Results: The initial submersions demonstrated that 1g each of cotton, rayon, rayon-polypropylene, and nylon-polyester were able to absorb 7.58g, 12.98g, 10.16g, and 9.73g of blood respectively. The second and third sequential trials, which were statistically similar, demonstrated that 1g of cotton, rayon, rayon-polypropolyene, and nylon-polyester were able to absorb 1.73g, 2.83g, 2.3g, and 2.3g of blood, respectively. The calculated densities of cotton, rayon, rayon-polypropylene, and nylon-polyester were 0.087g/cm³, .012g/cm³, 0.098g/cm³, and 0.093g/cm³, respectively. Conclusion: Per gram, rayon absorbed approximately 1.7 times more blood thancotton and three-quarters the amount of the storage space. Rayon also retained its superior absorption abilites on repeated uses, demonstrating the potential for re-use in remote and austere environments. Thus, rayon could serve as a viable alternative to traditional cotton laparotomy pads in the austere environments.

Keywords: hemorrhage; laparotomy; cotton; rayon; sponge; austere; surgery; packing; combat casualty care; absorption; density

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Keyword: acceleration

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Mechanical Forces Experienced by Simulated Patients Evacuated During Dismounted Military Movement in Mountainous Terrain

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

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Keyword: accuracy

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Accuracy and Reliability of Triage at the Point of Injury During Operation Enduring Freedom

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

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Keyword: ACE

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Review, Clinical Update, and Practice Guidelines for Excited Delirium Syndrome

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

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Keyword: acetaminophen, intravenous

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Rationale for Use of Intravenous Acetaminophen in Special Operations Medicine

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

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Keyword: acetazolamide

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Frostbite: A Novel Presentation of Glucose-6-Phosphate Dehydrogenase Deficiency?

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

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Keyword: acetylsalicylic acid

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Use of Acetylsalicylic Acid in the Prehospital Setting for Suspected Acute Ischemic Stroke

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

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Keyword: Acinetobacter junii

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An Unusual Wound Infection Due to Acinetobacter junii on the Island of Oahu: A Case Report

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

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Keyword: acquired brain injury

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

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

Abstract

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

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

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Keyword: actigraphy

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Sleep As A Strategy For Optimizing Performance

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

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Keyword: active assailant

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Medical Provider Ballistic Protection at Active Shooter Events

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

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Keyword: active learning

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Use Your Noodle to Simulate Tourniquet Use on a Limb With and Without Bone

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

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Keyword: active shooter

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Medical Provider Ballistic Protection at Active Shooter Events

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

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Keyword: active shooter incident

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Willingness of Emergency Medical Services Professionals to Respond to an Active Shooter Incident

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

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Keyword: activity

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The Importance of Physical Fitness for Injury Prevention: Part 1

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

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Keyword: acupuncture

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Physical Therapy Treatment Of Chronic Neck Pain A Discussion And Case Study: Using Dry Needling And Battlefield Acupuncture

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

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Keyword: acupuncture, battlefield

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Physical Therapy Treatment Of Chronic Neck Pain A Discussion And Case Study: Using Dry Needling And Battlefield Acupuncture

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

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Keyword: acute care

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Facial Trauma Care in the Austere Environment

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

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Keyword: acute compartment syndrome, pressure

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Lower Extremity Compartment Syndrome From Prolonged Limb Compression and Immobilization During an Airborne Operation

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

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Keyword: acute hemolytic anemia

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Frostbite: A Novel Presentation of Glucose-6-Phosphate Dehydrogenase Deficiency?

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

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Keyword: acute icteric hepatitis

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Hepatitis E

Burnett MW. 17(3). 114 - 115. (Journal Article)

Abstract

Keywords: infectious disease; hepatitis E virus; acute icteric hepatitis

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Keyword: acute moist dermatitis

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Picture This: Management of Canine Pyotraumatic Dermatitis (a.k.a., Hot Spot)

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

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Keyword: acute renal failure

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Exertional Rhabdomyolysis: Attrition Through Exercise, A Case Series and Review of the Literature

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

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Keyword: adaptation

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Precision Performance Nutrition What Can Special Operations Forces Communities Expect?

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

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Keyword: adulteration

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What the SOF Community Needs to Know About Dietary Supplements

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

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Keyword: advanced medic

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Conceptualized Use of Self-Expanding Foam to Rescue Special Operators From Abdominal Exsanguination: Percutaneous Damage Control for the Forward Deployed

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

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Keyword: Advanced Resuscitative Care

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Advanced Resuscitative Care in Tactical Combat Casualty Care: TCCC Guidelines Change 18-01:14 October 2018

Butler FK, Holcomb JB, Shackelford S, Barbabella S, Bailey JA, Baker JB, Cap AP, Conklin CC, Cunningham CW, Davis MS, DeLellis SM, Dorlac WC, DuBose JJ, Eastridge B, Fisher AD, Glasser JJ, Gurney J, 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

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Keyword: adventure racing

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Unforeseen Risk: Leptospirosis and the U.S. Special Operations Community

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

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Keyword: aeromedical evacuation

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Predicting When to Administer Blood Products During Tactical Aeromedical Evacuation: Evaluation of a US Model

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

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Keyword: aerosolization

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Blood Lead Toxicity Analysis of Multipurpose Canines and Military Working Dogs

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

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Keyword: Afghan Campaign 2001-present

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Quality of Care Assessment in Forward Detection of Extremity Compartment Syndrome in War

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

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Keyword: Afghan National Army

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Advanced Medical Technology Capacity Building and the Medical Mentoring Event: A Unique Application of SOF Counterinsurgency Medical Engagement Strategies

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

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Keyword: Afghanistan

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Accuracy and Reliability of Triage at the Point of Injury During Operation Enduring Freedom

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

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Medicine on the Edge of Darkness

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

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Keyword: Africa

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This Is Africa: An Introduction to Medical Operations on the African Continent

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

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This Is Africa. Bites, Stings, and Rigors: Clinical Considerations in African Operations

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

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MEDCAN-GRO: Medical Capacity for African Nations-Growing Regional Operability. A Case Study in Special Operations Forces Capacity Building

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

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A Painful Rash in an Austere Environment

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

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This Is Africa

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

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

Peffer J, Ley N, Wuelher J, d'Andrea P, Rittberg C, Losch J, Lynch JH. 15(4). 109 - 112. (Journal Article)

Abstract

Austere environments such as Africa pose clinical challenges, which are multiplied for Special Operations Forces (SOF) providers who must face these challenges with limited resources against the tyranny of distance. These limited resources apply not only to treatment tools but to diagnostic tools as well. Laboratory diagnostics may provide critical information in diagnosis, initial triage, and/or evacuation decisions, all of which may enhance a patient's survival. However, unlike in climatecontrolled, fixed-facility hospitals, the deployed SOF provider must have access to a simple, reliable device for point-of-care testing (POCT) to obtain clinically meaningful data in a practical manner given the surroundings.

Keywords: Africa; medicine, tactical; testing, laboratory; analyzers, blood, point-of-care; malaria; HIV; medicine, wilderness

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Schistosomiasis: Traverers in Africa

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.

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Keyword: after action review

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Review of 54 Cases of Prolonged Field Care

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

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Keyword: aftermath

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Warzone Stressor Exposure, Unit Support, and Emotional Distress Among U.S. Air Force Pararescuemen

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

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Keyword: Agitated Chaotic Event&tm;

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Review, Clinical Update, and Practice Guidelines for Excited Delirium Syndrome

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

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Keyword: agitated patients

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The Agitated Patient

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

Abstract

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

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

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Keyword: aid station

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Preparedness for Resuscitation at a Geographically Isolated Army Troop Medical Clinic: Lessons From Camp Blanding, Florida

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

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Keyword: Air Force

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Continuous One-Arm Kettlebell Swing Training on Physiological Parameters in US Air Force Personnel: A Pilot Study

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

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Keyword: airborne

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Scapula Fracture Secondary To Static Line Injury In A 22 Year Old Active Duty Soldier

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

Delayed Diagnosis of Pelvic hematoma without Fracture Due to Military Parachuting

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

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Pectoralis Major Injury During Basic Airborne Training

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

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Keyword: airway

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

Cashwell MJ, Wilcoxen AC, Meghoo CA. 13(3). 42 - 44. (Journal Article)

Abstract

Digital intubation is a useful technique that is rarely taught in conventional airway management courses. With limited equipment and minimal training, a Special Operations Forces (SOF) medic can use this technique to intubate an unconscious patient with a high degree of success. The objectives of this report are to (1) learn the sequence of events for successful digital intubation, (2) recognize and appreciate the advantages and limitations of this technique, and (3) appreciate the requirements for establishing a unit-level training program.

Keywords: digital intubation; airway

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Laryngeal Mask Airway Exchange Using a Gum Elastic Bougie With a Rotational Twist Technique

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

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Prehospital and En Route Cricothyrotomy Performed in the Combat Setting: A Prospective, Multicenter, Observational Study

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

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

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

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Are the King LTS Laryngeal Tube and the Ambu AuraOnce Laryngeal Mask Useful Airway Adjuncts for Military Medics?

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

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Concepts of Prehospital Advanced Airway Management in the Operational K9: A Focus on Cricothyrotomy

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

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Survival of Casualties Undergoing Prehospital Supraglottic Airway Placement Versus Cricothyrotomy

Schauer SG, Naylor JF, Chow AL, Maddry J, 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

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Keyword: airway device

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The Cric-Key™ and Cric-Knife™: A Combined Tube-Introducer and Scalpel-Hook Open Cricothyrotomy System

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™

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Keyword: airway management

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Comparison of Airway Control Methods and Ventilation Success With an Automatic Resuscitator

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

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Prehospital and En Route Cricothyrotomy Performed in the Combat Setting: A Prospective, Multicenter, Observational Study

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

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Ultrasound-Guided Airway Management in the Austere Setting

Rapp J, Hampton K. 17(1). 130 - 130. (Journal Article)

Abstract

Keywords: sonography; airway management

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Are the King LTS Laryngeal Tube and the Ambu AuraOnce Laryngeal Mask Useful Airway Adjuncts for Military Medics?

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

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Facial Trauma Care in the Austere Environment

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

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Keyword: airway obstruction

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Prehospital and En Route Cricothyrotomy Performed in the Combat Setting: A Prospective, Multicenter, Observational Study

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

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Keyword: airway training

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Advanced Medical Technology Capacity Building and the Medical Mentoring Event: A Unique Application of SOF Counterinsurgency Medical Engagement Strategies

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

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Keyword: airway, surgical

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Prehospital Cricothyrotomy Kits Used in Combat

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

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Keyword: albinism

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Medical Mission to Dominican Republic: One Dermatology Group's Experiences

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

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Keyword: albumin

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Albumin for Prehospital Fluid Resuscitation of Hemorrhagic Shock in Tactical Combat Casualty Care

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

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Keyword: alcohol

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Associations Among Back and Extremity Pain With Alcohol, Tobacco, and Caffeine Use Among US Air Force Pararescuemen

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

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Keyword: allergy, red ink

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

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&reg; [ILK]). However, given the Marine had recently deployed and is part of the active duty population, consideration of alternative, albeit rare, etiologies was imperative.

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

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Keyword: al-Qaeda I the Islamic Maghreb

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Experience Of A US Air Force Surgical And Critical Care Team Deployed In Support Of Special Operations Command Africa

Delmonaco BL, Baker A, Clay J, Kilbourn 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

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Keyword: alternative treatment

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Atropine Eye Drops: A Proposed Field Expedient Substitute in the Absence of Atropine Autoinjectors

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

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Keyword: alternative treatments

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The Benefits of Reflexology for the Chronic Pain Patient in a Military Pain Clinic

Kern C, McCoart A, Beltranm 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

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Keyword: altitude chamber

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Decompression Sickness Following Altitude-Chamber Training

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

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Keyword: amputations

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Abdominal Aortic Tourniquet™ Use in Afghanistan

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

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

Croushorn J, McLester J, Thomas G, McCord SR. 13(3). 1 - 4. (Journal Article)

Abstract

Junctional hemorrhage, bleeding from the areas at the junction of the trunk and its appendages, is a difficult problem in trauma. These areas are not amenable to regular tourniquets as they cannot fit to give circumferential pressure around the extremity. Junctional arterial injuries can rapidly lead to death by exsanguination, and out-of-hospital control of junctional bleeding can be lifesaving. The present case report describes an offlabel use of the Abdominal Aortic Tourniquet™ in the axilla and demonstrates its safety and effectiveness of stopping hemorrhage from a challenging wound. To our knowledge, the present report is the first human use of a junctional tourniquet to control an upper extremity junctional hemorrhage.

Keywords: AAT; hemorrhage; amputations

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Keyword: analgesia

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Battlefield Analgesia: TCCC Guidelines Are Not Being Followed

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

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Analgesia and Sedation Management During Prolonged Field Care

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

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Successful Use of Ketamine as a Prehospital Analgesic by Pararescuemen During Operation Enduring Freedom

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

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Battlefield Analgesia: Adherence to Tactical Combat Casualty Care Guidelines

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

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Impact of Continuous Ketamine Infusion Versus Alternative Regimens on Mortality Among Burn Intensive Care Unit Patients: Implications for Prolonged Field 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

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Keyword: analyzers, blood, point-of-care

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

Peffer J, Ley N, Wuelher J, d'Andrea P, Rittberg C, Losch J, Lynch JH. 15(4). 109 - 112. (Journal Article)

Abstract

Austere environments such as Africa pose clinical challenges, which are multiplied for Special Operations Forces (SOF) providers who must face these challenges with limited resources against the tyranny of distance. These limited resources apply not only to treatment tools but to diagnostic tools as well. Laboratory diagnostics may provide critical information in diagnosis, initial triage, and/or evacuation decisions, all of which may enhance a patient's survival. However, unlike in climatecontrolled, fixed-facility hospitals, the deployed SOF provider must have access to a simple, reliable device for point-of-care testing (POCT) to obtain clinically meaningful data in a practical manner given the surroundings.

Keywords: Africa; medicine, tactical; testing, laboratory; analyzers, blood, point-of-care; malaria; HIV; medicine, wilderness

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Keyword: anaphylactic shock

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Management of Anaphylaxis in an Austere or Operational Environment

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

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Keyword: anaphylaxis

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Management of Anaphylaxis in an Austere or Operational Environment

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

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Keyword: androgen steroids

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Androgens and Androgen Derivatives: Science, Myths, and Theories. Explored From a Special Operations Perspective

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

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Keyword: anesthesia

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Humanitarian Surgical Missions: Guidelines for Successful Anesthesia Support

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

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Ether Anesthesia in the Austere Environment: An Exposure and Education

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

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Keyword: animal model

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A Salmon Thrombin-Fibrinogen Dressing Controls Hemorrhage in a Swine Model Compared to Standard Kaolin-Coated Gauze

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

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Keyword: animal-assisted therapy

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Staff Attitudes Regarding the Impact of a Therapy Dog Program on Military Behavioral Health Patients

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

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Keyword: ankle fusion

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Return to Duty After Severe Bilateral Lower Extremity Trauma

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

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Keyword: ankle sprain

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A Novel Cryotherapy Compression Wrap in the Management of Acute Ankle Sprains: Potential Use for Special Operators on the Battlefield

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

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Keyword: anthrax

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Erythema Multiforme

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

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Keyword: antibiotics

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Prehospital Administration of Antibiotic Prophylaxis for Open Combat Wounds in Afghanistan: 2013-2014

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

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Keyword: antidote

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Atropine Eye Drops: A Proposed Field Expedient Substitute in the Absence of Atropine Autoinjectors

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

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Keyword: antipersprants

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Prevention of Foot Blisters

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

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Keyword: antiplatelet

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Use of Acetylsalicylic Acid in the Prehospital Setting for Suspected Acute Ischemic Stroke

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

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Keyword: antivenin

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This Is Africa. Bites, Stings, and Rigors: Clinical Considerations in African Operations

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

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Keyword: antivenom

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Differential Diagnosis of an Unusual Snakebite Presentation in Benin: Dry Bite or Envenomation?

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

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Keyword: anxiety

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Clinical Guidelines for Stellate Ganglion Block to Treat Anxiety Associated With Posttraumatic Stress Disorder

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

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Keyword: aortic balloon occlusion

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Feasibility Study Vascular Access and REBOA Placement: From Zero to Hero

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

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Keyword: APC III injuries

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Imaging Comparison of Pelvic Ring Disruption and Injury Reduction With Use of the Junctional Emergency Treatment Tool for Preinjury and Postinjury Pelvic Dimensions: A Cadaveric Study With Computed Tomography

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

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Keyword: appendicitis

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Abdominal Pain

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

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Keyword: arthritis, psoriatic

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Treatment of Psoriasis in the Deployed Setting

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

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Psoriasis

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

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Keyword: Article 5

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NATO Military Medical Exercise Vigorous Warrior 2017

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

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Keyword: articular deterioration

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Effects of Oral Chondroitin Sulfate on Osteoarthritis-Related Pain and Joint Structural Changes: Systematic Review and Meta-Analysis

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

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Keyword: articulating tactical traction splint

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Articulating Tractical Traction Splint Use on Pulseless Forearm Fracture

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

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Keyword: assessment

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

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

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Keyword: athletic performance

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Evaluation of the US Army Special Forces Tactical Human Optimization, Rapid Rehabilitation, and Reconditioning Program

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

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Keyword: atomized

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Use of Atomized Intranasal Tranexamic Acid as an Adjunctive Therapy in Difficult-to-Treat Epistaxis

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

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Keyword: atomized intranasal TXA

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Use of Atomized Intranasal Tranexamic Acid as an Adjunctive Therapy in Difficult-to-Treat Epistaxis

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

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Keyword: atopic dermatitis

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Medical Mission to Dominican Republic: One Dermatology Group's Experiences

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

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A Comparison of Two Chronic Skin Conditions: Atopic Dermatitis and Psoriasis

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

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Keyword: atrial fibriliation

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Atrial Fibrillation with Rapid Ventricular Response following use of Dietary Supplement Containing 1,3 Dimethylamylamine and Caffeine

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

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Keyword: atropine

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Atropine Eye Drops: A Proposed Field Expedient Substitute in the Absence of Atropine Autoinjectors

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

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Keyword: austere

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Management of Anaphylaxis in an Austere or Operational Environment

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

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Conceptualized Use of Self-Expanding Foam to Rescue Special Operators From Abdominal Exsanguination: Percutaneous Damage Control for the Forward Deployed

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

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

Sirkin MR, Cook P, Davis KG. 15(4). 54 - 58. (Journal Article)

Abstract

Background: The operative control of noncompressible hemorrhage is the single largest impact that could be addressed in reducing the mortality on the battlefield. Laprotomy pads, traditionally used for hemorrhage evacuation, are made of woven cotton, and, while effective, their use requires a substantial amount of space and adds weight. This poses no concern in traditional operating rooms but is a hindrance for mobile providers and providers in austere environments. We sought to compare different absorptive compunds to ascertain their utility as alternatives for traditional laparotomy pads. Methods: Samples of cotton laparotomy pads, pure rayon sheets, rayon-polypropylene composite sheets, and non-polyester composite "microfiber" sheets were weighed and submerged in heparinized whole bovine blood. After saturation, the favrics were weighed, wrung dry, reweighed, and resubmerged. This process was performed for a total of three sequential submersions. The saturated weights and dry weights of each fabric were used to calculate how much blood each fabric could absorb initially and after multiple repeated uses. The initial densities of the four fabrics was calculated and compared. Results: The initial submersions demonstrated that 1g each of cotton, rayon, rayon-polypropylene, and nylon-polyester were able to absorb 7.58g, 12.98g, 10.16g, and 9.73g of blood respectively. The second and third sequential trials, which were statistically similar, demonstrated that 1g of cotton, rayon, rayon-polypropolyene, and nylon-polyester were able to absorb 1.73g, 2.83g, 2.3g, and 2.3g of blood, respectively. The calculated densities of cotton, rayon, rayon-polypropylene, and nylon-polyester were 0.087g/cm³, .012g/cm³, 0.098g/cm³, and 0.093g/cm³, respectively. Conclusion: Per gram, rayon absorbed approximately 1.7 times more blood thancotton and three-quarters the amount of the storage space. Rayon also retained its superior absorption abilites on repeated uses, demonstrating the potential for re-use in remote and austere environments. Thus, rayon could serve as a viable alternative to traditional cotton laparotomy pads in the austere environments.

Keywords: hemorrhage; laparotomy; cotton; rayon; sponge; austere; surgery; packing; combat casualty care; absorption; density

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A Novel Ultrasound Transmission Gel for Resource-Constrained Environments

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

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Maggot Therapy for Wound Care in Austere Environments

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

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Use of a Tuning Fork for Fracture Evaluation: An Introduction for Education and Exposure

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

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Medicine on the Edge of Darkness

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

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Ether Anesthesia in the Austere Environment: An Exposure and Education

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

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Improvised Ground Evacuation Platforms for Austere Special Operations Casualty Transport

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

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Integrating Prolonged Field Care Into Rough Terrain and Mountain Warfare Training: The Mountain Critical Care Course

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

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Improvised Inguinal Junctional Tourniquets: Recommendations From the Special Operations Combat Medical Skills Sustainment Course

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

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Keyword: austere environments

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

Corey G, Lafayette T. 13(3). 74 - 80. (Journal Article)

Abstract

The wars in Afghanistan and Iraq are the only conflicts to which many medics have ever been exposed. These mature theaters have robust medical systems that ensure rapid access to full-spectrum medical care for all combat-wounded and medically injured personnel. As current conflicts draw to a close, U.S. medics may be deployed to environments that will require the ability to stabilize casualties for longer than 1 hour. Historical mission analysis reveals the need to review skills that have not been emphasized during upgrade and predeployment training. This unit's preparation for the extended care environment can be accomplished using a 4-point approach: (1) review of specific long-term skills training, (2) an extended care lab that reviews extended care skills and then lets the medic practice in a real-time scenario, (3) introduction to the HITMAN mnemonic tool, which helps identify and address patient needs, and (4) teleconsultation.

Keywords: extended care; austere environments; long-term skills training; teleconsultation

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Identification and Management of Bed Bug Infestations in Austere Environments

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

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A Modern Case Series of Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) in an Out-of-Hospital, Combat Casualty Care Setting

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

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The Sole Provider: Preparation for Deployment to a Medically Austere Theater

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

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Feasibility and Proposed Training Pathway for Austere Application of Resuscitative Balloon Occlusion of the Aorta

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

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Prolonged Field Care in Support of Operation Inherent Resolve, 2016

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

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Use of Drone Technology for Delivery of Medical Supplies During Prolonged Field Care

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

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Keyword: austere setting

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

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

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Keyword: austere surgery

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Surgical Instrument Sets for Special Operations Expeditionary Surgical Teams

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)

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The Golden Hour Offset Surgical Treatment Team Operational Concept: Experience of the 102nd Forward Surgical Team in Operation Freedom's Sentinel 2015-2016

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

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Keyword: austere, military

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The Shrail: A Comparison of a Novel Attachable Rail System With the Current Deployment Operating Table

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

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Keyword: aviation

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Corneal Foreign Body Management at a Role 1 Flight Line Aid Station

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

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Keyword: avulsion

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Pectoralis Major Injury During Basic Airborne Training

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

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Keyword: awareness

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Introduction to the NATO Special Operations Combat Medic Research Ongoing Series

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

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Keyword: Bacillus anthracis

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Case Report of an Anthrax Presentation Relevant to Special Operations Medicine

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

Abstract

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

Keywords: periocular anthrax; Bacillus anthracis; ophthalmology; diagnostics

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Keyword: Back Pack Health Worker Team

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Humanitarian Struggle in Burma's Conflict Zones

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

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Keyword: bacteria

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Recovery of Bacteria and Fungi From a Leg Wound

Washington MA, Barnhill JC, Duff MA, Griffin J. 15(4). 113 - 116. (Journal Article)

Abstract

Acute and chronic wound infections can both be encountered in the deployed setting. These wounds are often contaminated by bacteria and fungi derived from the external environment. In this article, we present the case of a wound infection simultaneously colonized by Enterobacter cloacae (a bacterial pathogen) and Trichosporon asahii (an unusual fungal pathogen). We describe the examination and treatment of the patient and review the distinguishing characteristics of each organism

Keywords: infection; bacteria; fungi; Enterobacter cloacae; Trichosporon asahii

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Keyword: bacteriology

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Staphylococcus sciuri: An Entomological Case Study and a Brief Review of the Literature

Washington MA, 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

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Keyword: bag-valve-mask

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A Comparison of Ventilation Rates Between a Standard Bag-Valve-Mask and a New Design in a Prehospital Setting During Training Simulations

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

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Keyword: ballistic eye protection

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

Brunstetter T, Diaz GY, Wasner C, Hart S, Burrows S. 13(3). 26 - 28. (Journal Article)

Abstract

From 5% to 22% of all U.S. Department of Defense combat casualties between 2001 and 2010 suffered some form of ocular trauma. Ocular injuries have an inordinately dramatic impact on return to duty, retention, and reintegration; only 25% of warfighters with severe ocular trauma return to duty. After a traumatic ocular event, the likelihood of saving an eye and preserving vision depends on several factors, especially the treatment quality at the point of injury. Every major organization associated with combat casualty care (e.g., the U.S. Army Institute of Surgical Research, the Committee on Tactical Combat Casualty Care, and the Department of Defense/VA Vision Center of Excellence) emphasizes the importance of placing a rigid eye shield on known/suspected eye injuries at point of injury. On the battlefield, there is no better way to protect an injured eye from further damage than with an eye shield, but shields are not readily available in individual first aid kits. Therefore, it is highly recommended that each Service rapidly integrate at least one rigid eye shield into every individual first aid kit, making them immediately available to every warfighter.

Keywords: rigid eye shield; ocular trauma; ballistic eye protection; eye injuries; open globe injuries; first aid kit

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Keyword: ballistics

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Medical Provider Ballistic Protection at Active Shooter Events

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

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Keyword: baloon aortic occlusion

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Methods for Early Control of Abdominal Hemorrhage: An Assessment of Potential Benefit

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

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Keyword: bamboo

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Evaluation of NuStat®, a Novel Nonimpregnated Hemostatic Dressing, Compared With Combat Gauze™ in Severe Traumatic Porcine Hemorrhage Model

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

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Keyword: bandage

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Management of External Hemorrhage in Tactical Combat Casualty Care: Chitosan-Based Hemostatic Gauze Dressings

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

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Keyword: bandages

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Impact of Marine Exposure on Hemostatic Gauzes Using Thromboelastography

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

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Keyword: barotrauma, inner ear

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

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

Abstract

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

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

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Keyword: basal cell carcinoma

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Giant Basal Cell Carcinoma

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

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Keyword: bat bugs

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Identification and Management of Bed Bug Infestations in Austere Environments

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

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Keyword: battlefield

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Effects of Intraosseous and Intravenous Administration of Hextend® on Time of Administration and Hemodynamics in a Swine Model

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

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Keyword: battlefield analgesia

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A Triple-Option Analgesia Plan for Tactical Combat Casualty Care: TCCC Guidelines Change 13-04

Butler FK, Kotwal RS, Buckenmaier CC, Edgar EP, O'Connor KC, Montgomery HR, Shackelford S, 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

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Keyword: battlefield REBOA

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Feasibility and Proposed Training Pathway for Austere Application of Resuscitative Balloon Occlusion of the Aorta

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

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Keyword: battlefield resuscitation

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Pediatric Trauma: Management From an Austere Prospective

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

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A Perspective on the Potential for Battlefield Resuscitative Endovascular Balloon Occlusion of the Aorta

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

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Keyword: battlefield trauma care

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TCCC Guidelines Comprehensive Review and Update: TCCC Guidelines Change 16-03

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

Keyword: bed bugs

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Identification and Management of Bed Bug Infestations in Austere Environments

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

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Oral Steroids for Dermatitis

Fisher AD, Clarke J, Williams TK. 15(2). 8 - 11. (Journal Article)

Abstract

Contact/allergic dermatitis is frequently treated inappropriately with lower-than-recommended doses or inadequate duration of treatment with oral and intramuscular glucocorticoids. This article highlights a case of dermatitis in a Ranger Assessment and Selection Program student who was improperly treated over 2 weeks with oral steroids after being bit by Cimex lectularius, commonly known as bed bugs. The article also highlights the pitfalls of improper oral steroid dosing and provides reasoning for longer-duration oral steroid treatment.

Keywords: dermatitis; steroids; bed bugs; military; Cimex lectularis

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Keyword: behavioral health

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Staff Attitudes Regarding the Impact of a Therapy Dog Program on Military Behavioral Health Patients

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

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Keyword: Bernhardt-Roth syndrome

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Load Carriage-Related Paresthesias (Part 2): Meralgia Paresthetica

Knapik JJ, Reynolds K, Orr R, Pope R. 17(1). 94 - 100. (Journal Article)

Abstract

This is the second of a two-part series addressing symptoms, evaluation, and treatment of load carriage- related paresthesias. Part 1 addressed rucksack palsy and digitalgia paresthetica; here, meralgia paresthetica (MP) is discussed. MP is a mononeuropathy involving the lateral femoral cutaneous nerve (LFCN). MP has been reported in load carriage situations where the LFCN was compressed by rucksack hipbelts, pistol belts, parachute harnesses, and body armor. In the US military, the rate of MP is 6.2 cases/10,000 personyears. Military Servicewomen have higher rates than Servicemen, and rates increase with age, longer loadcarriage distance or duration, and higher body mass index. Patients typically present with pain, itching, and paresthesia on the anterolateral aspect of the thigh. There are no motor impairments or muscle weakness, because the LFCN is entirely sensory. Symptoms may be present on standing and/or walking, and may be relieved by adopting other postures. Clinical tests to evaluate MP include the pelvic compression test, the femoral nerve neurodynamic test, and nerve blocks using lidocaine or procaine. In cases where these clinical tests do not confirm the diagnosis, specialized tests might be considered, including somatosensory evoked potentials, sensory nerve conduction studies, high-resolution ultrasound, and magnetic resonance imaging. Treatment should initially be conservative. Options include identifying and removing the compression if it is external, nonsteroidal inflammatory medication, manual therapy, and/or topical treatment with capsaicin cream. Treatments for intractable cases include injection of corticosteroids or local anesthetics, pulsed radiofrequency, electroacupuncture, and surgery. Military medical care providers may see cases of MP, especially if they are involved with units that perform regular operations involving load carriage.

Keywords: paresthesias, load carriage-related; meralgia paresthetica; mononeuropathy; nerve, lateral femoral cutaneous; Bernhardt-Roth syndrome

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Keyword: biologic exposure

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What's in a Rash? Viral Exanthem Versus CBRNE Exposure: Teleconsultation Support for Two Special Forces Soldiers With Diffuse Rash in an Austere Environment

Lee HD, Butterfield S, Maddry J, Powell D, Vasios WN, Yun H, Ferraro D, Pamplin JC. 18(2). 133 - 135. (Journal Article)

Abstract

Objective: Review clinical thought process and key principles for diagnosing weaponized chemical and biologic injuries. Clinical Context: Special Operation Forces (SOF) team deployed in an undisclosed, austere environment. Organic Expertise: Two SOF Soldiers with civilian EMT-Basic certification. Closest Medical Support: Mobile Forward Surgical Team (2 hours away); medical consults available by e-mail, phone, or video-teleconsultation. Earliest Evacuation: Earliest military evacuation from country 12-24 hours. With teleconsultation, patients departed to Germany as originally scheduled without need for Medical Evacuation.

Keywords: telemedicine; chemical exposure; biologic exposure; military personnel; emergency treatment; patient transfer; prolonged field care

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Keyword: biomechanics, collapsible tubes, steady flow, rheology, pres

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Laboratory Model of a Collapsible Tube to Develop Bleeding Control Interventions

Griffin LV, Kragh JF, Dubick MA. 18(1). 47 - 52. (Journal Article)

Abstract

Background: To develop knowledge of mechanical control of bleeding in first aid, a laboratory model was set up to simulate flow through a blood vessel. A collapsible tube was used to mimic an artery in two experiments to determine (1) the extent of volumetric flow reduction caused by increases in the degree of compression of the vessel and (2) the extent of flow reduction caused by increases in the length of compression. Methods: Water was used in vertical tubing. Gravity applied a pressure gradient of about 100mmHg to cause flow. A silicone tube (10mm-diameter lumen [the inner opening], 1mm-thick wall, 150mm length) was used. Tests of no compression of the external wall constituted the control group for both experiments. For all groups, flow volume was sampled over a period of time, and six samples were averaged. In both experiments, the study group consisted of tests with compression that was measured as the reduced area of the luminal cross section. In the first experiment, six groups with luminal area reductions of 0% (control), 74%, 81%, 91%, 94%, and 97% were tested. In the second experiment at 74% luminal area reduction, the three lengths of compression were 5mm, 20mm, and 70mm. The measured data were compared with calculated data by applying established mathematical equations. Results: In the first experiment, flow decreased with decreasing area due to luminal compression, but the association was a parabolic curve such that 94% or greater reduction in luminal area was required to reduce flow by greater than 50%. A reduction in luminal area of 97% reduced flow by 95%. In the second experiment, mean flow rates were not significantly different among the three lengths of compression. Measured data and calculated data were in good agreement. Conclusions: Compared with an uncompressed vessel, volumetric flow of water through a single, unsupported collapsible tube in steady, nonpulsatile conditions with compression applied to its external wall to produce a reduction in luminal area of 97% reduced flow by 95%. Flow was affected by the degree of compression but not by the length of compression.

Keywords: first aid/therapy, tourniquet; hemorrhage, prevention and control, bleeding control; biomechanics, collapsible tubes, steady flow, rheology, pres; models, theoretical

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Keyword: bioresponsiveness

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NATO Military Medical Exercise Vigorous Warrior 2017

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

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Keyword: biostatics, statistics

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Basic Biostatistics and Clinical Medicine

Banting J, Meriano T. 17(1). 76 - 76. (Journal Article)

Abstract

Keywords: biostatics, statistics; tests; specificity; sensitivity

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Keyword: bites, dog

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Estimation of Dog-Bite Risk and Related Morbidity Among Personnel Working With Military Dogs

Schermann H, Eiges N, Sabag A, Kazum E, Albagli A, Salai M, Shlaifer A. 17(3). 51 - 54. (Journal Article)

Abstract

Background: Soldiers serving in the Israel Defense Force Military Working Dogs (MWD) Unit spend many hours taming dogs' special skills, taking them on combat missions, and performing various dogkeeping activities. During this intensive work with the aggressive military dogs, bites are common, and some of them result in permanent disability. However, this phenomenon has not been quantified or reported as an occupational hazard. Methods: This was a retrospective cohort study based on self-administered questionnaires. Information was collected about soldiers' baseline demographics, duration of the experience of working with dogs, total number of bites they had, circumstances of bite events, and complications and medical treatment of each bite. Bite risk was quantified by incidence, mean time to first bite, and a Cox proportional hazards model. Rates of complications and the medical burden of bites were compared between combat soldiers and noncombat dogkeepers. Bite locations were presented graphically. Results: Seventy-eight soldiers participated and reported on 139 bites. Mean time of working with dogs was 16 months (standard deviation, ±9.4 months). Overall bite incidence was 11 bites per 100 person-months; the mean time to first bite event was 6.3 months. The Cox proportional hazards model showed that none of baseline characteristics significantly increased bite hazard. About 90% of bites occurred during routine activities, and 3.3% occurred on combat missions. Only in 9% of bite events did soldiers observed the safety precautions code. Bite complications included fractures, need for intravenous antibiotic treatment and surgical repair, prominent scarring, diminished sensation, and stiffness of proximal joints. Bite complications were similar between combat soldiers and dogkeepers. Most bites (57%) were located on hands and arms. Conclusion: MWD bites are an occupational hazard resulting in significant medical burden. Hands and arms were most common bite locations. Observance of safety precautions may be the most appropriate first-line preventive intervention. Barrier protection of upper extremities may reduce bite severity and complication rates.

Keywords: canine; combat; bites, dog; dogs, military working; Israeli Army; dog keepers

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Keyword: blast traumatic brain injury

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Blast Traumatic Brain Injury - What Do We Know?

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

Abstract

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

Keywords: blast traumatic brain injury; neuronal dysfunction

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Keyword: bleeding

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Combat Ready Clamp Medic Technique

Tovmassian RV, Kragh JF, Dubick MA, Billings S, Blackbourne LH. 12(4). 72 - 78. (Journal Article)

Abstract

Background: Junctional hemorrhage control device use on the battlefield might be lifesaving, but little experience is reported. The purpose of the present case report is to detail prehospital use of the Combat Ready Clamp (called the CRoC by its users, Combat Medical Systems, Fayetteville, NC; Instructions for Use, 2010) in casualty care in order to increase awareness of junctional hemorrhage control. Methods: The CRoC was used to control difficult inguinal bleeding on the battlefield for an Afghani man with a hindquarter traumatic amputation. Results: The device promptly controlled exsanguination from a critical injury when placed during rotary-wing casualty evacuation. The flight medic applied the device in 90 seconds. The device performed well without complications to control bleeding. Discussion: The CRoC, a new junctional hemorrhage control device, was used as indicated on the battlefield with mechanical and physiologic success and without device problems. By controlling difficult inguinal bleeding resulting from battlefield trauma, the device facilitated casualty stabilization and delivery to a surgical facility. The device facilitated the ability of a new flight medic to focus his expertise on a critically injured battlefield casualty with demonstrable success.

Keywords: tourniquet; bleeding; shock; prehospital care; emergency medical services

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

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

Abstract

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

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

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Conceptualized Use of Self-Expanding Foam to Rescue Special Operators From Abdominal Exsanguination: Percutaneous Damage Control for the Forward Deployed

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

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

Kirkpatrick AW, McKee JL, McKee I, Panebianco NL, Ball CG. 15(4). 71 - 74. (Journal Article)

Abstract

Bleeding to death has been identified as the leading cause of potentially preventable injury-related death worldwide. Temporary hemorrhage control could allow the patient to be transported to a site capable of damage- control surgery. A novel device that may offer a fast and effective means of controlling nontruncal bleeding (junctional and extremity) is the iTClamp (Innovative Trauma Care; http://innovativetraumacare.com). This case study demonstrated that a motivated and intelligent, but untrained, first responder could successfully localize the actual anatomic site of an exsanguinating bleed and then could relatively easily compress this site to control the bleeding site by using ultrasound-guided manual-compression techniques.

Keywords: hemorrhage; iTClamp; ultrasound; bleeding; control

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Keyword: bleeding control

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Worldwide Case Reports Using the iTClamp for External Hemorrhage Control

McKee JL, Kirkpatrick AW, Bennett BL, Jenkins DA, Logsetty S, Holcomb JB. 18(3). 39 - 44. (Journal Article)

Abstract

Background: Historically, hemorrhage control strategies consisted of manual pressure, pressure dressings, gauze with or without hemostatic ingredients for wound packing, or the use of tourniquets. The iTClamp is a relatively new alternative to stop external bleeding. Methods: An anonymous survey was used to evaluate the outcomes of the iTClamp in worldwide cases of external bleeding. Results: A total of 245 evaluable applications were reported. The iTClamp stopped the bleeding in 81% (n = 198) of the cases. Inadequate bleeding control was documented in 8% (n = 20) and in the remaining 11% (n = 27), bleeding control was not reported. The top three anatomic body regions for iTClamp application were the scalp, 37% (n = 91); arm, 20% (n = 49); and leg, 19% (n = 46). In 26% of the reported cases (direct pressure [23% (n = 63)] and tourniquets [3% (n = 8]), other techniques were abandoned in favor of the iTClamp. Conversely, the iTClamp was abandoned in favor of direct pressure 11 times (4.4%) and abandoned in favor of a tourniquet three times (1%). Conclusion: The iTClamp appears to be a fast and reliable device to stop external bleeding. Because of its function and possible applications, it has potential to lessen the gap between and add to the present selection of devices for treatment of external bleeding.

Keywords: trauma; bleeding control; emergency medical services; iTClamp

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Implementation and Evaluation of a First-Responder Bleeding-Control Training Program in a Rural Police Department

Reed JR, Carman MJ, Titch FJ, Kotwal RS. 18(3). 57 - 61. (Journal Article)

Abstract

Background: In the prehospital environment, nonmedical first responders are often the first to arrive on the scene of a traumatic event and must be prepared to provide initial care at the point of injury. In civilian communities, these nonmedical first responders often include law enforcement officers. Hemorrhage is a major cause of death in trauma, and many of these deaths occur in the prehospital environment; therefore, prehospital training efforts should be directed accordingly toward bleeding control. Methods: A bleeding control training program was implemented and evaluated in a rural police department in Pinehurst, North Carolina, from February to April 2017. A repeated measures observational study was conducted to evaluate the training program. Measured were self-efficacy (pre- and post-test), knowledge (pretest, post-test 1 [immediate], post-test 2 [at 4 weeks]), and limb-tourniquet application time (classroom, simulation exercise). Results: The study population was composed of 28 police officers (92.9% male) whose median age was 37 (interquartile range, 22-55) years. Mean self-efficacy scores, equating to user confidence and the decision to intervene, increased from pre- to post-training (34.54 [standard deviation (SD) 4.16] versus 35.62 [SD 4.17]; p = .042). In addition, mean knowledge test scores increased from pre- to immediately post-training (75.00 [SD 16.94] versus 85.83 [SD 11.00]; p = .006), as well as from preto 4 weeks post-training (75.00 [SD 16.94] versus 84.17 [SD 11.77]; p = .018). Lower limb-tourniquet application times were more rapid in the classroom than during the simulation exercise (23.06 seconds [SD 7.68] versus 31.91 seconds [SD 9.81]; p = .005). Conclusion: First-responder bleeding-control programs should be initiated and integrated at the local level throughout the Nation. Implementation and sustainment of such programs in police departments can save lives and enhance existing law enforcement efforts to protect and serve communities.

Keywords: bleeding control; first responder; hemorrhage; limb tourniquet; prehospital; trauma

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Keyword: blister/chemically induced

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Sulfur Mustard Exposure: Review of Acute, Subacute, and Long-Term Effects and Their Management

Wolfe GA, Petteys SM, Phelps JF, Wasmund JB, Plackett TP. 19(2). 81 - 86. (Journal Article)

Abstract

Sulfur mustard has been used in conflicts for more than a century. Despite international recognized bans on the use of chemical weapons, there continue to be reports of their use. The authors provide a contemporary overview of sulfur mustard injury and its management in the acute, subacute, and chronic periods.

Keywords: mustard gas; chemical terrorism; chemical warfare agents; blister/chemically induced; warfare

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Keyword: blisters

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Prevention of Foot Blisters

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

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Keyword: bloat

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Prehospital Care of Canine Gastric Dilatation and Volvulus

Palmer LE. 18(1). 91 - 98. (Journal Article)

Abstract

The intent of the Operational K9 (OpK9) ongoing series is to provide the Special Operations Medical Association community with clinical concepts and scientific information on preventive and prehospital emergency care relevant to the OpK9. Often the only medical support immediately available for an injured or ill OpK9 in the field is their handler or the human Special Operations Combat Medic or civilian tactical medic attached to the team (e.g., Pararescueman, 18D, SWAT medic). The information is applicable to personnel operating within the US Special Operations Command as well as civilian Tactical Emergency Medical Services communities that may have the responsibility of supporting an OpK9.

Keywords: Operational K9s; gastic dilation and volvulus; bloat; gastric decompression; trocarization; dogs

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Keyword: blood bank, walking

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

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

Abstract

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

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

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Keyword: blood flow restricted training

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A Case of Rhabdomyolysis Caused by Blood Flow-Restricted Resistance Training

Krieger J, Sims D, Wolterstorff C. 18(2). 16 - 17. (Case Reports)

Abstract

Blood flow-restricted resistance (BFRR) training is effective as a means to improve muscle strength and size while enduring less mechanical stress. It is generally safe but can have adverse effects. We present a case of an active duty Soldier who developed rhabdomyolysis as a result of a single course of BFRR training. He was presented to the emergency department with bilateral lower extremity pain, was admitted for electrolyte monitoring and rehydration, and had an uncomplicated hospital course and full recovery. This is an increasingly common mode of rehabilitation in the military, and practitioners and providers should be aware of it and its possible adverse effects.

Keywords: rhabdomyolysis; blood flow restricted training; ischemic training

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Keyword: blood flow restriction

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Blood Flow Restriction Rehabilitation for Extremity Weakness: A Case Series

Hylden C, Burns T, Stinner DJ, Owens J. 15(1). 50 - 56. (Journal Article)

Abstract

Background: Blood flow restricted (BFR) training, the brief and partial restriction of venous outflow of an extremity during low load resistance exercises, is a safe and effective method of improving strength in healthy, active individuals. A relatively unexplored potential of this adjunctive modality lies in treating patients with severe musculoskeletal trauma, persistent chronic quadriceps and hamstring weakness despite traditional therapy, and low improvement during early postoperative strengthening. Methods: This case series describes patients with chronic quadriceps and hamstring weakness who received an intervention of BFR at low loads, 20% of 1 repetition max (1RM), to restore strength. A case series was conducted of seven patients, all located at one hospital and all with traumatic lower extremity injuries. The seven patients were treated at the same medical center and with the same BFR protocol. All seven patients had isokinetic dynamometer testing that showed persistent thigh muscle weakness despite previous rehabilitation with traditional therapy and 35% to 75% peak torque deficit in either knee extension or flexion compared with the contralateral lower extremity. Patients underwent 2 weeks of BFR training therapy using a pneumatic tourniquet set at 110mmHg while performing leg extensions, leg presses, and reverse leg presses. All affected extremities were retested after 2 weeks (six treatment sessions). Dynamometer measurements were done with flexion and extension at two speeds: 90° and 300°/sec. The data recorded included peak torque normalized for body weight, average power, and total work. Results: All seven patients demonstrated improvements in peak torque, average power, and total work for both knee flexion and extension, with power being the most improved overall. Peak torque improved an average of 13% to 37%, depending on contraction direction and speed. Average power improved an average of 42% to 81%, and total work improved an average of 35% to 55%. Conclusion: BFR therapy at low loads can affect improvement in muscle strength in patients who are unable to perform high-resistance exercise or patients who have persistent extremity weakness despite traditional therapy.

Keywords: strengthening; muscle mass; tourniquet; physical therapy; blood flow restriction; vascular occlusion

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Keyword: blood products

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Fluid Resuscitation for Hemorrhagic Shock in Tactical Combat Casualty Care: TCCC Guidelines Change 14-01 - 2 June 2014

Butler FK, Holcomb JB, Schreiber MA, Kotwal RS, Jenkins DA, Champion HR, Bowling F, Cap AP, DuBose JJ, Dorlac WC, Dorlac GR, McSwain NE, Timby JW, Blackbourne LH, Stockinger Z, Strandenes G, Weiskopf RB, Gross K, Bailey JA. 14(3). 13 - 38. (Journal Article)

Abstract

This report reviews the recent literature on fluid resuscitation from hemorrhagic shock and considers the applicability of this evidence for use in resuscitation of combat casualties in the prehospital Tactical Combat Casualty Care (TCCC) environment. A number of changes to the TCCC Guidelines are incorporated: (1) dried plasma (DP) is added as an option when other blood components or whole blood are not available; (2) the wording is clarified to emphasize that Hextend is a less desirable option than whole blood, blood components, or DP and should be used only when these preferred options are not available; (3) the use of blood products in certain Tactical Field Care (TFC) settings where this option might be feasible (ships, mounted patrols) is discussed; (4) 1:1:1 damage control resuscitation (DCR) is preferred to 1:1 DCR when platelets are available as well as plasma and red cells; and (5) the 30-minute wait between increments of resuscitation fluid administered to achieve clinical improvement or target blood pressure (BP) has been eliminated. Also included is an order of precedence for resuscitation fluid options. Maintained as recommendations are an emphasis on hypotensive resuscitation in order to minimize (1) interference with the body's hemostatic response and (2) the risk of complications of overresuscitation. Hextend is retained as the preferred option over crystalloids when blood products are not available because of its smaller volume and the potential for long evacuations in the military setting.

Keywords: hemorrhage; fluid resuscitation; shock; plasma; blood products; damage control resuscitation

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Predicting When to Administer Blood Products During Tactical Aeromedical Evacuation: Evaluation of a US Model

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

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Keyword: blood transfusion

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Military Prehospital Use of Low Titer Group O Whole Blood

Warner N, Zheng J, Nix G, Fisher AD, Johnson JC, Williams JE, Northern DM, Hellums JS. 18(1). 15 - 18. (Case Reports)

Abstract

The military's use of whole-blood transfusions is not new but has recently received new emphasis by the Tactical Combat Casualty Care Committee. US Army units are implementing a systematic approach to obtain and use whole blood on the battlefield. This case report reviews the care of the first patient to receive low titer group O whole blood (LTOWB) transfusion, using a new protocol.

Keywords: blood transfusion; group O whole blood; Tactical Combat Casualty Care

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A Pilot Study of Four Intraosseous Blood Transfusion Strategies

Auten JD, Mclean JB, Kemp JD, Roszko PJ, Fortner GA, Krepela AL, Walchak AC, Walker CM, Deaton TG, Fishback JE. 18(3). 50 - 56. (Journal Article)

Abstract

Background: Intraosseous (IO) access is used by military first responders administering fluids, blood, and medications. Current IO transfusion strategies include gravity, pressure bags, rapid transfusion devices, and manual push-pull through a three-way stopcock. In a swine model of hemorrhagic shock, we compared flow rates among four different IO blood transfusion strategies. Methods: Nine Yorkshire swine were placed under general anesthesia. We removed 20 to 25mL/kg of each animal's estimated blood volume using flow of gravity. IO access was obtained in the proximal humerus. We then autologously infused 10 to 15mL/kg of the animal's estimated blood volume through one of four randomly assigned treatment arms. Results: The average weight of the swine was 77.3kg (interquartile range, 72.7kg-88.8kg). Infusion rates were as follows: gravity, 5mL/min; Belmont rapid infuser, 31mL/min; single-site pressure bag, 78mL/min; double-site pressure bag, 103mL/min; and push-pull technique, 109mL/min. No pulmonary arterial fat emboli were noted. Conclusion: The optimal IO transfusion strategy for injured Servicemembers appears to be single-site transfusion with a 10mL to 20mL flush of normal saline, followed immediately by transfusion under a pressure bag. Further study, powered to detect differences in flow rate and clinical complications. is required.

Keywords: blood transfusion; operational medicine; intraosseous infusion; intraosseous transfusion; hemorrhagic shock

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Case Presentation: Creation and Utilization of a Novel Field Improvised Autologous Transfusion System in a Combat Casualty

Scarborough T, Turconi M, Callaway DW. 19(2). 134 - 137. (Journal Article)

Abstract

This case report describes the technical aspects in first use of a novel field improvised autologous transfusion (FIAT) system. It highlights a potential solution for specific trauma patients during advanced resuscitative care (ARC) and prolonged field care (PFC) scenarios where other blood products are not available.

Keywords: blood transfusion; resuscitation; shock, hemorrhagic; fluid therapy; military medicine; warfare; unconventional medicine

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Keyword: blood, fresh whole

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Prolonged Field Care Working Group Fluid Therapy Recommendations

Baker BL, Powell D, Riesberg JC, Keenan S. 16(1). 112 - 117. (Journal Article)

Abstract

The Prolonged Field Care Working Group concurs that fresh whole blood (FWB) is the fluid of choice for patients in hemorrhagic shock, and the capability to transfuse FWB should be a basic skill set for Special Operations Forces (SOF) Medics. Prolonged field care (PFC) must also address resuscitative and maintenance fluid requirements in nonhemorrhagic conditions.

Keywords: prolonged field care; blood, fresh whole; shock, hemorrhagic; transfusion

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

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

Abstract

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

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

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Keyword: body armor

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Medical Provider Ballistic Protection at Active Shooter Events

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

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Keyword: body mass index

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The Importance of Physical Fitness for Injury Prevention: Part 2

Knapik JJ. 15(2). 112 - 115. (Journal Article)

Abstract

This report examines associations between injuries and flexibility, stretching, warm-up, and body composition. Military studies show that either too much or too little flexibility increases injury risk. Static stretching prior to exercise does not appear to reduce the overall injury incidence, although further research is needed on some types of injuries. Static stretching also appears to reduce strength and power (explosive strength). Warm-up (low intensity activity prior to exercise or sports) appears to reduce injury risk. Body mass index (BMI; weight in kg/ height in m²) is a surrogate measure of body fat because it is highly related to laboratory measures of body fat. However, Soldiers can also have a high BMI because of higher muscle mass. If high BMI reflects a larger percentage of body fat relative to height, injury risk might be increased because the additional fat would increase the intensity of physical activity, leading to more rapid fatigue and repetitive stress on the musculoskeletal system. Low BMI could reflect a paucity of fat or muscle/ bone, or both. Low BMI may make Soldiers more susceptible to injury if they lack the muscle mass or strength in the supportive structures (ligaments, bones) required to perform certain physical tasks, and if they overexert or overuse the available muscle mass or supportive structures. Studies in basic combat training show that both high and low BMI increases injury risk. However, studies among active duty Soldiers only show that injury risk increases as BMI increases, possibly because very few active duty Soldiers have very low BMI (i.e., less than 18 kg/m²).

Keywords: body mass index; physical fitness; injury prevention

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Keyword: Boko Haram

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Experience Of A US Air Force Surgical And Critical Care Team Deployed In Support Of Special Operations Command Africa

Delmonaco BL, Baker A, Clay J, Kilbourn 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

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Keyword: bone deterioration

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Effects of Oral Chondroitin Sulfate on Osteoarthritis-Related Pain and Joint Structural Changes: Systematic Review and Meta-Analysis

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

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Keyword: brachial plexus lesion

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Load Carriage-Related Paresthesias: Part 1: Rucksack Palsy and Digitalgia Paresthetica

Knapik JJ, Reynolds K, Orr R, Pope R. 16(4). 74 - 79. (Journal Article)

Abstract

This is the first of a two-part article discussing loadcarriage- related paresthesias, including brachial plexus lesions (rucksack palsy), digitalgia paresthetica, and meralgia paresthetica. Paresthesias are sensations of numbness, burning, and/or tingling, usually experienced as a result of nerve injury, compression, traction, or irritation. Rucksack palsy is a traction or compression injury to the brachial plexus, caused by the shoulder straps of the rucksack. The patient presents with paresthesia, paralysis, cramping with pain, and muscle weakness of the upper limb. Muscle-strength losses appear to be greater in those carrying heavier loads. Hypothetical risk factors for rucksack palsy include improper load distribution, longer carriage distances, and load weight. Nerve traction, compression, and symptoms may be reduced by use of a rucksack hip belt; wider, better-padded, and proper adjustment of the shoulder straps; reduction of weight in the rucksack; a more symmetric distribution of the load; and resistance training to improve the strength and hypertrophy of the shoulder muscles. Assessment and neck joint and nerve mobilization may relieve brachial plexus tension and reduce symptoms. Another load-carriage-related disorder is digitalgia paresthetica, likely caused by compression of the sensory digital nerves in the foot during load carriage. Patients have paresthesia in the toes. Although no studies have demonstrated effective prevention measures for digitalgia paresthetica, reducing loads and march distances may help by decreasing the forces and repetitive stress on the foot and lower leg. Specialty evaluations by a physical therapist, podiatrist, or other healthcare provider are important to rule out entrapment neuropathies such as tarsal tunnel syndrome. Part 2 of this article will discuss meralgia paresthetica.

Keywords: load-carriage-related paresthesia; brachial plexus lesion; rucksack palsy; digitalgia paresthetica; nerve compression; load distribution

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Keyword: brain

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The Agitated Patient

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

Abstract

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

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

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Keyword: bruxing

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Use of a Removable Mandibular Neuroprosthesis for the Reduction of Posttraumatic Stress Disorder (PTSD) and Mild Traumatic Brain Injury/PTSD-Associated Nightmares, Headaches, and Sleep Disturbances

Moeller DR, Duffey JM, Goolsby AM, Gallimore JT. 14(3). 64 - 73. (Journal Article)

Abstract

Introduction: Posttraumatic stress disorder (PTSD) has been associated with nighttime headaches (HAs), nightmares (NMs), and difficulty falling or staying asleep (sleep disturbances [SD]). The authors of the current study evaluated the correlative elements of using a removable mandibular neuroprosthesis (RMN) and the reduction of these symptoms in participants diagnosed with PTSD or mild traumatic brain injury (mTBI)/PTSD. The RMN device is a form of specialized dental splint that has a potential to reduce the painful stimuli of bruxing and potential upregulation of threat response systems that may occur during sleep. Method: A sample of 32 individuals was selected through random assignment from a volunteer base of 200 volunteers for examination by self-report according to an A-B-A-B design. The sample included 25 men and 7 women between the ages of 21 and 65; 21 had military experience and 11 were civilians. Participants were asked to rate the frequency and intensity of their HAs, NMs, and SD during each phase. Their responses were scored using a custom survey (equivalent forms reliability) that provides ratio-scaled results for symptom frequency and intensity. The original number of participants was 35 with three participants dropping out before the conclusion of the study. Results: Survey scores for PTSD-related sleep symptoms were relatively high at baseline (x̄ = 0.52) and significantly lower in the first experimental phase (x̄ = 0.20). Scores in the second experimental phase were likewise lower (x̄ = 0.38). Significant reductions in symptoms were reported across all three dimensions. Discussion: All participants reported some improvement in symptoms while using the device. No participants reported worsening of any symptoms as a result of using the RMN. Participants commonly reported that improvements in symptoms were immediate and did not diminish over time. Data indicate that there is a negative correlation between the use of an RMN and the reduction of HAs, NMs, and SD in persons diagnosed with PTSD or mTBI/PTSD.

Keywords: PTSD; mTBI; nightmares; headaches; sleep disturbances; DIMS; bruxism; bruxing; splint

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Keyword: bruxism

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Use of a Removable Mandibular Neuroprosthesis for the Reduction of Posttraumatic Stress Disorder (PTSD) and Mild Traumatic Brain Injury/PTSD-Associated Nightmares, Headaches, and Sleep Disturbances

Moeller DR, Duffey JM, Goolsby AM, Gallimore JT. 14(3). 64 - 73. (Journal Article)

Abstract

Introduction: Posttraumatic stress disorder (PTSD) has been associated with nighttime headaches (HAs), nightmares (NMs), and difficulty falling or staying asleep (sleep disturbances [SD]). The authors of the current study evaluated the correlative elements of using a removable mandibular neuroprosthesis (RMN) and the reduction of these symptoms in participants diagnosed with PTSD or mild traumatic brain injury (mTBI)/PTSD. The RMN device is a form of specialized dental splint that has a potential to reduce the painful stimuli of bruxing and potential upregulation of threat response systems that may occur during sleep. Method: A sample of 32 individuals was selected through random assignment from a volunteer base of 200 volunteers for examination by self-report according to an A-B-A-B design. The sample included 25 men and 7 women between the ages of 21 and 65; 21 had military experience and 11 were civilians. Participants were asked to rate the frequency and intensity of their HAs, NMs, and SD during each phase. Their responses were scored using a custom survey (equivalent forms reliability) that provides ratio-scaled results for symptom frequency and intensity. The original number of participants was 35 with three participants dropping out before the conclusion of the study. Results: Survey scores for PTSD-related sleep symptoms were relatively high at baseline (x̄ = 0.52) and significantly lower in the first experimental phase (x̄ = 0.20). Scores in the second experimental phase were likewise lower (x̄ = 0.38). Significant reductions in symptoms were reported across all three dimensions. Discussion: All participants reported some improvement in symptoms while using the device. No participants reported worsening of any symptoms as a result of using the RMN. Participants commonly reported that improvements in symptoms were immediate and did not diminish over time. Data indicate that there is a negative correlation between the use of an RMN and the reduction of HAs, NMs, and SD in persons diagnosed with PTSD or mTBI/PTSD.

Keywords: PTSD; mTBI; nightmares; headaches; sleep disturbances; DIMS; bruxism; bruxing; splint

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Keyword: building partner capacity in health (BPC-H)

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A Case Study of MEDCANGRO Relative to RAND Conceptual Framework*

Scott A, Hogan R. 15(2). 123 - 131. (Journal Article)

Abstract

The 2010 Department of Defense (DoD) Instruction 6000.16, Military Health Support for Stability Operations, established medical stability operations as a core military mission. National military leaders appreciated that to better manage risks for US military personnel operating in far forward locations, reduce cost and footprint requirements for operations, and aid partner nations with providing service to relevant populations in underserviced/undergoverned the US military would need to be employed strategically in efforts to build partner nation medical capacity. Medical Stability Operations has evolved into Global Health Engagement in the lexicon of planners but the goal is still the same. This article used a technical report authored by the RAND Corporation as the basis of a case study of a Special Operations Command Africa (SOCAF) Mission to the country of Niger to build a casualty evacuation capability. The case study evaluates the utility of a hypothetical framework developed by the RAND researchers relative to the actual events and outcomes of an actual mission. The principal finding is that the RAND technical report is of value to planners, Operators, and trainers as a systematic approach to successful building partner capacity in health (BPC-H) missions. The article also offers several examples of metrics that aid leadership in making better decisions as to when corrective actions might be required.

Keywords: building partner capacity in health (BPC-H); global health engagement (GHE); international health mission; medical stability operations (MSO)

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Keyword: Burma

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Humanitarian Struggle in Burma's Conflict Zones

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

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Keyword: burn injury

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Care of the Burn Casualty in the Prolonged Field Care Environment

Studer NM, Driscoll IR, Daly IM, Graybill JC. 15(3). 86 - 93. (Journal Article)

Abstract

Burns are frequently encountered on the modern battlefield, with 5% - 20% of combat casualties expected to sustain some burn injury. Addressing immediate lifethreatening conditions in accordance with the MARCH protocol (massive hemorrhage, airway, respirations, circulation, hypothermia/head injury) remains the top priority for burn casualties. Stopping the burning process, total burn surface area (TBSA) calculation, fluid resuscitation, covering the wounds, and hypothermia management are the next steps. If transport to definitive care is delayed and the prolonged field care stage is entered, the provider must be prepared to provide for the complex resuscitation and wound care needs of a critically ill burn casualty.

Keywords: burn injury; inhalation injury; Tactical Combat Casualty Care; prolonged field care; Silverlon; Water-Jel; Burntec

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Keyword: burns, chemical

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Garlic Burn to the Face

Oberle M, Wachs T, Brisson P. 16(4). 80 - 81. (Journal Article)

Abstract

Topical burns from the use of garlic have been reported rarely in the medical literature. Most cases have resulted from the use of naturopathic or home remedy treatments. A 20-year-old male military Servicemember presented to a military wound care clinic 7 days after applying a homemade topical preparation of garlic to the zygomatic region of the right side of his face. The patient had consulted the Internet for treatment of a minor skin lesion in that area. He created a garlic paste, applied it to the affected area, and covered it with a dressing. Twelve hours later, he noted an intense burning sensation where he had applied the garlic paste. After the initial blistering, the patient recovered without any additional treatment. Second-degree burns were an unintended consequence of the use of garlic as a home remedy.

Keywords: burns, chemical; garlic; military personnel

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Keyword: Burntec

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Care of the Burn Casualty in the Prolonged Field Care Environment

Studer NM, Driscoll IR, Daly IM, Graybill JC. 15(3). 86 - 93. (Journal Article)

Abstract

Burns are frequently encountered on the modern battlefield, with 5% - 20% of combat casualties expected to sustain some burn injury. Addressing immediate lifethreatening conditions in accordance with the MARCH protocol (massive hemorrhage, airway, respirations, circulation, hypothermia/head injury) remains the top priority for burn casualties. Stopping the burning process, total burn surface area (TBSA) calculation, fluid resuscitation, covering the wounds, and hypothermia management are the next steps. If transport to definitive care is delayed and the prolonged field care stage is entered, the provider must be prepared to provide for the complex resuscitation and wound care needs of a critically ill burn casualty.

Keywords: burn injury; inhalation injury; Tactical Combat Casualty Care; prolonged field care; Silverlon; Water-Jel; Burntec

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Keyword: BVM

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A Comparison of Ventilation Rates Between a Standard Bag-Valve-Mask and a New Design in a Prehospital Setting During Training Simulations

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

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Keyword: cadaver

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A Comparison Of Direct Versus Indirect Laryngoscopic Visualization During Endotracheal Intubation Of Lightly Embalmed Cadavers Utilizing The Glide Scope®, Storz Medi Pack Mobile Imaging Systemt™ And The New Storz C-MAC™ Videolaryngoscope

Boedeker BH, Nicholas TA, Carpenter J, Leighton S, Bernhagen MA, Murray WB, Wadman MC. 11(3). 21 - 29. (Journal Article)

Abstract

Background: Studies indicate that the skills needed to use video laryngoscope systems are easily learned by healthcare providers. This study compared several video laryngoscopic (VL) systems and a direct laryngoscope (DL) view when used by medical residents practicing intubation on cadavers. The video devices used included the Storz Medi Pack Mobile Imaging SystemTM, the Storz CMAC® VL System and the GlideScope®. Methods:After Institutional Review Board (IRB) approval, University of Nebraska Medical Center, Department of Emergency Medicine (UNMC EM) residents were recruited and given a brief pre-study informational period. The cadavers were lightly embalmed. The study subjects were asked to perform intubations on two cadavers using both DL and VL while using the three different VL systems. Procedural data was recorded for each attempt and pre and post experience perceptions were collected. Results: N=14. All subjects reported their varied previous intubation experience. The average airway score using DL: for the Storz VL was 1.54 (SD = 0.576) and for the C-MAC was 1.46 (SD = 0.637). Success in intubation of the standard airway using DL was 93% versus a 100% success rate when intubating with indirect VL visualization. Conclusion: Based on our data, we believe that the incorporation of VL into cadaver airway management training provided an improved learning environment for the study residents. In our study, the resident subjects were 93% successful with DL intubation even though 50% had less than 30 intubations. As well, there was a 100% success rate when intubating with indirect VL visualization. In conclusion, the researchers believe this cadaver model incorporated with VL is a powerful tool which may help improve the overall learning curve for orotracheal intubation.

Keywords: videolaryngoscopy; prehospital; direct laryngoscopy; indirect laryngoscopy; intubation; cadaver

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Keyword: cadaver training

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A Medical Training Event for Special Forces Medical Sergeants

Hellums JS. 12(1). 56 - 61. (Journal Article)

Abstract

Special Forces Medical Sergeants (SFMS) are independent multidisciplinary medical personnel who possess unique medical skill sets that require regular practice in order to maintain proficiency. Due to high operational tempo, the windows of opportunity to practice these abilities are usually limited to short periods of required training to maintain credentials. A Special Forces (SF) Battalion allowed their medical section to orchestrate a weeklong medical training event that included emergency procedure lectures, human cadaver training, ultrasound familiarization, medical administration instruction, and behavioral health discussions. This training enabled the SFMS to hone their competencies and increase their clinical confidence while working and learning from each other and other medical providers. The training event was a great success.

Keywords: Special Forces; skills sustainment; cadaver training; ultrasound; emergency medical procedures

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Keyword: caffeine

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Associations Among Back and Extremity Pain With Alcohol, Tobacco, and Caffeine Use Among US Air Force Pararescuemen

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

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Sleep As A Strategy For Optimizing Performance

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

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Caffeine and Performance

Yarnell AM, Deuster PA. 16(4). 64 - 70. (Journal Article)

Abstract

The role of caffeine in enhancing performance has been studied for years, and there is no doubt that caffeine can be performance enhancing. Also, a wealth of information allows for an interesting distinction between physical and cognitive performance. Most adults in America consume moderate doses of caffeine in various forms on a daily basis as caffeine is typically found in coffee, tea, soft drinks, dietary supplements, energy drinks, energy shots, and chocolate, as well as over-the-counter pills and gums. Although caffeine is readily available and widely consumed, when using it to enhance performance, a few factors should be considered. The authors discuss caffeine use among Servicemembers, its properties and effects on physical and cognitive performance, how to use it to optimize performance, and, finally, some of safety and regulatory considerations. The bottom line is that all individuals do not respond the same way to caffeine and their response depends on how the body uses and breaks down caffeine. Thus, as a user, you should monitor your own responses and performance changes when using caffeine based on the general recommendations provided.

Keywords: caffeine; performance enhancement

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Keyword: CAMELBAK Cleaning Tab&tm;

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

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

Abstract

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

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

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Keyword: Canadian C-spine rule, NEXUS Criteria

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Walking the Plank

Banting J, Meriano T. 16(3). 57 - 61. (Journal Article)

Abstract

Concepts and Objectives: 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: cervical spinal injury; Canadian C-spine rule, NEXUS Criteria; cervical collar

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Keyword: canine

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Review of Canine Deaths While in Service in US Civilian Law Enforcement (2002-2012)

Stojsih SE, Baker JL, Les CM, Bir CA. 14(4). 86 - 91. (Journal Article)

Abstract

Background: Working dogs have been proven effective in multiple military and law enforcement applications. Similar to their human counterparts, understanding mortality while still in service can help improve treatment of injuries, and improve equipment and training, to potentially reduce deaths. This is a retrospective study to characterize mortality of working dogs used in civilian law enforcement. Methods: Reported causes of death were gathered from two working dog and law enforcement officer memorial websites. Results: Of the 867 civilian law enforcement dogs reported to these memorial websites from 2002 to 2012 with reported causes of death while in service, the deaths of 318 were categorized as traumatic. The leading reported causes of traumatic death or euthanasia include trauma as a result of a vehicle strike, 25.8% (n = 82); heatstroke, 24.8% (n = 79); and penetrating ballistic trauma, 23.0% (n = 73). Conclusion: Although the information gathered was from online sources, this study casts some light on the risks that civilian law enforcement dogs undergo as part of the tasks to which they are assigned. These data underscore the need for a comprehensive database for this specialized population of working dogs to provide the robust, reliable data needed to develop prevention and treatment strategies for this valuable resource.

Keywords: canine; mortality; law enforcement; trauma

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The Operational Canine and K9 Tactical Emergency Casualty Care Initiative

Palmer LE, Maricle R, Brenner J. 15(3). 32 - 38. (Journal Article)

Abstract

Background: Approximately 20% to 25% of traumarelated, prehospital fatalities in humans are due to preventable deaths. Data are lacking, however, on the nature and the prevalence of operational canine (OC) prehospital deaths. It is plausible that OCs engaged in high-threat operations are also at risk for suffering some type of preventable death. Tactical Combat Casualty Care has significantly reduced human fatality rates on the battlefield. Standardized guidelines specifically for prehospital trauma care have not been developed for the OC caregiver. An initiation has been approved by the Committee for Tactical Emergency Casualty Care to form a K9-Tactical Emergency Casualty Care (TECC) working group to develop such guidelines. Significance: The intent of the K9-TECC initiative is to form best practice recommendations for the civilian high-risk OC caregiver. These recommendations are to focus on interventions that (1) eliminate the major causes of canine out-of-hospital preventable deaths, (2) are easily learned and applied by any civilian first responder, and (2) minimize resource consumption.

Keywords: canine; trauma; preventable death; Tactical Emergency Casualty Care; K9-TECC; guidelines

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Estimation of Dog-Bite Risk and Related Morbidity Among Personnel Working With Military Dogs

Schermann H, Eiges N, Sabag A, Kazum E, Albagli A, Salai M, Shlaifer A. 17(3). 51 - 54. (Journal Article)

Abstract

Background: Soldiers serving in the Israel Defense Force Military Working Dogs (MWD) Unit spend many hours taming dogs' special skills, taking them on combat missions, and performing various dogkeeping activities. During this intensive work with the aggressive military dogs, bites are common, and some of them result in permanent disability. However, this phenomenon has not been quantified or reported as an occupational hazard. Methods: This was a retrospective cohort study based on self-administered questionnaires. Information was collected about soldiers' baseline demographics, duration of the experience of working with dogs, total number of bites they had, circumstances of bite events, and complications and medical treatment of each bite. Bite risk was quantified by incidence, mean time to first bite, and a Cox proportional hazards model. Rates of complications and the medical burden of bites were compared between combat soldiers and noncombat dogkeepers. Bite locations were presented graphically. Results: Seventy-eight soldiers participated and reported on 139 bites. Mean time of working with dogs was 16 months (standard deviation, ±9.4 months). Overall bite incidence was 11 bites per 100 person-months; the mean time to first bite event was 6.3 months. The Cox proportional hazards model showed that none of baseline characteristics significantly increased bite hazard. About 90% of bites occurred during routine activities, and 3.3% occurred on combat missions. Only in 9% of bite events did soldiers observed the safety precautions code. Bite complications included fractures, need for intravenous antibiotic treatment and surgical repair, prominent scarring, diminished sensation, and stiffness of proximal joints. Bite complications were similar between combat soldiers and dogkeepers. Most bites (57%) were located on hands and arms. Conclusion: MWD bites are an occupational hazard resulting in significant medical burden. Hands and arms were most common bite locations. Observance of safety precautions may be the most appropriate first-line preventive intervention. Barrier protection of upper extremities may reduce bite severity and complication rates.

Keywords: canine; combat; bites, dog; dogs, military working; Israeli Army; dog keepers

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Concepts of Prehospital Advanced Airway Management in the Operational K9: A Focus on Cricothyrotomy

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

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Keyword: canine medicine

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Clinical Update: The Risk of Opioid Toxicity and Naloxone Use in Operational K9s

Palmer LE, Gautier A. 17(4). 86 - 92. (Journal Article)

Abstract

The increasing use of opioids (e.g., fentanyl, carfentanil) for illicit drug manufacturing poses a potential life-threatening hazard to law enforcement officers and first responders (e.g., EMS, fire and rescue) who may unknowingly come into contact with these drugs during the course of their daily activities. Similarly, Operational canines (OpK9s) of all disciplines-detection (drug, explosive, accelerant), patrol, tracking, search and rescue, and others-are at risk for accidental illicit opioid exposure. The most serious adverse effect of opioid exposure is respiratory depression leading to slow, shallow breathing or complete cessation of voluntary breathing (respiratory arrest). Naloxone, an opioid antagonist, is the antidote for reversing the effects of an opioid overdose in both humans and OpK9s. This clinical update describes the potential risks associated with opioid exposure as well as the use of naloxone as it pertains to the OpK9.

Keywords: Operational K9s; opioid; naloxone; intranasal; overdose; canine medicine

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Keyword: canines

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A Prospective Randomized Controlled Two-Arm Clinical Study Evaluating the Efficacy of a Bioelectric Dressing System for Blister Management in US Army Ranger Recruits

Housler GJ, Cross S, Marcel V, Kennedy DO, Husband M, Register A, Roberts T, Grubbs S, Dudewicz D, Setka n, Bay C, Wendelken ME, Izadjoo MJ. 17(2). 49 - 58. (Journal Article)

Abstract

This study focused on a clinically relevant healthcare problem in the military: acute soft tissue wounds, or blisters. The trial was a prospective, controlled, randomized two-arm study evaluating the efficacy of a bioelectric dressing, Procellera®, applied topically two to three times per week for 2 weeks to blisters developed in Ranger trainees during training at Fort Benning, Georgia. A total of 80 US Army Ranger recruits with blister wounds below the knee were randomly assigned to one of two treatment groups (n = 40/group). The primary goal was to assess the clinical efficacy (rate of healing) of administered Procellera in conjunction with the standard-of-care (SOC) treatment, moleskin and Tegaderm ®, on the healing rate of blisters compared with the SOC treatment alone. The secondary end points for efficacy were the quantities of wound fluid biomarkers and bacterial bioburden. The tertiary end point was assessment of pain in the treatment group compared with that of the control group during the 2-week study. The results showed no statistical difference between the SOC and SOC+Procellera groups in wound healing and pain. Wound fluid was reported for 24 participants (64.9%) in the SOC group and 21 participants (56.8%) in SOC+Procellera group at the baseline measurement (ρ = .475); however, the wounds were devoid of fluid on follow-up visits. The mild nature of the wounds in this study was apparent by the low pain scores at the beginning of the study, which disappeared by the follow-up visits. The average wound sizes were 2.2cm2 and 1.5cm2 for the SOC and SOC+Procellera groups, respectively. This trial protocol should be conducted on open softtissue wounds in severe heat. To our knowledge, this is the first clinical study conducted within the US Army Rangers training doctrine.

Keywords: canines; K9s; Operational K9s; Tactical Emergency Casualty Care; Procellera®; dressing, bioelectric; wound, acute; Rangers

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TacMed Updates: K9 Tactical Emergency Casualty Care Direct Threat Care Guidelines

Palmer LE, Yee A. 17(2). 174 - 187. (Classical Conference)

Abstract

Keywords: canines; K9s; Operational K9s; Tactical Emergency Casualty Care

Comparison of Postexercise Cooling Methods in Working Dogs

Davis MS, Marcellin-Little DJ, O'Connor E. 19(1). 56 - 60. (Journal Article)

Abstract

Background: Overheating is a common form of injury in working dogs. The purpose of this study was to evaluate the relative efficacy of three postexercise cooling methods in dogs with exercise-induced heat stress. Methods: Nine athletically conditioned dogs were exercised at 10kph for 15 minutes on a treadmill in a hot environmental chamber (30°C) three times on separate days. After exercise, the dogs were cooled using one of three Methods: natural cooling, cooling on a 4°C cooling mat, and partial immersion in a 30°C water bath for 5 minutes. Results: Time-weighted heat stress was lower for immersion cooling compared with the cooling mat and the control. The mean time required to lower gastrointestinal temperature to 39°C was 16 minutes for immersion cooling, 36 minutes for the cooling mat, and 48 minutes for control cooling. Conclusion: Water immersion decreased postexercise, time-weighted heat stress in dogs and provided the most rapid cooling of the three methods evaluated, even with the water being as warm as the ambient conditions. The cooling mat was superior to cooling using only fans, but not as effective as immersion. The placement of simple water troughs in working- dog training areas, along with specific protocols for their use, is recommended to reduce the occurrence of heat injury in dogs and improve the treatment of overheated dogs.

Keywords: canines; hyperthermia; heat injury

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In Vitro Compatibility of Canine and Human Blood: A Pilot Study

Edwards TH, Wienandt NA, Baxter RL, Mays EL, Gay SD, Cap AP. 19(2). 95 - 99. (Journal Article)

Abstract

Military working dogs (MWDs) are force multipliers that are exposed to the same risks as their human counterparts on the battlefield. Hemostatic resuscitation using blood products is a cornerstone of damage control resuscitation protocols for both humans and dogs. Canine-specific blood products are in short supply in mature theaters due to logistic and regulatory concerns and are almost nonexistent in austere environments, whereas human blood products are readily available at most surgical facilities. The objective of this study was to evaluate the in vitro compatibility of human and canine blood by using standard crossmatching techniques with the canine blood acting as the recipient and the human blood acting as the donor. Blood samples were collected from 20 government-owned canines (GOCs) and 7 healthy human volunteers in addition to washed red blood cells (RBCs) from a commercial blood typing kit. Major and minor crossmatches were conducted as well as a protein denatured crossmatch. All samples in this study showed strong cross-reactivity, with the majority demonstrating profound hemolysis and a minority showing substantial agglutination. Based on the results of this study, transfusion of human blood to an MWD cannot be recommended at this time.

Keywords: xenotransfusion; crossmatch; canines

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Keyword: canines, multipurpose

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Blood Lead Toxicity Analysis of Multipurpose Canines and Military Working Dogs

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

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Keyword: cannot intubate-cannot ventilate

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Intubation of the Right Atrium During an Attempted Modified Surgical Airway in a Pig

Bowman J, Juergens A, McClure M, Spear D. 17(2). 96 - 100. (Journal Article)

Abstract

In modern medicine, the surgical cricothyrotomy is an airway procedure of last resort. In austere environments, however, its simplicity may make it a more feasible option than carrying a full complement of laryngoscopes. To create a Transportation Security Agency-compliant compact first-response bag, we attempted to establish a surgical cricothyrotomy in a pig, using trauma shears, basic medical scissors, a pocket bougie, and an endotracheal tube. Bougies can provide tactile feedback via the "tracheal ring sign" and "stop sign" to indicate positive tracheal placement during orotracheal intubation. We report on a previously unknown serious potential complication that questions the use of scissors to establish a surgical airway and the reliability of tactile bougie signs when translated into certain surgical airways.

Keywords: emergency cricothyrotomy; cannot intubate-cannot ventilate; prehospital airway management

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Keyword: capability-based blueprinting

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Optimizing Warfighter Lethality Through Human Performance Education

Deuster PA, Lunasco T, Messina LA. 19(2). 100 - 104. (Journal Article)

Abstract

Humans are the heart of our warfighting efforts and, as such, human performance must be optimized and sustained to maintain effective and successful SOF Operators over the long haul. How do we do this? Based on the July 2018 signing of a Joint Requirements Oversight Council Memo (JROC) making Total Force Fitness (TFF) a required framework for taking care of our military Servicemembers, we propose three solutions for further optimizing the performance of SOF. The proposed solutions are human performance optimization (HPO)/TFF capability-based blueprinting (CBB), HPO integrator profession (HPO-I), and HPO-centric education and training across the total force. These solutions would potentiate the Preservation of the Force and Family (POTFF) concept by improving the targeting of resources and support of Operator and unit operational readiness. These solutions, the knowledge, skills, abilities, and experiences in HPO from a holistic perspective and the opportunity to obtain college credits through the Uniformed Services University of the Health Sciences (USU) College of Allied Health Sciences (CAHS) are described here.

Keywords: capability-based blueprinting; human performance education; human performance integrator

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Keyword: captivity

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An Introduction to Survival, Evasion, Resistance, and Escape (SERE) Medicine

Smith MB. 13(2). 25 - 32. (Journal Article)

Abstract

When an individual finds himself/herself in a survival, evasion, resistance, or escape (SERE) scenario, the ability to treat injuries/illnesses can be the difference between life and death. SERE schools are responsible for preparing military members for these situations, but the concept of SERE medicine is not particularly well defined. To provide a comprehensive working description of SERE medicine, operational and training components were examined. Evidence suggests that SERE medicine is diverse, injury/illness patterns are situationally dependent, and treatment options often differ from conventional clinical medicine. Ideally, medical lessons taught in SERE training are based on actual documented events. Unfortunately, the existing body of literature is dated and does not appear to be expanding. In this article, four distinct facets of SERE medicine are presented to establish a basis for future discussion and research. Recommendations to improve SERE medical curricula and data-gathering processes are also provided.

Keywords: SERE; survival, evasion, resistance, escape; captivity; isolation; wilderness

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Keyword: carbohydrate

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The 10 Commandments of Nutrition: 2014

Deuster PA, Lindsey AT, Butler FK. 14(3). 80 - 89. (Journal Article)

Abstract

The US Special Operations Command requires sound recommendations on nutrition to ensure optimal performance of Special Operations personnel. New information continues to emerge, and previous recommendations need to be modified as the evidence base continues to grow. The first 10 Commandments of Nutrition were published in the SEAL professional journal Full Mission Profile in 1992, published for the second time in this journal in 2005, and now revised a second time to reflect the newest science. Whether you are part of the Special Operations Forces (SOF) community or an athlete seeking to improve your performance, these are simple and helpful nutrition guidelines to follow.

Keywords: dietary supplements; omega-3 fatty acids; protein; carbohydrate; grains; fresh fruits and vegetables

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Energy Balance and Diet Quality During the US Marine Corps Forces Special Operations Command Individual Training Course

Sepowitz JJ, Armstrong NJ, Pasiakos SM. 17(4). 109 - 113. (Journal Article)

Abstract

Methods: This study characterized the total daily energy expenditure (TDEE), energy intake (EI), body weight, and diet quality (using the Healthy Eating Index-2010 [HEI]) of 20 male US Marines participating in the 9-month US Marine Corps Forces Special Operations Command Individual Training Course (ITC). Results: TDEE was highest (ρ < .05) during Raider Spirit (RS; 6,376 ± 712kcal/d) compared with Survival, Evasion, Resistance, and Escape (SERE; 4,011 ± 475kcal/d) School, Close-Quarters Battle (CQB; 4,189 ± 476kcal/d), and Derna Bridge (DB; 3,754 ± 314kcal/d). Body mass was lost (ρ < .05) during SERE, RS, and DB because EI was less than TDEE (SERE, -3,665kcal/d ± 475kcal/d; RS, -3,966 ± 776kcal/d; and DB, -1,027 ± 740kcal/d; p < .05). However, body mass was restored before the start of each subsequent phase and was not different between the start (86.4 ± 9.8kg) and end of ITC (86.7 ± 9.0kg). HEI score declined during ITC (before, 65.6 ± 11.2 versus after, 60.9 ± 9.7; p < .05) because less greens or beans and more empty calories were consumed (ρ < .05). Dietary protein intake was lowest during RS (0.9 ± 0.4g/kg) compared with all other phases, and carbohydrate intake during RS (3.6 ± 1g/kg), CQB (3.6 ± 1.0g/kg), and DB (3.7 ± 1.0g/kg) was lower than during the academic phase of SERE (5.1 ± 1.0g/kg; p < .05). Conclusion: These data suggest that ITC students, on average, adequately restore body mass between intermittent periods of negative energy balance. Education regarding the importance of maintaining healthy eating patterns while in garrison, consuming more carbohydrate and protein, and better matching EI with TDEE during strenuous training exercises may be warranted.

Keywords: Special Operations Forces; protein; carbohydrate; fatigue, volitional; military dietary reference intakes; weight loss

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Keyword: cardiac

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A Soldier With an Exertional Heat Injury, Ischemic-Appearing Electrocardiogram, and Elevated Troponins: A Clinical Case Report

Schauer SG, Pfaff JA. 17(1). 14 - 16. (Case Reports)

Abstract

Heat injuries are a common occurrence in the military training setting due to both the physically demanding nature of the training and the environments in which we train. Testing is often done after the diagnosis of a heat injury to screen for abnormalities. We present the case of a 20-year-old male Soldier with an abnormal electrocardiogram (ECG) with a possible injury pattern and an elevated troponin level. He underwent a diagnostic cardiac angiogram, which demonstrated no abnormal findings. He was returned to duty upon recovery from the catheterization. Ischemic-appearing ECG and troponin findings may be noted after heat injury. In this case, it was not associated with any cardiac lesions.

Keywords: injury, heat; heat-associated injuries; electrocardiogram; cardiac

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Keyword: cardiac risk

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Special Operations Soldier With Cardiac Family History: Use of CCTA and Protein Biomarker Testing to Detect Risk of Heart Attack From Noncalcified Plaque

Singh M, Kroman A, Singh J, Tariq H, Amin S, Morales-Pablon CA, Cahill KV, Harrison EE. 15(1). 7 - 10. (Case Reports)

Abstract

Objective: We sought to characterize the risk of a heart attack in a 48-year-old asymptomatic US Special Operations Command (SOCOM) Soldier without known coronary artery disease (CAD). Background: CAD continues to be a leading cause of morbidity and mortality among most age groups in the United States. Much research is dedicated to establishing new techniques to predict myocardial infarction (MI). Methods: Coronary computed tomography (CT) angiography, also known as CCTA, along with 7-protein serum biomarker risk assessment was performed for risk evaluation. Results: A 48-year-old SOCOM Soldier with a family history of heart disease had skeletal chest pain from war injuries and a 5-fold higher risk of heart attack over the next 5 years on the basis of protein markers. A nonobstructive left anterior descending coronary artery (LAD) plaque with a lipid-rich core and a thin fibrous cap (i.e., vulnerable plaque) was detected by CCTA. The patient was warned about his risk and prescribed four cardiac medications and scheduled for angioplasty even though he fell outside the guidelines by not having a severe obstructive blockage. Four days later, unfortunately, he had a heart attack before starting his medications and before angioplasty. Conclusion: CCTA with biomarker testing may have an important role in predicating acute coronary syndrome (ACS) in Special Operations Forces (SOF) Soldiers with at least one risk factor. Conventional stress testing and nuclear scanning would not detect non-flow-limiting vulnerable plaques in vulnerable patients. In order to collect more data, the PROTECT Registry has been started to evaluate asymptomatic Soldiers with at least one risk factor referred to the clinic by military physicians.

Keywords: cardiac risk; heart attack; CCTA; risk assessment

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Keyword: cardiorespiratory endurance

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The Importance of Physical Fitness for Injury Prevention: Part 1

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

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Keyword: care under fire

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CBRNE TC3: A Hybrid Approach to Casualty Care in the CBRNE Environment

Strain JE. 13(2). 44 - 53. (Journal Article)

Abstract

The implementation of Tactical Combat Casualty Care (TCCC) guidelines for the Operation Enduring Freedom and Operation Iraqi Freedom contingency operations has dramatically reduced preventable combat deaths. A study of these principles and their application to medical treatment in the chemical, biological, radiological, nuclear, and high-yield explosives (CBRNE), weapons of mass destruction (WMD) environment is presented as a potential readiness and force multiplier for units engaged in this area of operations. Preparing medical operators for support of WMD sampling and mitigation missions requires extensive preventive medicine and post-exposure and downrange trauma threat preparedness. Training and equipping CBRN operators with treatment skills and appropriate interventional material requires pre-implementation planning specific to WMD threats (e.g., anthrax, radiation, organophosphates, and contaminated trauma). A scenario-based study reveals the tactics, techniques, and procedures for training, resourcing, and fielding the CBRN operator of the future.

Keywords: TCCC Guideline; tactical field care; care under fire; WMD threats

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Keyword: care, out-of-hospital

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Resuscitation During Critical Care Transportation in Afghanistan

Tobin JM, Nordmann GR, Kuncir EJ. 15(3). 72 - 75. (Journal Article)

Abstract

Objective: These data describe the critical care procedures performed on, and the resuscitation markers of, critically wounded personnel in Afghanistan following point of injury (POI) transports and intratheater transports. Providing this information may help inform discussion on the design of critical care transportation platforms for future conflicts. Methods: The Department of Defense Trauma Registry (DoDTR) was queried for descriptive data on combat casualties with Injury Severity Score (ISS) greater than 15 who were transported in Operation Enduring Freedom (OEF) from 1 January 2010 to 31 December 2010. Both POI transportation events and interfacility transportation events were reviewed. Base deficit (BD) was evaluated as a maker of resuscitation, and international normalized ratio (INR) was evaluated as a measure of coagulopathy. Results: There were 1198 transportation events that occurred during the study period - 634 (53%) transports from the POI and 564 (47%) intratheater transports. Critical care interventions were performed during 147 (12.3%) transportation events, including intubation, cricothyrotomy, double-lumen endotracheal tube placement, needle or tube thoracostomy, central venous access placement, and cardiopulmonary resuscitation. The mean BD on arrival in the emergency department was -5.4 mEq/L for POI transports and 0.68 mEq/L intratheater transports (ρ < .001). The mean INR on arrival in the emergency department was 1.48 for POI transports and 1.21 for intratheater transports (ρ < .001). Conclusions: Critical care interventions were needed frequently during evacuation of severely injured personnel. Furthermore, many troops arrived acidotic and coagulopathic following initial transport from POI. Together, these data suggest that a platform capable of damage control resuscitation and critical care interventions may be warranted on longer transports of more critically injured patients.

Keywords: transportation; critical care; resuscitation, trauma; damage control; emergency medical services; care, out-of-hospital

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Keyword: caregiver

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Use Your Noodle to Simulate Tourniquet Use on a Limb With and Without Bone

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

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Keyword: caregivers

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Learning Curves of Emergency Tourniquet Use Exploring for Utility in Training

Kragh JF, Mabry RL, Parsons DL, Broussard DW, Aden JK, Dubick MA. 16(4). 7 - 14. (Journal Article)

Abstract

Background: Emergency tourniquet use to control hemorrhage from limb wounds is associated with improved survival and control of shock. In 2013, we introduced a way to measure learning curves of tourniquet users. With a dataset from an unrelated study, we had an opportunity to explore learning in detail. The study aim was to generate hypotheses about measurement methods in the learning of tourniquet users. Methods: We gathered data from a previous experiment that yielded a convenient sample of repeated tourniquet applications used as a marker of learning. Data on consecutive applications on a manikin were used in the current report and were associated with two users, three models of tourniquet, and six metrics (i.e., effectiveness, pulse cessation, blood loss, time to effectiveness, windlass turn number, and pressure applied). There were 840 tests (140 tests per user, two users, three models). Results: Unique characteristics of learning were associated with each user. Hypotheses generated included the following: trainee learning curves can vary in shape (e.g., flat, curved) by which metric of learning is chosen; some metrics may show much learning, whereas others show almost none; use of more than one metric may assess more comprehensively than using only one metric but may require more assessment time; number of uses required can vary by instructional goal (e.g., expertise, competence); awareness of the utility of specific metrics may vary by instructor; and some, but not all, increases in experience are associated with improved performance. Conclusions: This first-aid study generated hypotheses about caregiver learning for further study of tourniquet education and standards.

Keywords: first aid device; first aid education; first aid standards; first aid methods; caregivers; hemorrhage preventions; hemorrhage control; hemorrhage therapy; resuscitation; emergency medical services

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Keyword: CASEVAC

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Experience Of A US Air Force Surgical And Critical Care Team Deployed In Support Of Special Operations Command Africa

Delmonaco BL, Baker A, Clay J, Kilbourn 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

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Survey of Casualty Evacuation Missions Conducted by the 160th Special Operations Aviation Regiment During the Afghanistan Conflict

Redman TT, Mayberry KE, Mora AG, Benedict BA, Ross EM, Mapp JG, Kotwal RS. 18(2). 79 - 85. (Journal Article)

Abstract

Background: Historically, documentation of prehospital combat casualty care has been relatively nonexistent. Without documentation, performance improvement of prehospital care and evacuation through data collection, consolidation, and scientific analyses cannot be adequately accomplished. During recent conflicts, prehospital documentation has received increased attention for point-of-injury care as well as for care provided en route on medical evacuation platforms. However, documentation on casualty evacuation (CASEVAC) platforms is still lacking. Thus, a CASEVAC dataset was developed and maintained by the 160th Special Operations Aviation Regiment (SOAR), a nonmedical, rotary-wing aviation unit, to evaluate and review CASEVAC missions conducted by their organization. Methods: A retrospective review and descriptive analysis were performed on data from all documented CASEVAC missions conducted in Afghanistan by the 160th SOAR from January 2008 to May 2015. Documentation of care was originally performed in a narrative after-action review (AAR) format. Unclassified, nonpersonally identifiable data were extracted and transferred from these AARs into a database for detailed analysis. Data points included demographics, flight time, provider number and type, injury and outcome details, and medical interventions provided by ground forces and CASEVAC personnel. Results: There were 227 patients transported during 129 CASEVAC missions conducted by the 160th SOAR. Three patients had unavailable data, four had unknown injuries or illnesses, and eight were military working dogs. Remaining were 207 trauma casualties (96%) and five medical patients (2%). The mean and median times of flight from the injury scene to hospital arrival were less than 20 minutes. Of trauma casualties, most were male US and coalition forces (n = 178; 86%). From this population, injuries to the extremities (n = 139; 67%) were seen most commonly. The primary mechanisms of injury were gunshot wound (n = 89; 43%) and blast injury (n = 82; 40%). The survival rate was 85% (n = 176) for those who incurred trauma. Of those who did not survive, most died before reaching surgical care (26 of 31; 84%). Conclusion: Performance improvement efforts directed toward prehospital combat casualty care can ameliorate survival on the battlefield. Because documentation of care is essential for conducting performance improvement, medical and nonmedical units must dedicate time and efforts accordingly. Capturing and analyzing data from combat missions can help refine tactics, techniques, and procedures and more accurately define wartime personnel, training, and equipment requirements. This study is an example of how performance improvement can be initiated by a nonmedical unit conducting CASEVAC missions.

Keywords: casualty evacuations; CASEVAC; en route care; Tactical Combat Casualty Care; TCCC

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Keyword: casualties

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Integrating Chemical Biological, Radiologic, and Nuclear (CBRN) Protocols Into TCCC Introduction of a Conceptual Model - TCCC + CBRN = (MARCHE)2

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

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Keyword: casualty

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Prehospital Administration of Antibiotic Prophylaxis for Open Combat Wounds in Afghanistan: 2013-2014

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

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Keyword: casualty evacuations

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

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

Abstract

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

Keywords: Niger; casualty evacuations; Special Operations Command Africa

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Survey of Casualty Evacuation Missions Conducted by the 160th Special Operations Aviation Regiment During the Afghanistan Conflict

Redman TT, Mayberry KE, Mora AG, Benedict BA, Ross EM, Mapp JG, Kotwal RS. 18(2). 79 - 85. (Journal Article)

Abstract

Background: Historically, documentation of prehospital combat casualty care has been relatively nonexistent. Without documentation, performance improvement of prehospital care and evacuation through data collection, consolidation, and scientific analyses cannot be adequately accomplished. During recent conflicts, prehospital documentation has received increased attention for point-of-injury care as well as for care provided en route on medical evacuation platforms. However, documentation on casualty evacuation (CASEVAC) platforms is still lacking. Thus, a CASEVAC dataset was developed and maintained by the 160th Special Operations Aviation Regiment (SOAR), a nonmedical, rotary-wing aviation unit, to evaluate and review CASEVAC missions conducted by their organization. Methods: A retrospective review and descriptive analysis were performed on data from all documented CASEVAC missions conducted in Afghanistan by the 160th SOAR from January 2008 to May 2015. Documentation of care was originally performed in a narrative after-action review (AAR) format. Unclassified, nonpersonally identifiable data were extracted and transferred from these AARs into a database for detailed analysis. Data points included demographics, flight time, provider number and type, injury and outcome details, and medical interventions provided by ground forces and CASEVAC personnel. Results: There were 227 patients transported during 129 CASEVAC missions conducted by the 160th SOAR. Three patients had unavailable data, four had unknown injuries or illnesses, and eight were military working dogs. Remaining were 207 trauma casualties (96%) and five medical patients (2%). The mean and median times of flight from the injury scene to hospital arrival were less than 20 minutes. Of trauma casualties, most were male US and coalition forces (n = 178; 86%). From this population, injuries to the extremities (n = 139; 67%) were seen most commonly. The primary mechanisms of injury were gunshot wound (n = 89; 43%) and blast injury (n = 82; 40%). The survival rate was 85% (n = 176) for those who incurred trauma. Of those who did not survive, most died before reaching surgical care (26 of 31; 84%). Conclusion: Performance improvement efforts directed toward prehospital combat casualty care can ameliorate survival on the battlefield. Because documentation of care is essential for conducting performance improvement, medical and nonmedical units must dedicate time and efforts accordingly. Capturing and analyzing data from combat missions can help refine tactics, techniques, and procedures and more accurately define wartime personnel, training, and equipment requirements. This study is an example of how performance improvement can be initiated by a nonmedical unit conducting CASEVAC missions.

Keywords: casualty evacuations; CASEVAC; en route care; Tactical Combat Casualty Care; TCCC

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Keyword: CBRN

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Integrating Chemical Biological, Radiologic, and Nuclear (CBRN) Protocols Into TCCC Introduction of a Conceptual Model - TCCC + CBRN = (MARCHE)2

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

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Keyword: CBRNE

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Integrating Chemical Biological, Radiologic, and Nuclear (CBRN) Protocols Into TCCC Introduction of a Conceptual Model - TCCC + CBRN = (MARCHE)2

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

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Keyword: CCTA

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Special Operations Soldier With Cardiac Family History: Use of CCTA and Protein Biomarker Testing to Detect Risk of Heart Attack From Noncalcified Plaque

Singh M, Kroman A, Singh J, Tariq H, Amin S, Morales-Pablon CA, Cahill KV, Harrison EE. 15(1). 7 - 10. (Case Reports)

Abstract

Objective: We sought to characterize the risk of a heart attack in a 48-year-old asymptomatic US Special Operations Command (SOCOM) Soldier without known coronary artery disease (CAD). Background: CAD continues to be a leading cause of morbidity and mortality among most age groups in the United States. Much research is dedicated to establishing new techniques to predict myocardial infarction (MI). Methods: Coronary computed tomography (CT) angiography, also known as CCTA, along with 7-protein serum biomarker risk assessment was performed for risk evaluation. Results: A 48-year-old SOCOM Soldier with a family history of heart disease had skeletal chest pain from war injuries and a 5-fold higher risk of heart attack over the next 5 years on the basis of protein markers. A nonobstructive left anterior descending coronary artery (LAD) plaque with a lipid-rich core and a thin fibrous cap (i.e., vulnerable plaque) was detected by CCTA. The patient was warned about his risk and prescribed four cardiac medications and scheduled for angioplasty even though he fell outside the guidelines by not having a severe obstructive blockage. Four days later, unfortunately, he had a heart attack before starting his medications and before angioplasty. Conclusion: CCTA with biomarker testing may have an important role in predicating acute coronary syndrome (ACS) in Special Operations Forces (SOF) Soldiers with at least one risk factor. Conventional stress testing and nuclear scanning would not detect non-flow-limiting vulnerable plaques in vulnerable patients. In order to collect more data, the PROTECT Registry has been started to evaluate asymptomatic Soldiers with at least one risk factor referred to the clinic by military physicians.

Keywords: cardiac risk; heart attack; CCTA; risk assessment

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Keyword: cellulitis

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

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&reg; [ILK]). However, given the Marine had recently deployed and is part of the active duty population, consideration of alternative, albeit rare, etiologies was imperative.

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

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Keyword: cellulose

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Evaluation of NuStat®, a Novel Nonimpregnated Hemostatic Dressing, Compared With Combat Gauze™ in Severe Traumatic Porcine Hemorrhage Model

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

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Impact of Marine Exposure on Hemostatic Gauzes Using Thromboelastography

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

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Keyword: cervical collar

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Walking the Plank

Banting J, Meriano T. 16(3). 57 - 61. (Journal Article)

Abstract

Concepts and Objectives: 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: cervical spinal injury; Canadian C-spine rule, NEXUS Criteria; cervical collar

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Keyword: cervical spinal injury

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Walking the Plank

Banting J, Meriano T. 16(3). 57 - 61. (Journal Article)

Abstract

Concepts and Objectives: 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: cervical spinal injury; Canadian C-spine rule, NEXUS Criteria; cervical collar

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Keyword: CG

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Evaluation of NuStat®, a Novel Nonimpregnated Hemostatic Dressing, Compared With Combat Gauze™ in Severe Traumatic Porcine Hemorrhage Model

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

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Keyword: Chain of Survival

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The Ranger First Responder Program and Tactical Emergency Casualty Care Implementation: A Whole-Community Approach to Reducing Mortality From Active Violent Incidents

Fisher AD, Callaway DW, Robertson JN, Hardwick SA, Bobko JP, Kotwal RS. 15(3). 46 - 53. (Journal Article)

Abstract

Active violent incidents are dynamic and challenging situations that can produce a significant amount of preventable deaths. Lessons learned from the military's experience in Afghanistan and Iraq through the Committee on Tactical Combat Casualty Care and the 75th Ranger Regiment's Ranger First Responder Program have helped create the Committee for Tactical Emergency Casualty Care (C-TECC) to address the uniqueness of similar wounding patterns and to end preventable deaths. We propose a whole-community approach to active violent incidents, using the C-TECC Trauma Chain of Survival and a tiered approach for training and responsibilities: the first care provider, nonmedical professional first responders, medical first responders, and physicians and trauma surgeons. The different tiers are critical early links in the Chain of Survival and this approach will have a significant impact on active violent incidents.

Keywords: Committee on Tactical Combat Casualty Care; Ranger First Responder Program; Committee on Emergency Casualty Care; wounding patterns; Chain of Survival; preventable death

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Keyword: chemdestruction

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Medical Mission to Dominican Republic: One Dermatology Group's Experiences

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

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Keyword: chemical exposure

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What's in a Rash? Viral Exanthem Versus CBRNE Exposure: Teleconsultation Support for Two Special Forces Soldiers With Diffuse Rash in an Austere Environment

Lee HD, Butterfield S, Maddry J, Powell D, Vasios WN, Yun H, Ferraro D, Pamplin JC. 18(2). 133 - 135. (Journal Article)

Abstract

Objective: Review clinical thought process and key principles for diagnosing weaponized chemical and biologic injuries. Clinical Context: Special Operation Forces (SOF) team deployed in an undisclosed, austere environment. Organic Expertise: Two SOF Soldiers with civilian EMT-Basic certification. Closest Medical Support: Mobile Forward Surgical Team (2 hours away); medical consults available by e-mail, phone, or video-teleconsultation. Earliest Evacuation: Earliest military evacuation from country 12-24 hours. With teleconsultation, patients departed to Germany as originally scheduled without need for Medical Evacuation.

Keywords: telemedicine; chemical exposure; biologic exposure; military personnel; emergency treatment; patient transfer; prolonged field care

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Keyword: chemical terrorism

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Sulfur Mustard Exposure: Review of Acute, Subacute, and Long-Term Effects and Their Management

Wolfe GA, Petteys SM, Phelps JF, Wasmund JB, Plackett TP. 19(2). 81 - 86. (Journal Article)

Abstract

Sulfur mustard has been used in conflicts for more than a century. Despite international recognized bans on the use of chemical weapons, there continue to be reports of their use. The authors provide a contemporary overview of sulfur mustard injury and its management in the acute, subacute, and chronic periods.

Keywords: mustard gas; chemical terrorism; chemical warfare agents; blister/chemically induced; warfare

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Keyword: chemical warfare

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Atropine Eye Drops: A Proposed Field Expedient Substitute in the Absence of Atropine Autoinjectors

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

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Keyword: chemical warfare agents

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Sulfur Mustard Exposure: Review of Acute, Subacute, and Long-Term Effects and Their Management

Wolfe GA, Petteys SM, Phelps JF, Wasmund JB, Plackett TP. 19(2). 81 - 86. (Journal Article)

Abstract

Sulfur mustard has been used in conflicts for more than a century. Despite international recognized bans on the use of chemical weapons, there continue to be reports of their use. The authors provide a contemporary overview of sulfur mustard injury and its management in the acute, subacute, and chronic periods.

Keywords: mustard gas; chemical terrorism; chemical warfare agents; blister/chemically induced; warfare

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Keyword: chemoprophylaxis

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This Is Africa. Bites, Stings, and Rigors: Clinical Considerations in African Operations

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

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Keyword: chest

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Chest Seal Placement for Penetrating Chest Wounds by Prehospital Ground Forces in Afghanistan

Schauer SG, April MD, Naylor JF, Simon EM, Fisher AD, Cunningham CW, Morissette DM, Fernandez JD, Ryan KL. 17(3). 85 - 89. (Journal Article)

Abstract

Background: Thoracic trauma represents 5% of all battlefield injuries. Communicating pneumothoraces resulting in tension physiology remain an important etiology of prehospital mortality. In addressing penetrating chest trauma, current Tactical Combat Casualty Care (TCCC) guidelines advocate the immediate placement of a vented chest seal device. Although the Committee on TCCC (CoTCCC) has approved numerous chest seal devices for battlefield use, few data exist regarding their use in a combat zone setting. Objective: To evaluate adherence to TCCC guidelines for chest seal placement among personnel deployed to Afghanistan. Methods: We obtained data from the Prehospital Trauma Registry (PHTR). Joint Trauma System personnel linked patients to the Department of Defense Trauma Registry, when available, for outcome data upon reaching a fixed facility. Results: In the PHTR, we identified 62 patients with documented gunshot wound (GSW) or puncture wound trauma to the chest. The majority (74.2%; n = 46) of these were due to GSW, with the remainder either explosive-based puncture wounds (22.6%; n = 14) or a combination of GSW and explosive (3.2%; n = 2). Of the 62 casualties with documented GSW or puncture wounds, 46 (74.2%) underwent chest seal placement. Higher proportions of patients with medical officers in their chain of care underwent chest seal placement than those that did not (63.0% versus 37.0%). The majority of chest seals placed were not vented. Conclusion: Of patients with a GSW or puncture wound to the chest, 74.2% underwent chest seal placement. Most of the chest seals placed were not vented in accordance with guidelines, despite the guideline update midway through the study period. These data suggest the need to improve predeployment training on TCCC guidelines and matching of the Army logistical supply chain to the devices recommended by the CoTCCC.

Keywords: chest; wound; seal; prehospital; military; combat

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Keyword: chest seal

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

Butler FK, DuBose JJ, Otten EJ, Bennett DR, Gerhardt RT, Kheirabadi BS, Gross K, Cap AP, Littlejohn LF, Edgar EP, Shackelford S, Blackbourne LH, Kotwal RS, Holcomb JB, Bailey JA. 13(3). 81 - 86. (Journal Article)

Abstract

During the recent United States Central Command (USCENTCOM) and Joint Trauma System (JTS) assessment of prehospital trauma care in Afghanistan, the deployed director of the Joint Theater Trauma System (JTTS), CAPT Donald R. Bennett, questioned why TCCC recommends treating a nonlethal injury (open pneumothorax) with an intervention (a nonvented chest seal) that could produce a lethal condition (tension pneumothorax). New research from the U.S. Army Institute of Surgical Research (USAISR) has found that, in a model of open pneumothorax treated with a chest seal in which increments of air were added to the pleural space to simulate an air leak from an injured lung, use of a vented chest seal prevented the subsequent development of a tension pneumothorax, whereas use of a nonvented chest seal did not. The updated TCCC Guideline for the battlefield management of open pneumothorax is: "All open and/ or sucking chest wounds should be treated by immediately applying a vented chest seal to cover the defect. If a vented chest seal is not available, use a non-vented chest seal. Monitor the casualty for the potential development of a subsequent tension pneumothorax. If the casualty develops increasing hypoxia, respiratory distress, or hypotension and a tension pneumothorax is suspected, treat by burping or removing the dressing or by needle decompression." This recommendation was approved by the required two-thirds majority of the Committee on TCCC in June 2013.

Keywords: pneumothorax; chest seal; TCCC Guideline

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Keyword: chest trauma, penetrating

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Prolonged Field Care of a Casualty With Penetrating Chest Trauma

Barnhart G, Cullinan W, Pickett JR. 16(4). 99 - 101. (Case Reports)

Abstract

As Special Operations mission sets shift to regions with less coalition medical infrastructure, the need for quality long-term field care has increased. More and more, Special Operations Medics will be expected to maintain casualties in the field well past the "golden hour" with limited resources and other tactical limitations. This case report describes an extended-care scenario (>12 hours) of a casualty with a chest wound, from point of injury to eventual casualty evacuation and hand off at a Role II facility. This case demonstrates the importance of long-term tactical medical considerations and the effectiveness of minimal fluid resuscitation in treating penetrating thoracic trauma.

Keywords: prolonged field care; chest trauma, penetrating; resuscitation, fluid

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Keyword: Chikungunya

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This Is Africa. Bites, Stings, and Rigors: Clinical Considerations in African Operations

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

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Chikungunya

Burnett MW. 14(4). 129 - 130. (Journal Article)

Abstract

Chikungunya is a rapidly emerging infectious disease caused by a virus of the genus Alphavirus, family Togaviridae. Most commonly, patients have an acute onset of fever with often debilitating symmetric joint discomfort that can relapse months after the initial infection. This infection is typically transmitted by the bite of an infected Aedes aegypti or Aedes albopictus mosquito, vectors that also transmit dengue and yellow fever. Special Operations Forces Medical Providers should be aware of this disease, which is currently being diagnosed worldwide.

Keywords: Chikungunya; infectious disease; virus; mosquito vector

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Keyword: chitosan

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Impact of Marine Exposure on Hemostatic Gauzes Using Thromboelastography

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

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Keyword: choice behavior

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Study of Tourniquet Use in Simulated First Aid: User Judgment

Kragh JF, Tan AR, Newton NJ, Aden JK, Dubick MA. 18(3). 15 - 21. (Journal Article)

Abstract

Background: The purpose of this study was to survey the judgments of tourniquet users in simulation to discern opportunities for further study. Methods: The study design constituted two parts: questions posed to four tourniquet users and then their tourniquet use was surveyed in simulated first aid, where the users had to decide how to perform among five different cases. The questions addressed judged confidence, blood volumes, a reason bleeding resumes, regret of preventable death, hemorrhage assessment, need for side-by-side use of tourniquets, shock severity, predicting reliability, and difference in blood losses. The mechanical performance was tested on a manikin. Case 1 had no bleeding. Case 2 had limb-wound bleeding that indicated tourniquet use in first aid. Case 3 was like case 2, except the patient was a child. Case 4 was like case 2, except caregiving was under gunfire. Case 5 was like case 4, but two tourniquets were to be used side by side. Each user made tests of the five cases to constitute a block. Each user had three blocks. Case order was randomized within blocks. The study had 60 tests. Results: In answering questions relevant to first-aid use of limb tourniquets, judgments were in line with previous studies of judgment science, and thus were plausibly applicable. Mechanical performance results on the manikin were as follows: 38 satisfactory, 10 unsatisfactory (a loose tourniquet and nine incorrect tourniquet placements), and 12 not applicable (case 1 needed no mechanical intervention). For cases 1 to 5, satisfactory results were: 100%, 83%, 100%, 75%, and 58%, respectively. For blocks 1 to 3, satisfactory results were 50%, 83%, and 83%, respectively. Conclusion: For tourniquet use in simulated first aid, the results are plausibly applicable because user judgments were coherent with those in previous studies of judgment science. However, the opportunities for further studies were noted.

Keywords: psychomotor performance; practice-based learning; choice behavior; motivation; readiness

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Your Metric Matters! Choose Wisely to Assess User Performance With Tourniquets in Simulated First Aid

Zhao NO, Kragh JF, Aden JK, Jordan BS, Parsons DL, Dubick MA. 18(3). 22 - 27. (Journal Article)

Abstract

Background: Readiness to perform lifesaving interventions during emergencies is based on a person's preparation to proficiently execute the skills required. Graphically plotting the performance of a tourniquet user in simulation has previously aided us in developing our understanding of how the user actually behaves. The purpose of this study was to explore performance assessment and learning curves to better understand how to develop best teaching practices. Methods: These were retrospective analyses of a convenience sample of data from a prior manikin study of 200 tourniquet uses among 10 users. We sought to generate hypotheses about performance assessments relevant to developing best teaching practices. The focus was on different metrics of user performance. Results: When one metric was chosen over another, failure counts summed cumulatively over 200 uses differed as much as 12-fold. That difference also indicated that the degree of challenge posed to user performance differed by the metric chosen. When we ranked user performance with one metric and then with another, most (90%; nine of 10) users changed rank: five rose and four fell. Substantial differences in performance outcomes resulted from the difference in metric chosen, which, in turn, changed how the outcome was portrayed and thus interpreted. Hypotheses generated included the following: The usefulness of a specific metric may vary by the user's level of skill from novice to expert; demonstration of the step order in skill performance may suffice for initial training of novices; a mechanical metric of effectiveness, like pulse stoppage, may aid in later training of novices; and training users how to practice on their own and self-assess performance may aid their self-development. Conclusion: The outcome of the performance assessments varied depending on the choice of metric in this study of simulated use of tourniquets.

Keywords: education standards measures; implementation; individuality; choice behavior; first aid

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Use Your Noodle to Simulate Tourniquet Use on a Limb With and Without Bone

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

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Keyword: chromoblastomycosis

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Medical Mission to Dominican Republic: One Dermatology Group's Experiences

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

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Keyword: chrondroitin sulfate

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Effects of Oral Chondroitin Sulfate on Osteoarthritis-Related Pain and Joint Structural Changes: Systematic Review and Meta-Analysis

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

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Keyword: chronic pain

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The Benefits of Reflexology for the Chronic Pain Patient in a Military Pain Clinic

Kern C, McCoart A, Beltranm 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

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Keyword: cigarettes

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Epidemiological Evidence and Possible Mechanisms for the Association Between Cigarette Smoking and Injuries (Part 1)

Knapik JJ, Bedno SA. 18(1). 108 - 112. (Journal Article)

Abstract

Surveys indicated that 24% of military personnel are current cigarette smokers. Smoking is well known to increase the risk of cancers, cardiovascular and respiratory diseases, reproductive problems, and other medical maladies, but one of the little known effects of smoking is that on injuries. There is considerable evidence from a variety of sources that (1) smoking increases overall injury risk, (2) the greater the amount of smoking, the higher is the injury risk, and (3) smoking is an independent injury risk factor. Smoking not only affects the overall injury risk but also impairs healing processes following fractures (e.g., longer healing times, more nonunions, more complications), ligament injury (e.g., lower subjective function scores, greater joint laxity, lower subsequent physical activity, more infections), and wounding (e.g., delayed healing, more complications, less satisfying cosmetic results). Smoking may elicit effects on fractures through low bone mineral density (BMD), lower dietary intake of calcium and vitamin D, altered calcium metabolism, and effects on osteogenesis and sex hormones. Effects on wound healing may be mediated through altered neutrophils and monocytes functions resulting in reduced ability to fight infections and remove damaged tissue, reduced gene expression of cytokines important for tissue healing, and altered fibroblast function leading to lower density and amount of new tissue formation. Limited data suggest smoking cessation has favorable effects on various aspects of bone health over periods of 1 to 30 years. Favorable effects on neutrophil and monocyte functions may occur as early as 4 weeks, but fibroblast function and collagen metabolism (important for wound remodeling) appear to take considerably longer and may be dependent on the amount of prior smoking. Part 2 of this series will use this information to explore the possibility of a causal relationship between smoking and injuries.

Keywords: smoking; injury; cigarettes; tobacco

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Keyword: Cimex lectularis

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Oral Steroids for Dermatitis

Fisher AD, Clarke J, Williams TK. 15(2). 8 - 11. (Journal Article)

Abstract

Contact/allergic dermatitis is frequently treated inappropriately with lower-than-recommended doses or inadequate duration of treatment with oral and intramuscular glucocorticoids. This article highlights a case of dermatitis in a Ranger Assessment and Selection Program student who was improperly treated over 2 weeks with oral steroids after being bit by Cimex lectularius, commonly known as bed bugs. The article also highlights the pitfalls of improper oral steroid dosing and provides reasoning for longer-duration oral steroid treatment.

Keywords: dermatitis; steroids; bed bugs; military; Cimex lectularis

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Keyword: cinnarizine

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Cinnarizine for Sea Sickness During a Remote Pacific Ocean Rescue Mission

Lyon RF, Rush SC, Roland T, Jethanamest D, Schawn CP, Kharod C. 15(2). 1 - 6. (Case Reports)

Abstract

Motion sickness can be a limiting factor for sea and air missions. We report the experience of a Pararescue (PJ) team on a Pacific Ocean rescue mission in which motion sickness was prevalent. Cinnarizine, an antagonist of H1-histamine receptors, was used to treat affected PJs. We also report findings of a survey of PJs regarding motion sickness. A family of four on a disabled sailboat 900 miles off the coast of Mexico sent out a distress call because their 1-year-old daughter became severely ill with fever and diarrhea. Four PJs were deployed on a C-130, performed a free-fall parachute insertion into the ocean, and boarded the sailboat. All four PJs experienced onset of motion sickness at some point during the early part of the mission and symptoms persisted through the first 24 hours. Three PJs experienced ongoing nausea, vomiting, dizziness, and sensory imbalances. The captain of the sailboat offered the three sick PJs approximately 18mg of cinnarizine two or three times a day with relief of symptoms and improvement on operational effectiveness. A new, anonymous, voluntary survey of Air National Guard PJs and combat rescue officers revealed that 78.4% of Operators have experienced motion sickness at sea. We discuss the current theories on motion sickness, the effect of motion sickness on operational effectiveness, and research on treatment of motion sickness, including the medication cinnarizine.

Keywords: motion sickness; cinnarizine; military operations; military medicine; sea sickness; medication, motion sickness; pararescue

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Keyword: class

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Cypress Creek EMS Basic Tactical Operational Medical Support Course

Godbee DC. 19(2). 34 - 39. (Journal Article)

Abstract

Keywords: Cypress Creek EMS Basic Tactical Operational Medical Support; tactical EMS; course; class

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Keyword: cleaning methodologies

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

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

Abstract

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

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

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Keyword: climate

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Routine Screening Laboratory Studies for Nonheat Stroke Field Heat Injuries Are Unnecessary: A Retrospective Review

Schauer SG, Pfaff JA. 18(1). 88 - 90. (Journal Article)

Abstract

Background: Heat injuries are common in the military training environment. Base policies often mandate that heat causalities require evaluation at a higher level of care, which comes at significant use of resources. Laboratory studies are often ordered routinely, but their utility is unclear at this time. Methods: This project evaluated the use of screening laboratory studies for heat casualties brought to Bayne-Jones Army Community Hospital, Fort Polk, Louisiana. Casualties brought from the field directly to the emergency department (ED) were included. Abnormalities in laboratory study findings, admission/discharge rates, and length of stay were documented. Results: From May through September 2014, 104 casualties were seen in the ED because of heat injury. Laboratory tests were ordered for 101 patients. Of these, 11 patients were admitted to the hospital because of laboratory, history, and/or physical examination abnormalities. Nine were discharged in less than 24 hours. The remaining two were discharged within 48 hours; both had documented altered mental status on arrival to the ED. Laboratory test abnormalities were seen in most of the patients and appeared to have no impact on the decision to admit. Conclusion: Routine laboratory studies appeared to have low clinical utility in this patient population. A more targeted approach based on the history and physical examination may reduce military resource use.

Keywords: heat injury; heat exhaustion; heat stroke; climate; rhabdomyolysis; heat

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Keyword: clinical diagnosis

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Differential Diagnosis of an Unusual Snakebite Presentation in Benin: Dry Bite or Envenomation?

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

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Keyword: clinical evidence

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No Shit, There I Was: The Case for Narrative-Based Clinical Knowledge

Froede K. 11(1). 21 - 24. (Journal Article)

Abstract

Relevant literature demonstrates the absolute necessity of Special Operations Forces (SOF) clinical narratives to the medics they teach and care they deliver, and discusses the concept of narrative pedagogy via review of extant literature and also SOF-specific clinical literature. SOF clinicians (medics, physicians' assistants, physicians, etc.) provide advanced trauma, clinical, and preventive care in the most austere of combat environments. SOF clinicians have adopted specific paradigms for schooling, teaching, learning, and practice. An overarching theme within SOF-generated clinical literature is that of hermeneutics and the narrative pedagogy; SOF clinicians generate their evidence from experience and frequently tell stories to educate their peers, colleagues, and student medics to increase the knowledge of the entire community.

Keywords: Special Forces; medics; narrative pedagogy; hermeneutics; clinical evidence

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Keyword: clinical guidelines

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Clinical Guidelines for Stellate Ganglion Block to Treat Anxiety Associated With Posttraumatic Stress Disorder

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

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Keyword: clinical practice guidelines

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Evaluation and Treatment of Ocular Injuries and Vision-Threatening Conditions in Prolonged Field Care

Reynolds ME, Hoover C, Riesberg JC, Mazzoli RA, Colyer M, Barnes S, Calvano CJ, Karesh JW, Murray CK, Butler FK, Keenan S, Shackelford S. 17(4). 115 - 126. (Journal Article)

Abstract

Keywords: ocular injuries; vision-threatening conditions; prolonged field care; clinical practice guidelines

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Keyword: clinical presentation

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Middle East Respiratory Syndrome

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

Abstract

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

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

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Keyword: coagulation

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Point-of-Care Coagulation Testing for Trauma Patients in a Military Setting: A Prospective Study

Cotte J, d'Aranda E, Chauvin V, Kaiser E, Meaudre E. 13(4). 59 - 62. (Journal Article)

Abstract

Background and Objective: Almost 50% of military trauma patients who need transfusions develop a coagulopathy. Immediately treating this coagulopathy improves the patient's prognosis. Field military hospitals often lack laboratory devices needed to diagnose a clinically significant coagulopathy and have limited blood product resources such as plasma. Point-of-care (POC) devices for the measurement of prothrombin time (PT) are available and have been tested in a variety of situations, including hemorrhagic surgery. The authors compared a POC device, the Coaguchek XS Pro (F. Hoffmann-La Roche Ltd., Basel, Switzerland), with laboratory measures for determining the PT in military trauma patients in a field hospital. Methods: This single-center prospective study was designed to compare POC coagulation monitoring with traditional laboratory testing. It was conducted at the French military hospital located at Kabul International Airport. All patients with trauma injuries resulting from war operations were included. A blood sample was drawn immediately on admission. PT was determined both in the laboratory and with use of the Coaguchek XS pro. Results: Forty patients with war trauma were enrolled during a 3-month period. The authors recorded 69 measurements. The two methods were correlated with a correlation coefficient of 0.78 (ρ < .001). The Bland- Altman plot showed a mean difference of 5.8% (95% confidence interval -14.9% to 26.6%). Using a PT cutoff of 60%, POC had a sensitivity of 77.1% and a specificity of 94.1%. Results from POC PT measurement were available within a mean of 25.8 minutes before laboratory measures. Conclusions: The Coaguchek XS Pro device can be used successfully in an austere environment without compromising its performance.

Keywords: point-of-care; coagulation; prothrombin time; military trauma

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Impact of Marine Exposure on Hemostatic Gauzes Using Thromboelastography

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

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Keyword: coagulopathy

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Combat Trousers as Effective Improvised Pelvic Binders A Comparative Cadaveric Study

Loftus A, Morris R, Friedmann Y, Pallister I, Parker PJ. 17(3). 35 - 39. (Journal Article)

Abstract

Background: Improvised explosive devices and landmines can cause pelvic fractures, which, in turn, can produce catastrophic hemorrhage. This cadaveric study compared the intrapelvic pressure changes that occurred with the application of an improvised pelvic binder adapted from the combat trousers worn by British military personnel with the commercially available trauma pelvic orthotic device (TPOD). Methods: Six unembalmed cadavers (three male, three female) were used to simulate an unstable pelvic fracture with complete disruption of the posterior arch (AO/OTA 61-C1) by dividing the pelvic ring anteriorly and posteriorly. A 3-4cm manometric balloon filled with water was placed in the retropubic space and connected to a 50mL syringe and water manometer via a three-way tap. A baseline pressure of 8cm H2O (average central venous pressure) was set. The combat trouser binder (CTB) and TPOD were applied to each cadaver in a random sequence and the steady intrapelvic pressure changes were recorded. Statistical analysis was performed using the Wilcoxon rank-sum test and a paired t test depending on the normality of the data to determine impact on the intrapelvic pressure of each intervention compared with baseline. Results: The median steady intrapelvic pressure achieved after application of the CTB was 16cm H2O and after application of the TPOD binder was 18cm H2O, both of which were significantly greater than the baseline pressure (ρ < .01 and .036, respectively) but not significantly different from each other (ρ > .05). Conclusion: Pelvic injuries are increasingly common in modern theaters of war. The CTB is a novel, rapidly deployable, yet effective, method of pelvic binding adapted from the clothes the casualty is already wearing. This technique may be used in austere environments to tamponade and control intrapelvic hemorrhage.

Keywords: pelvic fracture; pelvic binder; trauma; hemorrhage; coagulopathy; military; combat; prehospital emergency care

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Keyword: cocaine

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Review, Clinical Update, and Practice Guidelines for Excited Delirium Syndrome

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

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Keyword: cognitive

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Sleep As A Strategy For Optimizing Performance

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

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Keyword: colloid

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Effect of Hetastarch Bolus in Trauma Patients Requiring Emergency Surgery

Ryan ML, Ogilvie MP, Pereira BM, Gomez-Rodriguez JC, Livingstone AS, Proctor KG. 12(3). 57 - 67. (Journal Article)

Abstract

If blood products are not available, current military guidelines recommend a hetastarch bolus (HEX, Hextend ™ 6% hetastarch in lactated electrolyte buffer, www. hospira.com) for initial treatment of hypovolemic shock in the field. We previously reported that a HEX bolus plus standard of care (SOC = crystalloid plus blood products) was safe during initial resuscitation in 1714 trauma patients. This study tests the hypothesis that HEX+SOC is more effective than SOC alone for volume expansion in trauma patients requiring urgent operation. Methods: From July 2009 to August 2010, the records from all adults who required emergency surgery within 4 hours of admission were screened for a retrospective cohort observational study. Burns, and those with primary neurosurgical or orthopedic indications, were excluded. The study population was comprised of 281 patients with blunt (n = 72) or penetrating (n = 209) trauma; 141 received SOC and 140 received SOC+HEX in the emergency room only (ER, n = 81) or the ER and operating room (OR, n = 59). Each case was reviewed with waiver of consent. Results: After penetrating injury, with SOC, the injury severity score was 17 and mortality was 12%; the corresponding values in the HEX(ER) and HEX(OR) groups were 19-21 and 8%, but these apparent differences did not reach significance. However, in patients receiving HEX, initial heart rate was higher, base deficit was lower, and hematocrit was lower (consistent with relative hypovolemia), even though blood product requirements were reduced, and urine output was greater (all ρ < 0.05). These effects were absent in patients with blunt trauma. Platelet consumption was higher with HEX after either penetrating (ρ = 0.004) or blunt trauma (ρ = 0.045), but coagulation tests were unchanged. Conclusion: HEX is safe for initial resuscitation in young patients who required urgent operation after penetrating trauma, but there was no apparent effect after blunt trauma. A bolus of HEX reduced transfusion requirements without inducing coagulopathy or causing renal dysfunction, but a randomized controlled trial is necessary to eliminate the possibility of selection bias.

Keywords: hydroxyethyl starch; Hextend®; trauma resuscitation; colloid; Tactical Combat Casualty Care; first responder; field medic

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Albumin for Prehospital Fluid Resuscitation of Hemorrhagic Shock in Tactical Combat Casualty Care

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

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Keyword: Colombia

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Surveillance for Ehrlichia canis, Anaplasma phagocytophilum, Borrelia burgdorferi, and Dirofilaria immitis in Dogs From Three Cities in Colombia

McCown ME, Monterroso VH, Cardona W. 14(1). 86 - 90. (Journal Article)

Abstract

Objective: Emerging infectious and zoonotic diseases are made up in large proportion by vector-borne diseases (VBD). Dogs are parasitized by disease vectors such as ticks and mosquitoes, making dogs adequate reservoirs for zoonoses. Risk of exposure to VBD exists for the U.S. military personnel and Military Working Dogs (MWD) when deployed globally. The importance of canine VBD surveillance relates to veterinary and public health significance for the host nations as well as for the U.S. troops and MWDs. The objective of this work was to survey dogs from the cities of Medellin, Barranquilla, and Cartagena in Colombia to determine the prevalence of heartworm disease (Dirofilaria immitis), ehrlichiosis (Ehrlichia canis), Lyme disease (Borrelia burgdorferi), and anaplasmosis (Anaplasma phagocytophilum). Methods: Canine (n = 498) blood samples (1-3mL) were collected during July 2011 from Medellin (n = 175), Barranquilla (n = 223), and Cartagena (n = 100) and were tested on-site using IDEXX SNAP® 4Dx® Test Kits. Results: The overall combined sample prevalence of E. canis, A. phagocytophilum, D. immitis, and B. burgdorferi was 62%, 33%, 1.6%, and 0%, respectively. In Medellin, 26% of the samples were positive for E. canis, 12% for A. phagocytophilum, and 0% for D. immitis. In Barranquilla, sample prevalence for E. canis, A. phagocytophilum, and D. immitis was 83%, 40%, and 2%, respectively. In Cartagena, E. canis, A. phagocytophilum, and D. immitis prevalence was 80%, 51%, and 3%, respectively. Conclusion: E. canis and A. phagocytophilum are present in all three surveyed cities. There is a higher sample prevalence for E. canis and A. phagocytophilum than for D. immitis. In addition, the prevalence for these organisms is higher in Barranquilla and Cartagena than in Medellin. Overall, this study emphasizes the value of surveillance for VBDs in order to determine disease prevalence, develop risk assessments, and implement control measures.

Keywords: zoonotic disease; parasites; vector-borne disease; dogs; public health; surveillance; Colombia

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Point Prevalence Survey for Tick-Borne Pathogens in Military Working Dogs, Shelter Animals, and Pet Populations in Northern Colombia

McCown ME, Alleman A, Sayler KA, Chandrashekar R, Thatcher B, Tyrrell P, Stillman B, Beall M, Barbet AF. 14(4). 81 - 85. (Journal Article)

Abstract

Background: Based on the high tick-borne pathogen results from a 2011 surveillance study in three Colombian cities, an in-depth point prevalence survey was conducted to determine the seroprevalence of tick-borne pathogens at a specific point in time in 70 working dogs, 101 shelter dogs, and 47 client-owned dogs in Barranquilla, Colombia. Results: Of the 218 serum samples, 163 (74%) were positive for Ehrlichia canis and 116 (53%) for Anaplasma platys. Exposure to tick-borne pathogens was highest in shelter and working dogs where more than 90% of the samples were seropositive or positive on polymerase chain reaction for one or more organisms as compared to 51% in client-owned animals. Conclusion: Surveillance for exposure to tickborne pathogens provides vital information necessary to protect and conserve the health of local humans and animals, deployed military service members, and working dogs in various parts of the world. This study and resultant data demonstrate the value of following a broadbased surveillance study with a more specific, focused analysis in an area of concern. This area's high levels of exposure warrant emphasis by medical planners and advisors on precautionary measures for military dogs, Special Operations Forces personnel, and the local public.

Keywords: tick-borne pathogens; point prevalence; surveillance; US Military SOF; military working dogs; Colombia

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Keyword: color vision

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Optimizing Tactical Medical Performance: The Effect of Light Hue on Vision Testing

Van Buren JP, Wake J, McLaughlin J, LaPorta AJ, Enzenauer RW, Calvano CJ. 18(2). 75 - 78. (Journal Article)

Abstract

Background: Red and blue are the historical tactical lighting hues of choice to ensure light discipline and to preserve dark adaptation. As yet, no scientifically ideal hue for use in Special Operations medicine has been identified. We propose red/green polychromatic light as a superior choice that preserves visual function for tactical medical tasks in austere settings. Methods: Thirty participants were enrolled in this institutional review board-approved study. Participants completed four vision tasks in low-light settings under various lighting conditions. The Pelli-Robson Near Contrast Sensitivity test (PR), tumbling E visual acuity test, Farnsworth D-15 color-vision test (FD15), and pseudoisochromatic plate (PiP) testing was performed under white, green, or red light illumination and also red/green and red/green/yellow lights. PR and tumbling E tests were performed using blue and blue/red lights. Results: The test results for each light were compared against a white-light standard. Contrast sensitivity as measured by PR testing showed no statistical difference when white light was used compared with red/green or red/green/yellow light, and the differences between red, green, blue, and blue/red all were statistically different from when white light was used. When measuring visual acuity, blue light was the only color for which there was a statistically significant decrease in visual acuity in comparison with white. There was no reduction in visual acuity with any other lights compared with white. Performance on FD15 testing with all single-hue and multihue lights was significantly worse than with white light for measuring color-vision perception. Color discrimination as measured by PiP testing showed red and green light was significantly worse than with white light, whereas test results when green/red and green/red/yellow lights were used were not statistically different from white. Conclusion: Red/Green/yellow and red/green were superior light sources and performance results only were worse than white light on FD15 testing.

Keywords: SOFMED; tactical lighting; visual acuity; contrast sensitivity; color vision

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Keyword: combat

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Development of a Rugged handheld Device for Real-Time Analysis of heart Rate: Entropy in Critically Ill Patients

Mejaddam AY, van der Wilden GM, Chang Y, Cropano CM, Sideris AC, Hwbejire JO, Velmahos GC, Alam HB, de Moya MA, King DR. 13(1). 29 - 33. (Journal Article)

Abstract

Introduction: The usefulness of heart rate variability (HRV) and heart rate complexity (HRC) analysis as a potential triage tool has been limited by the inability to perform real-time analysis on a portable, handheld monitoring platform. Through a multidisciplinary effort of academia and industry, we report on the development of a rugged, handheld and noninvasive device that provides HRV and HRC analysis in real-time in critically ill patients. Methods: After extensive re-engineering, real-time HRV and HRC analyses were incorporated into an existing, rugged, handheld monitoring platform. Following IRB approval, the prototype device was used to monitor 20 critically ill patients and 20 healthy controls to demonstrate real-world discriminatory potential. Patients were compared to healthy controls using a Student's t test as well as repeated measures analysis. Receiver operator characteristic (ROC) curves were generated for HRV and HRC. Results: Critically ill patients had a mean APACHE-2 score of 15, and over 50% were mechanically ventilated and requiring vasopressor support. HRV and HRC were both lower in the critically ill patients compared to healthy controls (ρ < 0.0001) and remained so after repeated measures analysis. The area under the ROC for HRV and HRC was 0.95 and 0.93, respectively. Conclusions: This is the first demonstration of real-time, handheld HRV and HRC analysis. This prototype device successfully discriminates critically ill patients from healthy controls. This may open up possibilities for real-world use as a trauma triage tool, particularly on the battlefield.

Keywords: heart rate complexity; heart rate variability; entropy; triage; combat

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A Study of Prehospital Medical Documentation by Military Medical Providers During Precombat Training

McGarry AB, Mott JC, Kotwal RS. 15(1). 79 - 84. (Journal Article)

Abstract

Documentation of medical care provided is paramount for improving performance and ultimately reducing morbidity and mortality. However, documentation of prehospital trauma care on the battlefield has historically been suboptimal. Modernization of prehospital documentation tools have aligned data and information to be gathered with up-to-date treatment being rendered through Tactical Combat Casualty Care (TCCC) protocols and practices. Our study was conducted to evaluate TCCC Card completion, and accuracy of card completion, by military medical providers conducting precombat training through the Tactical Combat Medical Care Course. Study results do not show a deficiency in TCCC documentation training as provided by this course which should translate to adequate ability to accurately document prehospital trauma care on the battlefield. Leadership emphasis and community acceptance is required to increase compliance with prehospital documentation.

Keywords: combat; documentation; prehospital; trauma

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Battlefield Analgesia: TCCC Guidelines Are Not Being Followed

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

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Accuracy and Reliability of Triage at the Point of Injury During Operation Enduring Freedom

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

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The Highest-Impact Combat Orthopedic and Extremity Injury Articles in the Past 70 Years: A Citation Analysis

Nam JJ, Do WS, Stinner DJ, Wenke JC, Orman JA, Kragh JF. 17(1). 55 - 66. (Journal Article)

Abstract

The objective of this study was to identify the most-cited peer-reviewed combat orthopedic and extremity injury articles published during the past 70 years. Orthopedic trauma presents ongoing challenges to both US civilian and military healthcare personnel. Improvements in combat trauma and extremity injury survival and quality of life are the result of advances in orthopedic trauma research. The Web of Science (including Science Citation Index) was searched for the most cited articles related to combat orthopedic trauma, published from 1940 to 2013. The most-cited article was by Owens et al. (Journal of Orthopaedic Trauma, 2007; 137 citations). Between the 1990s and 2000s, there was a 256% increase in the number of highly cited publications. A total of 69% of the articles were on the topics of comorbid vascular trauma (25%), epidemiology (23%), or orthopedic trauma (21%). This study identifies some of the most important contributions to combat orthopedic trauma and research and the areas of greatest scientific interest to the specialty during the past seven decades and highlights key research that has contributed to the evolution of modern combat orthopedic traumatology.

Keywords: combat; orthopaedics; trauma; extremity injury

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QuikClot® Combat Gauze® Use by Ground Forces in Afghanistan The Prehospital Trauma Registry Experience

Schauer SG, April MD, Naylor JF, Fisher AD, Cunningham CW, Ryan KL, Thomas KC, Brillhart DB, Fernandez JD, Antonacci MA. 17(2). 101 - 106. (Journal Article)

Abstract

Background: QuikClot® Combat Gauze® (QCCG) was fielded in 2008 to replace previous generations of hemostatic products. To the best of our knowledge, despite nearly a decade of use, there are no published data on use among US combatant forces. We describe the use of QCCG by ground forces in Afghanistan and compare patients who received QCCG compared with the remaining population in the database who did not receive QCCG. Methods: Data were obtained from the Prehospital Trauma Registry (PHTR). Joint Trauma System personnel linked patients to the Department of Defense Trauma Registry (DODTR) for outcome data, when available, upon reaching a fixed facility. Results: Of the 705 patients within the entire PHTR, 118 (16.7%) had documented use of QCCG. Most patients (69.5%) were Afghan; all were male. Lower extremities accounted for the most common site of application (39.7%). Hemorrhage control occurred in 88.3% of encounters with hemorrhage control status documented. Patients receiving QCCG generally had higher rates of concomitant interventions. Of the 705 patients, 190 were linkable to the DODTR for outcome data; 25 of the 28 (89.3%) in the QCCG group were discharged alive compared with 153 of the 162 (94.4%) in the non-QCCG group (ρ = .300). Conclusion: QCCG appears to have common use on the battlefield as a concomitant intervention for obtaining hemorrhage control. Patients receiving QCCG had higher rates of gunshot wounds compared with the baseline population and were generally sicker. Hemorrhage control success was like that reported in other military and civilian settings.

Keywords: hemorrhage; gauze; combat; military; QuikClot®; hemostatic; combat

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QuikClot® Combat Gauze® Use by Ground Forces in Afghanistan The Prehospital Trauma Registry Experience

Schauer SG, April MD, Naylor JF, Fisher AD, Cunningham CW, Ryan KL, Thomas KC, Brillhart DB, Fernandez JD, Antonacci MA. 17(2). 101 - 106. (Journal Article)

Abstract

Background: QuikClot® Combat Gauze® (QCCG) was fielded in 2008 to replace previous generations of hemostatic products. To the best of our knowledge, despite nearly a decade of use, there are no published data on use among US combatant forces. We describe the use of QCCG by ground forces in Afghanistan and compare patients who received QCCG compared with the remaining population in the database who did not receive QCCG. Methods: Data were obtained from the Prehospital Trauma Registry (PHTR). Joint Trauma System personnel linked patients to the Department of Defense Trauma Registry (DODTR) for outcome data, when available, upon reaching a fixed facility. Results: Of the 705 patients within the entire PHTR, 118 (16.7%) had documented use of QCCG. Most patients (69.5%) were Afghan; all were male. Lower extremities accounted for the most common site of application (39.7%). Hemorrhage control occurred in 88.3% of encounters with hemorrhage control status documented. Patients receiving QCCG generally had higher rates of concomitant interventions. Of the 705 patients, 190 were linkable to the DODTR for outcome data; 25 of the 28 (89.3%) in the QCCG group were discharged alive compared with 153 of the 162 (94.4%) in the non-QCCG group (ρ = .300). Conclusion: QCCG appears to have common use on the battlefield as a concomitant intervention for obtaining hemorrhage control. Patients receiving QCCG had higher rates of gunshot wounds compared with the baseline population and were generally sicker. Hemorrhage control success was like that reported in other military and civilian settings.

Keywords: hemorrhage; gauze; combat; military; QuikClot®; hemostatic; combat

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Prehospital Cricothyrotomy Kits Used in Combat

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

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Combat Trousers as Effective Improvised Pelvic Binders A Comparative Cadaveric Study

Loftus A, Morris R, Friedmann Y, Pallister I, Parker PJ. 17(3). 35 - 39. (Journal Article)

Abstract

Background: Improvised explosive devices and landmines can cause pelvic fractures, which, in turn, can produce catastrophic hemorrhage. This cadaveric study compared the intrapelvic pressure changes that occurred with the application of an improvised pelvic binder adapted from the combat trousers worn by British military personnel with the commercially available trauma pelvic orthotic device (TPOD). Methods: Six unembalmed cadavers (three male, three female) were used to simulate an unstable pelvic fracture with complete disruption of the posterior arch (AO/OTA 61-C1) by dividing the pelvic ring anteriorly and posteriorly. A 3-4cm manometric balloon filled with water was placed in the retropubic space and connected to a 50mL syringe and water manometer via a three-way tap. A baseline pressure of 8cm H2O (average central venous pressure) was set. The combat trouser binder (CTB) and TPOD were applied to each cadaver in a random sequence and the steady intrapelvic pressure changes were recorded. Statistical analysis was performed using the Wilcoxon rank-sum test and a paired t test depending on the normality of the data to determine impact on the intrapelvic pressure of each intervention compared with baseline. Results: The median steady intrapelvic pressure achieved after application of the CTB was 16cm H2O and after application of the TPOD binder was 18cm H2O, both of which were significantly greater than the baseline pressure (ρ < .01 and .036, respectively) but not significantly different from each other (ρ > .05). Conclusion: Pelvic injuries are increasingly common in modern theaters of war. The CTB is a novel, rapidly deployable, yet effective, method of pelvic binding adapted from the clothes the casualty is already wearing. This technique may be used in austere environments to tamponade and control intrapelvic hemorrhage.

Keywords: pelvic fracture; pelvic binder; trauma; hemorrhage; coagulopathy; military; combat; prehospital emergency care

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Estimation of Dog-Bite Risk and Related Morbidity Among Personnel Working With Military Dogs

Schermann H, Eiges N, Sabag A, Kazum E, Albagli A, Salai M, Shlaifer A. 17(3). 51 - 54. (Journal Article)

Abstract

Background: Soldiers serving in the Israel Defense Force Military Working Dogs (MWD) Unit spend many hours taming dogs' special skills, taking them on combat missions, and performing various dogkeeping activities. During this intensive work with the aggressive military dogs, bites are common, and some of them result in permanent disability. However, this phenomenon has not been quantified or reported as an occupational hazard. Methods: This was a retrospective cohort study based on self-administered questionnaires. Information was collected about soldiers' baseline demographics, duration of the experience of working with dogs, total number of bites they had, circumstances of bite events, and complications and medical treatment of each bite. Bite risk was quantified by incidence, mean time to first bite, and a Cox proportional hazards model. Rates of complications and the medical burden of bites were compared between combat soldiers and noncombat dogkeepers. Bite locations were presented graphically. Results: Seventy-eight soldiers participated and reported on 139 bites. Mean time of working with dogs was 16 months (standard deviation, ±9.4 months). Overall bite incidence was 11 bites per 100 person-months; the mean time to first bite event was 6.3 months. The Cox proportional hazards model showed that none of baseline characteristics significantly increased bite hazard. About 90% of bites occurred during routine activities, and 3.3% occurred on combat missions. Only in 9% of bite events did soldiers observed the safety precautions code. Bite complications included fractures, need for intravenous antibiotic treatment and surgical repair, prominent scarring, diminished sensation, and stiffness of proximal joints. Bite complications were similar between combat soldiers and dogkeepers. Most bites (57%) were located on hands and arms. Conclusion: MWD bites are an occupational hazard resulting in significant medical burden. Hands and arms were most common bite locations. Observance of safety precautions may be the most appropriate first-line preventive intervention. Barrier protection of upper extremities may reduce bite severity and complication rates.

Keywords: canine; combat; bites, dog; dogs, military working; Israeli Army; dog keepers

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Prehospital Administration of Tranexamic Acid by Ground Forces in Afghanistan: The Prehospital Trauma Registry Experience

Schauer SG, April MD, Naylor JF, Wiese J, Ryan KL, Fisher AD, Cunningham CW, Mitchell N, Antonacci MA. 17(3). 55 - 58. (Journal Article)

Abstract

Background: Tranexamic acid (TXA) was shown to reduce overall mortality and death secondary to hemorrhage in a large prospective study. This intervention is time sensitive. As such, the Tactical Combat Casualty Care (TCCC) guidelines recommend use of this low-cost, safe intervention among patients with possible hemorrhagic shock, penetrating trauma to the thorax or trunk, or extremity amputation. Objective: Prehospital administration of TXA by ground forces in the Afghanistan combat theater is described. Methods: We obtained data from the Prehospital Trauma Registry. We searched for all patients with documented hypotension, amputation, or penetrating trauma to the torso. Results: From January 2013 to September 2014, there were 272 patients who met inclusion criteria. Most injuries (97.8%; n = 266) were battle injuries. Of the 272 patients who met criteria to receive prehospital TXA, 51 (18.8%) received TXA, whereas the remaining 221 (81.2%) did not. Higher proportions of patients receiving TXA versus patients not receiving TXA received hemostatic dressings, pressure dressings, and tourniquet placement. Conversely, the proportion of patients receiving intravenous fluids was higher in the no-TXA group. Conclusion: Overall, proportions of eligible patients receiving TXA were low despite emphasis in the guidelines. The reasons for this low adherence to TCCC guidelines are likely multifactorial. Future research should seek to identify reasons TXA is not given when indicated and to develop training and technology to increase prehospital TXA administration.

Keywords: tranexamic acid; prehospital; trauma; combat; military; TXA

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Chest Seal Placement for Penetrating Chest Wounds by Prehospital Ground Forces in Afghanistan

Schauer SG, April MD, Naylor JF, Simon EM, Fisher AD, Cunningham CW, Morissette DM, Fernandez JD, Ryan KL. 17(3). 85 - 89. (Journal Article)

Abstract

Background: Thoracic trauma represents 5% of all battlefield injuries. Communicating pneumothoraces resulting in tension physiology remain an important etiology of prehospital mortality. In addressing penetrating chest trauma, current Tactical Combat Casualty Care (TCCC) guidelines advocate the immediate placement of a vented chest seal device. Although the Committee on TCCC (CoTCCC) has approved numerous chest seal devices for battlefield use, few data exist regarding their use in a combat zone setting. Objective: To evaluate adherence to TCCC guidelines for chest seal placement among personnel deployed to Afghanistan. Methods: We obtained data from the Prehospital Trauma Registry (PHTR). Joint Trauma System personnel linked patients to the Department of Defense Trauma Registry, when available, for outcome data upon reaching a fixed facility. Results: In the PHTR, we identified 62 patients with documented gunshot wound (GSW) or puncture wound trauma to the chest. The majority (74.2%; n = 46) of these were due to GSW, with the remainder either explosive-based puncture wounds (22.6%; n = 14) or a combination of GSW and explosive (3.2%; n = 2). Of the 62 casualties with documented GSW or puncture wounds, 46 (74.2%) underwent chest seal placement. Higher proportions of patients with medical officers in their chain of care underwent chest seal placement than those that did not (63.0% versus 37.0%). The majority of chest seals placed were not vented. Conclusion: Of patients with a GSW or puncture wound to the chest, 74.2% underwent chest seal placement. Most of the chest seals placed were not vented in accordance with guidelines, despite the guideline update midway through the study period. These data suggest the need to improve predeployment training on TCCC guidelines and matching of the Army logistical supply chain to the devices recommended by the CoTCCC.

Keywords: chest; wound; seal; prehospital; military; combat

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Prehospital Administration of Antibiotic Prophylaxis for Open Combat Wounds in Afghanistan: 2013-2014

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

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Junctional Tourniquet Use During Combat Operations in Afghanistan: The Prehospital Trauma Registry Experience

Schauer SG, April MD, Fisher AD, Cunningham CW, Gurney J. 18(2). 71 - 74. (Journal Article)

Abstract

Background: Hemorrhage is the leading cause of potentially preventable death on the battlefield. Although the resurgence of limb tourniquets revolutionized hemorrhage control in combat casualties in the recent conflicts, the mortality rate for patients with junctional hemorrhage is still high. Junctional tourniquets (JTQs) offer a mechanism to address the high mortality rate. The success of these devices in the combat setting is unclear given a dearth of existing data. Methods: From the Prehospital Trauma Registry (PHTR) and the Department of Defense Trauma Registry, we extracted cases of JTQ use in Afghanistan. Results: We identified 13 uses of a JTQ. We excluded one case in which an improvised pelvic binder was used. Of the remaining 12 cases of JTQ use, seven had documented success of hemorrhage control, three failed to control hemorrhage, and two were missing documentation regarding success or failure. Conclusion: We report 12 cases of prehospital use of JTQ in Afghanistan. The findings from this case series suggest these devices may have some utility in achieving hemorrhage control strictly at junctional sites (e.g., inguinal creases). However, they also highlight device limitations. This analysis demonstrates the need for continued improvements in technologies for junctional hemorrhage control, prehospital documentation, data fidelity and collection, as well as training and sustainment of the training for utilization of prehospital hemorrhage control techniques.

Keywords: junctional tourniquet; junctional hemorrhage; trauma; combat

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Are the King LTS Laryngeal Tube and the Ambu AuraOnce Laryngeal Mask Useful Airway Adjuncts for Military Medics?

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

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The Prehospital Trauma Registry Experience With Intraosseous Access

Schauer SG, Naylor JF, April MD, Fisher AD, Cunningham CW, Fernandez JD, Shreve BP, Bebarta VS. 19(1). 52 - 55. (Journal Article)

Abstract

Background: Peripheral intravenous (IV) cannulation is often difficult to obtain in a patient with hemorrhagic shock, delaying the appropriate resuscitation of critically ill patients. Intraosseous (IO) access is an alternative method. To date, few data exist on use of this procedure by ground forces in Afghanistan. Here, we compare patient characteristics and concomitant interventions among patients undergoing IO access versus those undergoing IV access only. Methods: We obtained data from the Prehospital Trauma Registry (PHTR). When possible, patients were linked to the Department of Defense Trauma Registry for outcome data. To develop the cohorts, we searched for all patients with documented IO or IV access placement. Those with both IO and IV access documented were placed in the IO group. Results: Of the 705 available patients in the PHTR, we identified 55 patients (7.8% of the population) in the IO group and 432 (61.3%) in the IV group. Among patients with documentation of access location, the most common location was the tibia (64.3%; n = 18). Compared with patients with IV access, those who underwent IO access had higher urgent evacuation rates (90.9% versus 72.4%; p = .01) and air evacuation rates (58.2% versus 14.8%; p < .01). The IO cohort had significantly higher rates of interventions for hypothermia, chest seals, chest tubes, needle decompressions, and tourniquets, but a significantly lower rate of analgesic administration (ρ ≤ .05). Conclusion: Within the registry, IO placement was relatively low (<10%) and used in casualties who received several other life-saving interventions at a higher rate than casualties who had IV access. Incidentally, lower proportions of analgesia administration were detected in the IO group compared with the IV group, despite higher intervention rates.

Keywords: hemorrhagic shock; intraosseous access; intravenous access; prehospital; combat; hypotension; resuscitation; military

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Battlefield Analgesia: Adherence to Tactical Combat Casualty Care Guidelines

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

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Keyword: Combat Application Tourniquet

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

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

Abstract

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

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

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Limb Tourniquet Configuration: Preliminary Investigation of Problems and Principles

Kragh JF, Aden JK, Dubick MA. 19(1). 35 - 43. (Journal Article)

Abstract

Background: A tourniquet's readiness during emergencies depends on how it is configured. We investigated configuration so ways of improving readiness can be developed. Methods: This study was conducted at the Institute of Surgical Research in 2018 as sequential investigations by one user of Combat Application Tourniquets (C-A-Ts) in a band-and-rod design. Results: Each tourniquet comes packaged with paper instructions for use, which include directions on how to configure it in preparation for caregiving. The paper and video instructions for use omit tensioning of the tourniquet in configuration, and the video misconfigured a time strap over the rod. In first-aid classrooms, we saw unwitting learners troubleshoot that misconfiguration. Problems with configuration were also seen in caregiving and with tourniquets stowed in kits. In deliberate practice, we self-applied a tourniquet to a thigh. In configuration after each of 100 uses, tourniquet elongation due to tensioning averaged 2.4 in was important for restoring the tourniquet to its full length. During configuration, if the C-A-T's stabilization plate slid along the band, out of position, the user slid the plate back into position. In various ways of testing other C-A-Ts, elongations averaged from 0.4 in to 0.9 in, depending on whether the tourniquet was self-applied or applied to a firm manikin. Elongation increments accrued as the tourniquet's band flattened. Configuration time averaged 22 seconds, and accrued experience improved the compactness of configuration. Conclusion: People are too often unreliable at putting C-A-Ts into the optimal configuration for use. That ready-to-use configuration includes the tourniquet being at its full length, having the stabilization plate positioned correctly along the band, and having the strap fastened to its clip of origin. When used, tourniquets had normal, small elongations in part due to band flattening. This tourniquet study showed the importance of optimal configuration to first-aid readiness practices.

Keywords: Combat Application Tourniquet; tourniquet configuration; limb tourniquet; Stop the Bleed; medical device; combat injury first aid; tourniquet band flattening; tourniquet elongation; use instruction; resuscitation; emergency

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Ease of Use of Emergency Tourniquets on Simulated Limbs of Infants: Deliberate Practice

Kragh JF, Wright-Aldossari B, Aden JK, Dubick MA. 19(2). 41 - 47. (Journal Article)

Abstract

Background: To investigate questions about application of emergency tourniquets in very young children, we investigated practices of Combat Application Tourniquet (C-A-T) use on a simulated infant-sized limb to develop ways to improve readiness for caregiving. Methods: This study was conducted as investigations of C-A-Ts used by two individuals in deliberate practice. The practice setup simulating a limb of infants aged 3-5 months included a handrail (circumference, 5.25 in.). This setup needed a specific modification to the instructions for use to adhere the band between the clips. Each user performed 100 practices. Results: With accrual of experience, application time was shorter for each user, on average in a power law of practice, and more ease was associated when less time was taken to apply the tourniquet. The ease of use was associated with accrued experience through deliberate practice of a tourniquet user while under coached learning. A check of tourniquet fit on a 4.25-in. limb also entailed the modification used in the 5.25-in. limb. However, an additional modification of wrapping the band in a figure-8 pattern around the rod was needed because the rod and clip could not meet. The fit on a 3.25-in. limb was impracticable for a workaround. Tourniquet use was harder for smaller limbs (i.e., 4.25 in. and 3.25 in.). A map of tourniquet fit was sketched of which sized limbs were too big, too small, within the fit zone, or at its borders. Conclusion: C-A-Ts mechanically fit the simulated limbs of infants aged 3-5 months, and C-A-T use was practicably easy enough to allow experienced users to fit tourniquets to limbs well using a specific modification of the routine technique. The findings and knowledge generated in this study are available to inform researches and developments in best preparation practices for instructing first aid.

Keywords: Combat Application Tourniquet; limb tourniquet; Stop the Bleed; medical device; combat injury first aid; use instruction; resuscitation; emergency

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Keyword: combat burns

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Experience in Treating Combat Burns in Afghanistan by Using Silver-Nylon Dressing

Pozza M, Matthew P, Lunardi F. 14(1). 1 - 5. (Case Reports)

Abstract

Background: On the battlefield, insidious and devastating weapons like the improvised explosive device (IED) rapidly emit extreme heat (thousands of degrees), create a shock wave (overpressure) that can hurl bodies long distances (inducing secondary fall lesions), and deliver thousands of pieces of shrapnel over hundreds of meters. Materials and Methods: Very often, Soldiers injured by an IED blast are inside their vehicle. Subsequently, they are exposed to the thermal effects of the blast. Frequently, these patients have complex wounds that consist of extensive burn areas, bone fractures, and internal organ lesions. The use of silver-nylon burn wrap dressing is widely documented for its bactericidal properties. Silverlon® Burn Dressings is an elastic bandage made of nylon and plated with pure metallic silver. Results: In summer 2008, in a U.S. advanced Role 2 facility, two U.S. Soldiers with extensive second- and third-degree burn injuries were successfully treated with the use of Silverlon Burn Dressings and Silverlon® Burn Gloves. Conclusions: From this experience emerged the ease of use silver-nylon dressing in treating badly burned Soldiers on the battlefield.

Keywords: silver-nylon dressing; combat burns; emergency burn treatment

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Keyword: combat casualty care

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Prehospital Emergency Care: Evaluation of the Junctional Emergency Tourniquet Tool With a Perfused Cadaver Model

Gates K, Baer L, Holcomb JB. 14(1). 40 - 44. (Journal Article)

Abstract

Objective: Junctional bleeding from the groin is a leading cause of potentially preventable death on the battlefield. To address this problem, a novel device called the Junctional Emergency Treatment Tool (JETT™) was developed. The JETT was designed to stabilize pelvic ring fractures while controlling lower extremity bleeding sustained during high-energy traumatic events on the battlefield and in the civilian environment. Our purpose was to assess the effectiveness of the JETT in the control of simulated life threatening hemorrhage from proximal injuries in the groin of a perfused cadaver. Methods: The JETT was compared with the standard issue combat tourniquet and a Food and Drug Administration (FDA)-cleared junctional hemorrhage control clamp (CRoC™) in a perfused human cadaver model. The JETT's ability to stop pulsatile flow at the common femoral artery was assessed through proximal aorta and distal measurements of arterial flow rates and pressures. Results: In three cadavers, when the JETT or the CRoC was applied in the groin, there was an immediate cessation of fluid flow from the common femoral artery while the inlet flow aortic pulsatile pressure was maintained. However, the time to bilateral application of the JETT was faster (10 seconds vs. 68 seconds) than bilateral sequential application of two CRoC devices. Conclusions: The JETT is a single device capable of effectively and quickly controlling bilateral lower extremity junctional hemorrhage at normal physiological blood pressures.

Keywords: hemorrhage; tourniquet; wounds and injuries; junctional hemorrhage; combat casualty care; femoral artery

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Imaging Comparison of Pelvic Ring Disruption and Injury Reduction With Use of the Junctional Emergency Treatment Tool for Preinjury and Postinjury Pelvic Dimensions: A Cadaveric Study With Computed Tomography

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

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

Sirkin MR, Cook P, Davis KG. 15(4). 54 - 58. (Journal Article)

Abstract

Background: The operative control of noncompressible hemorrhage is the single largest impact that could be addressed in reducing the mortality on the battlefield. Laprotomy pads, traditionally used for hemorrhage evacuation, are made of woven cotton, and, while effective, their use requires a substantial amount of space and adds weight. This poses no concern in traditional operating rooms but is a hindrance for mobile providers and providers in austere environments. We sought to compare different absorptive compunds to ascertain their utility as alternatives for traditional laparotomy pads. Methods: Samples of cotton laparotomy pads, pure rayon sheets, rayon-polypropylene composite sheets, and non-polyester composite "microfiber" sheets were weighed and submerged in heparinized whole bovine blood. After saturation, the favrics were weighed, wrung dry, reweighed, and resubmerged. This process was performed for a total of three sequential submersions. The saturated weights and dry weights of each fabric were used to calculate how much blood each fabric could absorb initially and after multiple repeated uses. The initial densities of the four fabrics was calculated and compared. Results: The initial submersions demonstrated that 1g each of cotton, rayon, rayon-polypropylene, and nylon-polyester were able to absorb 7.58g, 12.98g, 10.16g, and 9.73g of blood respectively. The second and third sequential trials, which were statistically similar, demonstrated that 1g of cotton, rayon, rayon-polypropolyene, and nylon-polyester were able to absorb 1.73g, 2.83g, 2.3g, and 2.3g of blood, respectively. The calculated densities of cotton, rayon, rayon-polypropylene, and nylon-polyester were 0.087g/cm³, .012g/cm³, 0.098g/cm³, and 0.093g/cm³, respectively. Conclusion: Per gram, rayon absorbed approximately 1.7 times more blood thancotton and three-quarters the amount of the storage space. Rayon also retained its superior absorption abilites on repeated uses, demonstrating the potential for re-use in remote and austere environments. Thus, rayon could serve as a viable alternative to traditional cotton laparotomy pads in the austere environments.

Keywords: hemorrhage; laparotomy; cotton; rayon; sponge; austere; surgery; packing; combat casualty care; absorption; density

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Telemedicine to Reduce Medical Risk in Austere Medical Environments: The Virtual Critical Care Consultation (VC3) Service

Powell D, McLeroy RD, Riesberg JC, Vasios WN, Miles EA, Dellavolpe J, Keenan S, Pamplin JC. 16(4). 102 - 109. (Journal Article)

Abstract

One of the core capabilities of prolonged field care is telemedicine. We developed the Virtual Critical Care Consult (VC3) Service to provide Special Operations Forces (SOF) medics with on-demand, virtual consultation with experienced critical care physicians to optimize management and improve outcomes of complicated, critically injured or ill patients. Intensive-care doctors staff VC3 continuously. SOF medics access this service via phone or e-mail. A single phone call reaches an intensivist immediately. An e-mail distribution list is used to share information such as casualty images, vital signs flowsheet data, and short video clips, and helps maintain situational awareness among the VC3 critical care providers and other key SOF medical leaders. This real-time support enables direct communication between the remote provider and the clinical subject matter expert, thus facilitating expert management from near the point of injury until definitive care can be administered. The VC3 pilot program has been extensively tested in field training exercises and validated in several real-world encounters. It is an immediately available capability that can reduce medical risk and is scalable to all Special Operations Command forces.

Keywords: critical care; telemedicine; military personnel; emergency treatment; patient transfer; combat casualty care

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Case of a 5-Year-Old Foreign National Who Sustained Penetrating Abdominal Trauma

McLeroy RD, Ellis JL, Karnopp JM, Dellavolpe J, Gurney J, Keenan S, Powell D, Riesberg JC, Edwards M, Matos R, Pamplin JC. 16(4). 110 - 113. (Journal Article)

Abstract

Objective: Review application of telemedicine support for penetrating trauma. Clinical Context: Special Operations Resuscitation Team (SORT) deployed in Africa Area of Responsibility (AOR) Organic expertise: Internal Medicine physician, two Special Operations Combat medics (SOCMs), and one radiology technician Closest surgical support: Non-US surgical support 20km away; a nonsurgeon who will perform surgeries; neighboring country partner-force surgeon 2 hours by fixedwing flight. Earliest Evacuation: Evacuated 4 days after presentation to a neighboring country with surgical capability.

Keywords: critical care; telemedicine; military personnel; emergency treatment; patient transfer; combat casualty care

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Embedded Fragment Removal and Wound Debridement in a Non-US Partner Force Soldier

McLeroy RD, Spelman S, Jacobson E, Gurney J, Keenan S, Powell D, Riesberg JC, Pamplin JC. 16(4). 114 - 116. (Journal Article)

Abstract

Objective: Review application of telemedicine support for removal of fragment and wound management. Clinical Context: Special Forces Operational Detachment- Alpha deployed in Central Command area of responsibility operating out of a small aid station ("house" phase of prolonged field care) Organic expertise: 18D Special Operations Combat medic Closest Medical Support: Combined Joint Special Operations Task Force (CJSOTF) surgeon located in another country; thus, all consults were either via telephone or over Secret Internet Protocol Router e-mail. Earliest Evacuation: NA

Keywords: critical care; telemedicine; military personnel; emergency treatment; patient transfer; combat casualty care

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Evaluation of XSTAT® and QuickClot® Combat Gauze® in a Swine Model of Lethal Junctional Hemorrhage in Coagulopathic Swine

Cox JM, Rall JM. 17(3). 64 - 67. (Journal Article)

Abstract

Background: Hemorrhage is associated with most potentially survivable deaths on the battlefield. Effective and field-tested products are lacking to treat junctional and noncompressible injuries. XSTAT® is a newly developed, U.S. Food and Drug Administration-approved product designed to treat junctional hemorrhage. The Committee on Tactical Combat Casualty Care has recently approved the product for use as part of its treatment guidelines, but data are lacking to assess its efficacy in different wounding patterns and physiologic states. Methods: Dilutional coagulopathy was induced in 19 large (70-90kg), healthy, male swine by replacing 60% of each animal's estimated blood volume with room temperature Hextend ®. After dissection, isolation, and lidocaine incubation, uncontrolled hemorrhage was initiated by transection of both axillary artery and vein. Free bleeding was allowed to proceed for 30 seconds until intervention with either XSTAT or QuickClot® Combat Gauze® (CG) followed by standard backing. Primary outcomes were survival, hemostasis, and blood loss. Results: XSTAT-treated animals achieved hemostasis in less time and remained hemostatic longer than those treated with CG. Less blood was lost during the first 10 minutes after injury in the XSTAT group than the CG group. However, no differences in survival were observed between XSTAT-treated and CG-treated groups. All animals died before the end of the observation period except one in the XSTAT-treated group. Conclusion: XSTAT performed better than CG in this model of junctional hemorrhage in coagulopathic animals. Continued testing and evaluation of XSTAT should be performed to optimize application and determine appropriate indications for use.

Keywords: XStat™; trauma; hemorrhage; hemorrhage, junctional; combat casualty care

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Experience With Prehospital Damage Control Capability in Modern Conflict: Results From Surgical Resuscitation Team Use

DuBose JJ, Martens D, Frament C, Haque I, Telian S, Benson PJ. 17(4). 68 - 71. (Journal Article)

Abstract

Background: Early resuscitation and damage control surgery (DCS) are critical components of modern combat casualty care. Early and effective DCS capabilities can be delivered in a variety of settings through the use of a mobile surgical resuscitation team (SRT). Methods: Twelve years of after-action reports from SRTs were reviewed. Demographics, interventions, and outcomes were analyzed. Results: Data from 190 casualties (185 human, five canine) were reviewed. Among human casualties, 12 had no signs of life at intercept and did not survive. Of the remaining 173 human casualties, 96.0% were male and 90.8% sustained penetrating injuries. Interventions by the SRT included intravascular access (50.9%) and advanced airway establishment (29.5%). Resuscitation included whole blood (3.5%), packed red blood cells (20.8%), and thawed plasma (11.0%). Surgery was provided for 63 of the 173 human casualties (36.4%), including damage control laparotomy (23.8%) and arterial injury shunting or repair (19.0%). SRTs were effectively used to augment an existing medical treatment facility (70.5%), to facilitate casualty transport (13.3%), as an independent surgical entity at a forward ground structure (9.2%), and in mobile response directly to the point of injury (6.9%). Overall survival was 97.1%. Conclusion: An SRT provides a unique DCS capability that can be successfully used in a variety of flexible roles.

Keywords: resuscitation; damage control surgery; combat casualty care; mobile surgical resuscitation team

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Old Tricks for New Dogs? John Caddy and the Victorian Origins of TCCC

Reynolds PS. 18(2). 58 - 62. (Journal Article)

Abstract

The success of Tactical Combat Casualty Care (TCCC) in reducing potentially preventable combat deaths may rely on both specific interventions (such as tourniquets) and the systematized application of immediate care. Essential elements of a combat care system include clear specification of immediate care priorities, standardized methodology, and inclusion and training of all nonmedical personnel in early response. Although TCCC is fairly recent, the construct is similar to that first suggested during the mid-nineteenth century by John Turner Caddy (1822-1902), a British Royal Navy staff surgeon. Although naval warfare engagements at the time were relatively infrequent, casualties could be numerous and severe and often overwhelmed the small medical staff on board. Caddy recognized that nonmedical personnel properly trained in the fundamentals of combat injury management would result in lives saved and greatly improved morale. The novelty was in his attempt to make procedures simple enough to be performed by nonmedical personnel under stress. However, Caddy's guidelines were completely overlooked for nearly two centuries. The principles of best practice for managing combat trauma injuries learned in previous wars have often been lost between conflicts. Understanding the historical roots of combat first responder care may enable us to better understand and overcome barriers to recognition and retention of essential knowledge.

Keywords: combat casualty care; Crimea; hemorrhage; military medicine; tourniquet; wounds and injuries

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Adapting to Death: Clarifying the Roles of Special Operations Combat Medics in Prolonged Field Care

Jeschke EA. 18(4). 153 - 156. (Journal Article)

Abstract

I suggest that Special Operations Forces (SOF) medicine should explicitly acknowledge the Special Operations combat medic's role in attending death. This acknowledgment will allow researchers to evaluate and delimit the medic's needs in relationship to an expanded set of roles that move beyond life-saving care. This article comprises four sections. First, I provide background to my argument by exploring some assumptions of modern medicine and objections to exploring battlefield death care. Second, I describe how I see the medic's role expanding with the introduction of prolonged field care. Third, I address the implications of the medic's expanded role in relationship to role and function stress and strain. Fourth, I address the moral complexity related to withdrawing or withholding care. I conclude by briefly highlighting some of the implications for future research. In explicitly engaging death as a medical reality for which the medic ought to be prepared, SOF medicine could set the foundational development for seeing death as a valuable gift to be explored, not a failure to be avoided or burden to be overcome.

Keywords: death; ethics; combat casualty care; prolonged field care; Special Operations medic; death care; unconventional medicine

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Fever of Unknown Origin in US Soldier: Telemedical Consultation Limitations in a Deployment to West Africa

Auchincloss PJ, Nam JJ, Blyth D, Childs G, Kraft K, Robben PM, Pamplin JC. 19(2). 123 - 126. (Journal Article)

Abstract

Objective: Review the application of telemedicine support for managing a patient with possible sepsis, suspected malaria, and unusual musculoskeletal symptoms. Clinical Context: Regionally Aligned Forces (RAF) supporting US Army Africa/Southern European Task Force (USARAF/ SETAF) in the Africa Command area of responsibility. Care provided by a small Role I facility on the compound. Organic Medical Expertise: Five 68W combat medics (one is the patient); one SOCM trained 68W combat medic. No US provider present in country. Closest Medical Support: Organic battalion physician assistant (PA) located in the USA; USARAF PA located in Italy; French Role II located in bordering West African country; medical consultation sought via telephone, WhatsApp® (communication with French physician) or over unclassified, encrypted e-mail. Earliest Evacuation: Estimated at 12 to 24 hours with appropriate country clearances and approval to fly from three countries including French forces support approval.

Keywords: critical care; telemedicine; military medicine; emergency treatment; prolonged field care; combat casualty care; patient transfer

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Keyword: combat exposure

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Warzone Stressor Exposure, Unit Support, and Emotional Distress Among U.S. Air Force Pararescuemen

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

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Keyword: Combat Gauze™

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A Salmon Thrombin-Fibrinogen Dressing Controls Hemorrhage in a Swine Model Compared to Standard Kaolin-Coated Gauze

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

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Evaluation of NuStat®, a Novel Nonimpregnated Hemostatic Dressing, Compared With Combat Gauze™ in Severe Traumatic Porcine Hemorrhage Model

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

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The Effects of Movement on Hemorrhage When QuikClot® Combat Gauze™ Is Used in a Hypothermic Hemodiluted Porcine Model

Garcia-Blanco J, Gegel B, Burgert J, Johnson S, Johnson D. 15(1). 57 - 60. (Journal Article)

Abstract

Background: The purpose of this study was to compare the effectiveness of QuikClot® Combat Gauze™ (QCG) to a control wound dressing to withstand movement in a porcine model with hemodilution and hypothermia. Design: This was a prospective study with a between-subjects experimental design. Twenty-six Yorkshire swine were randomly assigned to two groups: QCG (n = 13) or a control dressing (n = 13). Methods: The subjects were exsanguinated to 30% of the blood volume; hypothermia was induced for 10 minutes. The hemostatic agent, QCG, was placed into the wound, followed by standard wound packing. If hemostasis was achieved, 5L of crystalloid solution were rapidly administered intravenously, and the wound was again observed for rebleeding. If no bleeding occurred, the extremity on the side of the injury was systematically moved through flexion, extension, abduction, and adduction sequentially 10 times or until rebleeding occurred. Results: An independent t test indicated there were significant differences in the number of movements before rebleeding between the QCG group (mean ± standard deviation [SD], 32.92 ± 14.062) and the control group (mean ± SD, 6.15 ± 15.021) (ρ < .0001). Conclusion: QCG produces a robust clot that can withstand more movement than a control dressing.

Keywords: movement; hemorrhage; QuikClot®; Combat Gauze™; hypothermic hemodiluted porcine model

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Keyword: combat injury

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Pediatric Trauma: Management From an Austere Prospective

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

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Keyword: combat injury first aid

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Limb Tourniquet Configuration: Preliminary Investigation of Problems and Principles

Kragh JF, Aden JK, Dubick MA. 19(1). 35 - 43. (Journal Article)

Abstract

Background: A tourniquet's readiness during emergencies depends on how it is configured. We investigated configuration so ways of improving readiness can be developed. Methods: This study was conducted at the Institute of Surgical Research in 2018 as sequential investigations by one user of Combat Application Tourniquets (C-A-Ts) in a band-and-rod design. Results: Each tourniquet comes packaged with paper instructions for use, which include directions on how to configure it in preparation for caregiving. The paper and video instructions for use omit tensioning of the tourniquet in configuration, and the video misconfigured a time strap over the rod. In first-aid classrooms, we saw unwitting learners troubleshoot that misconfiguration. Problems with configuration were also seen in caregiving and with tourniquets stowed in kits. In deliberate practice, we self-applied a tourniquet to a thigh. In configuration after each of 100 uses, tourniquet elongation due to tensioning averaged 2.4 in was important for restoring the tourniquet to its full length. During configuration, if the C-A-T's stabilization plate slid along the band, out of position, the user slid the plate back into position. In various ways of testing other C-A-Ts, elongations averaged from 0.4 in to 0.9 in, depending on whether the tourniquet was self-applied or applied to a firm manikin. Elongation increments accrued as the tourniquet's band flattened. Configuration time averaged 22 seconds, and accrued experience improved the compactness of configuration. Conclusion: People are too often unreliable at putting C-A-Ts into the optimal configuration for use. That ready-to-use configuration includes the tourniquet being at its full length, having the stabilization plate positioned correctly along the band, and having the strap fastened to its clip of origin. When used, tourniquets had normal, small elongations in part due to band flattening. This tourniquet study showed the importance of optimal configuration to first-aid readiness practices.

Keywords: Combat Application Tourniquet; tourniquet configuration; limb tourniquet; Stop the Bleed; medical device; combat injury first aid; tourniquet band flattening; tourniquet elongation; use instruction; resuscitation; emergency

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Ease of Use of Emergency Tourniquets on Simulated Limbs of Infants: Deliberate Practice

Kragh JF, Wright-Aldossari B, Aden JK, Dubick MA. 19(2). 41 - 47. (Journal Article)

Abstract

Background: To investigate questions about application of emergency tourniquets in very young children, we investigated practices of Combat Application Tourniquet (C-A-T) use on a simulated infant-sized limb to develop ways to improve readiness for caregiving. Methods: This study was conducted as investigations of C-A-Ts used by two individuals in deliberate practice. The practice setup simulating a limb of infants aged 3-5 months included a handrail (circumference, 5.25 in.). This setup needed a specific modification to the instructions for use to adhere the band between the clips. Each user performed 100 practices. Results: With accrual of experience, application time was shorter for each user, on average in a power law of practice, and more ease was associated when less time was taken to apply the tourniquet. The ease of use was associated with accrued experience through deliberate practice of a tourniquet user while under coached learning. A check of tourniquet fit on a 4.25-in. limb also entailed the modification used in the 5.25-in. limb. However, an additional modification of wrapping the band in a figure-8 pattern around the rod was needed because the rod and clip could not meet. The fit on a 3.25-in. limb was impracticable for a workaround. Tourniquet use was harder for smaller limbs (i.e., 4.25 in. and 3.25 in.). A map of tourniquet fit was sketched of which sized limbs were too big, too small, within the fit zone, or at its borders. Conclusion: C-A-Ts mechanically fit the simulated limbs of infants aged 3-5 months, and C-A-T use was practicably easy enough to allow experienced users to fit tourniquets to limbs well using a specific modification of the routine technique. The findings and knowledge generated in this study are available to inform researches and developments in best preparation practices for instructing first aid.

Keywords: Combat Application Tourniquet; limb tourniquet; Stop the Bleed; medical device; combat injury first aid; use instruction; resuscitation; emergency

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Keyword: combat load

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Risk Factors for Injuries During Airborne Static Line Operations

Knapik JJ, Steelman R. 14(3). 95 - 97. (Journal Article)

Abstract

US Army airborne operations began in World War II. Continuous improvements in parachute technology, aircraft exit procedures, and ground landing techniques have reduced the number of injuries over time from 27 per 1,000 descents to about 6 per 1,000 jumps. Studies have identified a number of factors that put parachutists at higher injury risk, including high wind speeds, night jumps, combat loads, higher temperatures, lower fitness, heavier body weight, and older age. Airborne injuries can be reduced by limiting risker training (higher wind speeds, night jumps, combat load) to the minimum necessary for tactical and operational proficiency. Wearing a parachute ankle brace (PAB) will reduce ankle injuries without increasing other injuries and should be considered by all parachutists, especially those with prior ankle problems. A high level of upper body muscular endurance and aerobic fitness is not only beneficial for general health but also associated with lower injury risk during airborne training.

Keywords: wind; night; combat load; temperature; fitness; parachute ankle brace

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Keyword: combat medic

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Evaluation of Commercially Available Traction Splints for Battlefield Use

Studer NM, Grubb SM, Horn GT, Danielson PD. 14(2). 46 - 55. (Journal Article)

Abstract

Background: Femoral fracture is a common battlefield injury with grave complications if not properly treated. Traction splinting has been proved to decrease morbidity and mortality in battlefield femur fractures. However, little standardization of equipment and training exists within the United States Armed Forces. Currently, four traction splints that have been awarded NATO Stock Numbers are in use: the CT-6 Leg Splint, the Kendrick Traction Device (KTD), the REEL Splint (RS), and the Slishman Traction Splint (STS). Objective: The purpose of this study was to determine the differences between the four commercially available traction devices sold to the U.S. Government. Methods: After standardized instruction, subjects were timed and evaluated in the application of each of the four listed splints. Participant confidence and preferences were assessed by using Likert-scaled surveys. Free response remarks were collected before and after timed application. Results: Subjects had significantly different application times on the four devices tested (analysis of variance [ANOVA], ρ < .01). Application time for the STS was faster than that for both the CT-6 (t-test, ρ < .0028) and the RS (ρ < .0001). Subjects also rated the STS highest in all post-testing subjective survey categories and reported significantly higher confidence that the STS would best treat a femoral fracture (ρ < .00229). Conclusions: The STS had the best objective performance during testing and the highest subjective evaluation by participants. Along with its ability to be used in the setting of associated lower extremity amputation or trauma, this splint is the most suitable for battlefield use of the three devices tested.

Keywords: combat medic; medical training; traction splinting; Tactical Combat Casualty Care; femoral

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Keyword: combat readiness

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Clinical Relevance of Optimizing Vitamin D Status in Soldiers to Enhance Physical and Cognitive Performance

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

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Keyword: Combat Ready Clamp

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Evaluation and Testing of Junctional Tourniquets by Special Operation Forces Personnel: A Comparison of the Combat Ready Clamp and the Junctional Emergency Treatment Tool

Theodoridis CA, Kafka KE, Perez AM, Curlee JB, Yperman PC, Oppermann N, Holmstroem E, Niegsch DD, Mannino A, Ramundo N. 16(1). 44 - 50. (Journal Article)

Abstract

Background: Previous research has shown that external hemorrhage from proximal leg amputations and junctional sites represents 19.2% of potentially survivable lethal hemorrhage. A recent effort to address this problem has resulted in the development of various junctional tourniquets. This study assessed and compared two Tactical Combat Casualty Care Committee-approved junctional tourniquets, the Combat Ready Clamp (CRoC) and the Junctional Emergency Treatment Tool (JETT), to contribute to their future development and to better inform on the decisions for device selection by military units. Aims of the study also were to provide concrete feedback and suggestions on how to effectively apply the devices. Methods: Via a specific questionnaire, 75 international attendees of the International Special Training Centre Medical Branch Special Operations Forces Advanced Medical First Responder course evaluated the CRoC and the JETT on different parameters. Both devices were tested objectively through timed applications aimed at stopping unilateral lower-extremity distal pulse on 33 of these 75 students, verified by palpation by Medical Branch instructors. Subjective and objective data were examined for mutual correlation. Results: Users ranked the JETT higher than the CRoC on all parameters, including effectiveness on the battlefield (ρ < .001), ease of use (ρ < .039), speed of application (ρ < .001), and not slipping in use (ρ < .001), although the difference on other parameters such as effectiveness in hemorrhage control was not statistically significant. Considering all parameters together, the JETT was evaluated as a better device than the CRoC (ρ < .001). The application time measurement suggested that the JETT was applied faster (by approximately 15 seconds on average; p < .001). The fastest CRoC and JETT applications were 37 and 29 seconds, respectively. The JETT was not easier to use or more effective than the CRoC; there was a 9% failure rate of the JETT occluding a unilateral common femoral artery. The JETT's efficacy in occluding a unilateral common femoral artery can be compromised if the device's pelvic binder is not sufficiently tightened prior to threading the T-handled pad. The CRoC's application time can be drastically reduced if the device is kept assembled and firm pressure is immediately asserted upon placement on the intended location through the vertical arm, then threading the device. Both devices were applied safely; no adverse effects were reported during or after application. Conclusion: Even though the JETT might be preferred by military medical providers, the CRoC still has merits. As both devices proved to occlude the arterial flow in no less than 54 seconds on average, they could be used to supplement direct pressure and wound packing, the latter two still being considered the immediate actions for inguinal bleeding control. Considering that the CRoC and the JETT can be applied in as little as 37 and 29 seconds, respectively, users should be effectively trained and entirely proficient on either device to justify their election as the primary countermeasure to hemorrhage not amenable to regular tourniquets.

Keywords: hemorrhage, junctional; tourniquet, junctional; Combat Ready Clamp; Junctional Emergency Treatment Tool; Tactical Combat Casualty Care Committee; hemorrhage control

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Evaluation of Two Junctional Tourniquets Used on the Battlefield: Combat Ready Clamp® versus SAM® Junctional Tourniquet

Meusnier J, Dewar C, Mavrovi E, Caremil F, Wey P, Martinez J. 16(3). 41 - 46. (Journal Article)

Abstract

Background: Junctional hemorrhage (i.e., between the trunk and limbs) are too proximal for a tourniquet and difficult to compress. These hemorrhages are responsible for 20% of preventable deaths by bleeding on the battlefield. The majority of these involve the groin area. Devices allowing a proximal compression for arterial axes have been recently developed. Objective: The purpose of this study was to compare the use of two junctional- tourniquet models, the Combat Ready Clamp (CRoC®) and the SAM® Junctional Tourniquet (SJT), in simulated out-of-hospital trauma care when tourniquets were ineffective to stop the arterial flow. Methods: During our clinical study, 84 healthy volunteers wearing battle dress performed a physical exercise to come approximate the operational context. The volunteers were randomly divided into two groups according to the device (the CRoC or SJT) used as supplement to a tourniquet self-applied to the root of the thigh. The primary study end point was the complete interruption of popliteal arterial flow, measured with Doppler auscultation. Time to effectiveness and subjective questionnaire data to evaluate the devices' application were also collected. Results: Junctional device effectiveness was almost 90% for both the CRoC and the SJT, and did not differ between them, either used with a tourniquet (ρ = .36) or alone (ρ = .71). The time to effectiveness of the SJT was significantly shorter than that of the CRoC (ρ = .029). Conclusion: The SJT and the CRoC were equally effective. The SJT was faster to apply and preferred by the users. Our study provides objective evidence to the French Tactical Casualty Care Committee for improving junctional hemorrhage treatment.

Keywords: junctional tourniquet; hemorrhage; groin; medical device; Combat Ready Clamp; SAM® Junctional Tourniquet

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Keyword: combat resuscitation team

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Feasibility and Proposed Training Pathway for Austere Application of Resuscitative Balloon Occlusion of the Aorta

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

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Keyword: combat stress

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Preparing Soldiers for the Stress of Combat

Flanagan SC, Kotwal RS, Forsten RD. 12(2). 33 - 41. (Journal Article)

Abstract

Protracted use of stressors during military training courses does not necessarily enhance a Soldier's ability to regulate stress on the battlefield. Extensive stress during training can be a contributing factor to suboptimal neurologic and overall long-term health. Prolonged high-stress military training programs, as well as extended duration combat deployments, should be comprehensively scrutinized for opportunities to preserve health and increase combat effectiveness. Contemporary research in neuroscience and psychology can provide insight into training techniques that can be used to control stress and optimize performance in combat. Physical fitness training programs can elevate the stress threshold. Extensive situational training can also inoculate Soldiers to specific combat stressors. Training methods such as these will enable Soldiers to achieve higher levels of performance while under enemy fire and are encouraged for units deploying to combat.

Keywords: combat stress; military training; military deployment; physical training; posttraumatic stress disorder; sleep deprivation; stress inoculation training

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Keyword: combative

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The Agitated Patient

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

Abstract

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

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

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Keyword: combat-load

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Delayed Diagnosis of Pelvic hematoma without Fracture Due to Military Parachuting

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

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Keyword: Committee on Emergency Casualty Care

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The Ranger First Responder Program and Tactical Emergency Casualty Care Implementation: A Whole-Community Approach to Reducing Mortality From Active Violent Incidents

Fisher AD, Callaway DW, Robertson JN, Hardwick SA, Bobko JP, Kotwal RS. 15(3). 46 - 53. (Journal Article)

Abstract

Active violent incidents are dynamic and challenging situations that can produce a significant amount of preventable deaths. Lessons learned from the military's experience in Afghanistan and Iraq through the Committee on Tactical Combat Casualty Care and the 75th Ranger Regiment's Ranger First Responder Program have helped create the Committee for Tactical Emergency Casualty Care (C-TECC) to address the uniqueness of similar wounding patterns and to end preventable deaths. We propose a whole-community approach to active violent incidents, using the C-TECC Trauma Chain of Survival and a tiered approach for training and responsibilities: the first care provider, nonmedical professional first responders, medical first responders, and physicians and trauma surgeons. The different tiers are critical early links in the Chain of Survival and this approach will have a significant impact on active violent incidents.

Keywords: Committee on Tactical Combat Casualty Care; Ranger First Responder Program; Committee on Emergency Casualty Care; wounding patterns; Chain of Survival; preventable death

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Advanced Resuscitative Care in Tactical Combat Casualty Care: TCCC Guidelines Change 18-01:14 October 2018

Butler FK, Holcomb JB, Shackelford S, Barbabella S, Bailey JA, Baker JB, Cap AP, Conklin CC, Cunningham CW, Davis MS, DeLellis SM, Dorlac WC, DuBose JJ, Eastridge B, Fisher AD, Glasser JJ, Gurney J, 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

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Keyword: Committee on Tactical Combat Casualty Care

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The Ranger First Responder Program and Tactical Emergency Casualty Care Implementation: A Whole-Community Approach to Reducing Mortality From Active Violent Incidents

Fisher AD, Callaway DW, Robertson JN, Hardwick SA, Bobko JP, Kotwal RS. 15(3). 46 - 53. (Journal Article)

Abstract

Active violent incidents are dynamic and challenging situations that can produce a significant amount of preventable deaths. Lessons learned from the military's experience in Afghanistan and Iraq through the Committee on Tactical Combat Casualty Care and the 75th Ranger Regiment's Ranger First Responder Program have helped create the Committee for Tactical Emergency Casualty Care (C-TECC) to address the uniqueness of similar wounding patterns and to end preventable deaths. We propose a whole-community approach to active violent incidents, using the C-TECC Trauma Chain of Survival and a tiered approach for training and responsibilities: the first care provider, nonmedical professional first responders, medical first responders, and physicians and trauma surgeons. The different tiers are critical early links in the Chain of Survival and this approach will have a significant impact on active violent incidents.

Keywords: Committee on Tactical Combat Casualty Care; Ranger First Responder Program; Committee on Emergency Casualty Care; wounding patterns; Chain of Survival; preventable death

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

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

Abstract

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

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

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Keyword: competency, procedural

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

Schauer SG, Varney SM, Cox KL. 15(4). 67 - 70. (Journal Article)

Abstract

Background: Emergency medicine physicians (EPs) are often placed in far-forward, isolated areas in theater. Maintenance of their emergency intervention skills is vital to keep the medical forces deployment ready. The US Army suggests that working at a Military Treatment Facility (MTF) is sufficient to keep emergency procedural skills at a deployment-ready level. We sought to compare the volume of emergency procedures that providers reported necessary to maintain their skills with the number available in the MTF setting. Methods: EPs were surveyed to quantify the number of procedures they reported they would need to perform yearly to stay deployment-ready. We obtained procedure data for their duty stations and compared the procedure volume with the survey responses to determine if working at an MTF is sufficient to keep providers' skills deployment ready. Results: The reported necessary average numbers per year were as follows: tube thoracostomy (5.9), intubation (11.4), cricothyrotomy (4.2), lumbar puncture (5.2), central line (10.0), focused assessment with sonography for trauma (FAST) (21.3), reductions (10.6), splints (10.5), and sedations (11.7). None of the procedure volumes at MTFs met provider requirements with the exception of FAST examinations at the only trauma center. Conclusions: This suggests the garrison clinical environment is inadequate for maintaining procedure skills. Further research is needed to determine modalities that will provide adequate training volume.

Keywords: procedure; skills, procedural; competency, procedural; physicians, emergency medicine; skills; maintenance; deployment; volume

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Keyword: competitions

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Competing to Increase Capability: The Team From the Land Down Under's Experience at the National Tactical Medicine Competition 2018

Makrides T, Davoren B. 18(2). 149 - 152. (Journal Article)

Abstract

Keywords: National Tactical Medicine Competition 2018; competitions

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Keyword: complementary treatments

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The Benefits of Reflexology for the Chronic Pain Patient in a Military Pain Clinic

Kern C, McCoart A, Beltranm 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

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Keyword: compliance

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Battlefield Analgesia: Adherence to Tactical Combat Casualty Care Guidelines

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

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Keyword: compression

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A Novel Cryotherapy Compression Wrap in the Management of Acute Ankle Sprains: Potential Use for Special Operators on the Battlefield

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

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Keyword: compression bandage

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"Evita Una Muerte, Esta en Tus Manos" Program: Bystander First Aid Training for Terrorist Attacks

Pajuelo Castro JJ, Meneses Pardo JC, Salinas Casado PL, Hernandez Martin P, Montilla Canet R, del Campo Cuesta JL, Incera Bustio G, Martin Ayuso D. 17(4). 133 - 137. (Journal Article)

Abstract

Background: The latest terrorist attacks in Europe and in the rest of the world, and the military experience in the most recent conflicts leave us with several lessons learned. The most important is that the fate of the wounded rests in the hands of the one who applies the first dressing, because the victims usually die within the first 10 minutes, before professional care providers or police personnel arrive at the scene. A second lesson is that the primary cause of preventable death in these types of incidents involving explosives and firearms is massive hemorraghe. Objective: There is a need to develop a training oriented to citizens so they can identify and use available resources to avoid preventable deaths that occur in this kind of incidents, especially massive hemorrhage. Methods: A 7-hour training intervention program was developed and conducted between January and May 2017. Data were collected from participants' answers on a multiple-choice test before and after undertaking the training. Improved mean score for at least 75% of a group's members on the posttraining test was considered reflective of adequate knowledge. Results: A total of 173 participants (n = 74 men [42.8%]; n = 99 women [57.2%]) attended the training. They were classified into three groups: a group of citizens/ first responders with no prior health training, a group of health professionals, and a group of nursing students. Significant differences (ρ < .05) between mean pre- and post-training test scores occurred in each of the three groups. Conclusion: There was a clear improvement in the knowledge of the students after the training when pre- and post-training test scores were compared within the three groups. The greatest improvement was seen in the citizens/first responders group

Keywords: tourniquet; hemostatic; compression bandage; terrorism; mass-casualty event

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Keyword: concept analysis

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The Myth of Hyperresilience Evolutionary Concept Analysis of Resilience in Special Operations Forces

Rocklein Kemplin K, Paun O, Sons N, Brandon JW. 18(1). 54 - 60. (Journal Article)

Abstract

Despite many resilience studies and resilience-building initiatives in the military, resilience as a concept remains granularly unexamined, vague, and inconsistently interpreted throughout military-specific research literature. Specifically, studies of military suicide and related mental health constructs assert that Servicemembers in Special Operations Forces (SOF) possess higher levels of resilience without providing an empirical basis for these statements. To provide rigorous evidence for future studies of resilience in SOF, a concept analysis was performed via Rodgers' evolutionary method to contextualize resilience in the SOF community and provide accurate redefinitions on which theoretical and methodological frameworks can be constructed reliably.

Keywords: resilience; military; concept analysis; Special Operations Forces; suicide

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Keyword: concussion

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Deployed Assessment and Management of mTBI Casualties

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

Abstract

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

Keywords: traumatic brain injury; concussion

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Potential of Visual Sensory Screening, Diagnostic Evaluation, and Training for Treatment of Postconcussive Symptoms and Performance Enhancement for Special Forces Qualified Personnel

Suttles ST. 15(2). 54 - 63. (Journal Article)

Abstract

Mild traumatic brain injury (mTBI) or concussive injuries remain a challenge for both athletes and clinicians, given high incidence rates and heterogeneous clinical trajectories. Moreover, exposure to blast in combat is compounded by chronic, frequent exposure to a variety of subclinical impacts and overpressure, in some cases annually over many years. Subsequent injuries are often more severe than the original and lead to higher incidence of chronic symptoms in combat units, particularly Special Operations Forces (SOF), which is compounded by a propensity to underreport or avoid Army medical systems altogether. The unique nature and psychological makeup of SOF Soldiers suggest that new guidelines for progressive return-to-activity and return-to-duty decision-making within the traditional medical setting may not be generalizable to this population. Further, the traditional criteria for return to duty and return to play in sport may be insensitive to persistent deficits, resulting in premature return. There is presidential and Department of Defense mandates for continued research in the areas of diagnostics, treatment, and assessments for return to duty. With recent shift toward understanding clinical trajectories, particularly visual and vestibular trajectories, promising new technology from the field of sports vision may prove useful toward that endeavor. Since the advent of performance programs within SOF units, these Soldiers build trust with performance personnel, which include rehabilitative personnel, through consistent and regular shared experience. Implementation of comprehensive vision and visual performance screening in conjunction with the study of sports vision technology within the performance setting, in conjunction with unit medical personnel, may yield important findings for diagnosis and treatment of mTBI; to include the chronically symptomatic postconcussive Soldiers. Last, with a wealth of literature supporting visual skills training for athlete populations, to include competitive shooters, the implementation of visual skills training will likely be a useful adjunct to performance training of SOF personnel.

Keywords: traumatic brain injury, mild; concussion; sensory station; rehabilitation; visual skills; return to duty; Special Operations; human performance

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Keyword: conducted energy weapons

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Taser and Conducted Energy Weapons

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

Abstract

Keywords: taser; conducted energy weapons

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Keyword: conductive energy weapon

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Review, Clinical Update, and Practice Guidelines for Excited Delirium Syndrome

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

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Keyword: contamination

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Chemical Contamination Transfer in the Management of War Casualties

Collectif MCV T. 18(3). 67 - 70. (Journal Article)

Abstract

The use of chemical weapons agents (CWAs) was suspected in recent conflicts, during international conflicts, terrorist attacks, or civil wars. Little is known about the prevention needed for caregivers exposed to the risk of contamination transfer. We present a case of chemical contamination of health servicemembers during the management of casualties.

Keywords: weapons, chemical; contamination; improvised explosive devices

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Keyword: contrast sensitivity

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Tactical Lighting in Special Operations Medicine: Survey of Current Preferences

Calvano CJ, Enzenauer RW, Eisnor DL, LaPorta AJ. 13(1). 15 - 21. (Journal Article)

Abstract

Success in Special Operations Forces medicine (SOFMED) is dependent on maximizing visual capability without compromising the provider or casualty position when under fire. There is no single ideal light source suitable for varied SOFMED environments. We present the results of an online survey of Special Operations Medical Operators in an attempt to determine strengths and weaknesses of current systems. There was no consensus ideal hue for tactical illumination. Most Operators own three or more lights, and most lights were not night vision compatible. Most importantly, nearly 25% of respondents reported that lighting issues contributed to a poor casualty outcome; conversely, a majority (50 of 74) stated their system helped prevent a poor outcome. Based on the results of this initial survey, we can affirm that the design and choice of lighting is critical to SOFMED success. We are conducting ongoing studies to further define ideal systems for tactical applications including field, aviation, and marine settings.

Keywords: lighting; tactical; dark adaptation; contrast sensitivity; illumination

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Tactical Lighting in Special Operations Medicine: Survey of Current Preferences

Calvano CJ, Enzenauer RW, Eisnor DL, LaPorta AJ. 13(4). 15 - 21. (Journal Article)

Abstract

Success in Special Operations Forces medicine (SOFMED) is dependent on maximizing visual capability without compromising the provider or casualty position when under fire. There is no single ideal light source suitable for varied SOFMED environments. We present the results of an online survey of Special Operations Medical Operators in an attempt to determine strengths and weaknesses of current systems. There was no consensus ideal hue for tactical illumination. Most Operators own three or more lights, and most lights were not night vision compatible. Most importantly, nearly 25% of respondents reported that lighting issues contributed to a poor casualty outcome; conversely, a majority (50 of 74) stated their system helped prevent a poor outcome. Based on the results of this initial survey, we can affirm that the design and choice of lighting is critical to SOFMED success. We are conducting ongoing studies to further define ideal systems for tactical applications including field, aviation, and marine settings.

Keywords: lighting; tactical; dark adaptation; contrast sensitivity; illumination

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Optimizing Tactical Medical Performance: The Effect of Light Hue on Vision Testing

Van Buren JP, Wake J, McLaughlin J, LaPorta AJ, Enzenauer RW, Calvano CJ. 18(2). 75 - 78. (Journal Article)

Abstract

Background: Red and blue are the historical tactical lighting hues of choice to ensure light discipline and to preserve dark adaptation. As yet, no scientifically ideal hue for use in Special Operations medicine has been identified. We propose red/green polychromatic light as a superior choice that preserves visual function for tactical medical tasks in austere settings. Methods: Thirty participants were enrolled in this institutional review board-approved study. Participants completed four vision tasks in low-light settings under various lighting conditions. The Pelli-Robson Near Contrast Sensitivity test (PR), tumbling E visual acuity test, Farnsworth D-15 color-vision test (FD15), and pseudoisochromatic plate (PiP) testing was performed under white, green, or red light illumination and also red/green and red/green/yellow lights. PR and tumbling E tests were performed using blue and blue/red lights. Results: The test results for each light were compared against a white-light standard. Contrast sensitivity as measured by PR testing showed no statistical difference when white light was used compared with red/green or red/green/yellow light, and the differences between red, green, blue, and blue/red all were statistically different from when white light was used. When measuring visual acuity, blue light was the only color for which there was a statistically significant decrease in visual acuity in comparison with white. There was no reduction in visual acuity with any other lights compared with white. Performance on FD15 testing with all single-hue and multihue lights was significantly worse than with white light for measuring color-vision perception. Color discrimination as measured by PiP testing showed red and green light was significantly worse than with white light, whereas test results when green/red and green/red/yellow lights were used were not statistically different from white. Conclusion: Red/Green/yellow and red/green were superior light sources and performance results only were worse than white light on FD15 testing.

Keywords: SOFMED; tactical lighting; visual acuity; contrast sensitivity; color vision

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Keyword: control

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

Kirkpatrick AW, McKee JL, McKee I, Panebianco NL, Ball CG. 15(4). 71 - 74. (Journal Article)

Abstract

Bleeding to death has been identified as the leading cause of potentially preventable injury-related death worldwide. Temporary hemorrhage control could allow the patient to be transported to a site capable of damage- control surgery. A novel device that may offer a fast and effective means of controlling nontruncal bleeding (junctional and extremity) is the iTClamp (Innovative Trauma Care; http://innovativetraumacare.com). This case study demonstrated that a motivated and intelligent, but untrained, first responder could successfully localize the actual anatomic site of an exsanguinating bleed and then could relatively easily compress this site to control the bleeding site by using ultrasound-guided manual-compression techniques.

Keywords: hemorrhage; iTClamp; ultrasound; bleeding; control

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Keyword: conventional US Air Force

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Experience Of A US Air Force Surgical And Critical Care Team Deployed In Support Of Special Operations Command Africa

Delmonaco BL, Baker A, Clay J, Kilbourn 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

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Keyword: cooling

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

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

Abstract

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

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

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Keyword: coping

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Swedish Specialized Boarding Element Members' Experiences of Naval Hostile Duty

Hindorf M, Lundberg L, Jonsson A. 18(3). 45 - 49. (Journal Article)

Abstract

Background: The Swedish naval specialized boarding element participated in Operation Atalanta in 2013 to mitigate piracy by escorting and protecting ships included in the United Nations World Food Program in the Indian Ocean. We describe the experiences of the Swedish naval specialized boarding-element members during 4 months of international naval hostile duty. Some studies have reported experiences of naval duty for the Coast Guard or the merchant fleet; however, we did not find any studies that identified or described experiences of long-time duty onboard ship for the naval armed forces. Materials and Methods: The respondents wrote individual notes of daily events while onboard. Conventional content analysis was used on the collected data, using an inductive approach. Results: The findings revealed three broad themes: military preparedness, coping with the naval context, and handling physical and mental strain. Different categories emerged indicating that the participants need the ability to adapt to the naval environment and to real situations. Conclusion: The Swedish naval forces should train their specialized element members in coping strategies.

Keywords: Swedish Navy; naval duty; mental strain; coping; qualitative method

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Keyword: Coronavirus

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Middle East Respiratory Syndrome

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

Abstract

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

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

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Keyword: cortisol

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High Intensity Scenario Training of Military Medical Students to Increase Learning Capacity and Management of Stress Response

Mueller G, Moloff A, Wedmore I, Schoeff J, LaPorta AJ. 12(2). 71 - 76. (Journal Article)

Abstract

A delicate balance exists between a beneficial stress response that enhances memory and recall performance and a detrimental high stress response that impairs memory and learning. Repetitive training in stressful situations enables people to lower their stress levels from the detrimental range to a more beneficial one.1 This is particularly true for physicians in training as they seek to achieve advanced skills and knowledge in the fields of triage, emergency medicine, and surgery prior to graduation. This need is significant for medical students entering military service after graduation. We theorize that military medical students can advance their proficiencies through an Intensive Skills Week (ISW) prior to entering their third and forth year rotations. To test this theory, Rocky Vista University will hold a week long high-intensity first-responder, emergency medicine and surgical training course, facilitated by military medical physicians, to further students' skills and maximize training using the Human Worn Partial Surgical Task Simulator (Cut Suit). We also see the possible benefit to physician and non-physician military personnel, especially Special Operations Forces (SOF) medical personnel, from developing and implementing similar training programs when live tissue or cadaver models are unavailable or not feasible.

Keywords: stress; cortisol; medical student; enhanced learning scenario; high intensisty

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Keyword: cotton

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

Sirkin MR, Cook P, Davis KG. 15(4). 54 - 58. (Journal Article)

Abstract

Background: The operative control of noncompressible hemorrhage is the single largest impact that could be addressed in reducing the mortality on the battlefield. Laprotomy pads, traditionally used for hemorrhage evacuation, are made of woven cotton, and, while effective, their use requires a substantial amount of space and adds weight. This poses no concern in traditional operating rooms but is a hindrance for mobile providers and providers in austere environments. We sought to compare different absorptive compunds to ascertain their utility as alternatives for traditional laparotomy pads. Methods: Samples of cotton laparotomy pads, pure rayon sheets, rayon-polypropylene composite sheets, and non-polyester composite "microfiber" sheets were weighed and submerged in heparinized whole bovine blood. After saturation, the favrics were weighed, wrung dry, reweighed, and resubmerged. This process was performed for a total of three sequential submersions. The saturated weights and dry weights of each fabric were used to calculate how much blood each fabric could absorb initially and after multiple repeated uses. The initial densities of the four fabrics was calculated and compared. Results: The initial submersions demonstrated that 1g each of cotton, rayon, rayon-polypropylene, and nylon-polyester were able to absorb 7.58g, 12.98g, 10.16g, and 9.73g of blood respectively. The second and third sequential trials, which were statistically similar, demonstrated that 1g of cotton, rayon, rayon-polypropolyene, and nylon-polyester were able to absorb 1.73g, 2.83g, 2.3g, and 2.3g of blood, respectively. The calculated densities of cotton, rayon, rayon-polypropylene, and nylon-polyester were 0.087g/cm³, .012g/cm³, 0.098g/cm³, and 0.093g/cm³, respectively. Conclusion: Per gram, rayon absorbed approximately 1.7 times more blood thancotton and three-quarters the amount of the storage space. Rayon also retained its superior absorption abilites on repeated uses, demonstrating the potential for re-use in remote and austere environments. Thus, rayon could serve as a viable alternative to traditional cotton laparotomy pads in the austere environments.

Keywords: hemorrhage; laparotomy; cotton; rayon; sponge; austere; surgery; packing; combat casualty care; absorption; density

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Keyword: Counter-Insurgency

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Advanced Medical Technology Capacity Building and the Medical Mentoring Event: A Unique Application of SOF Counterinsurgency Medical Engagement Strategies

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

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Keyword: Counter-measure Strategies

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Tools to Assess and Reduce Injury Risk (Part 1)

Knapik JJ. 17(3). 116 - 119. (Journal Article)

Abstract

Many injuries are preventable. Useful tools are available that can aid in assessing injury risks and developing methods to reduce these risks. This is part 1 of a two-part article that will discuss these tools, which include the Haddon Matrix, the 10 Countermeasure Strategies, the Injury Control Process, and the Army Risk-Management Process. The Haddon Matrix is 3 ® 3 table that, across the top (columns), provides an approach to conceptualizing injury prevention and control through modifications of the human, equipment, and environment; and, across rows, thinking about injury prevention and control before, during, and after the injury-producing event. The basic premise of the 10 Countermeasure Strategies is that injuries are largely due to energy exchanges between a person and the external environment in such a way that body cannot properly avoid or absorb the energy and anatomic structures are damaged. The Countermeasure Strategies are (1) eliminating the hazard altogether, (2) reducing the amount of the hazard, (3) preventing release of the hazard, (4) modifying the rate or spatial distribution of the hazard, (5) separating in space or time the hazard and the individual, (6) separating the individual from the hazard using a barrier, (7) modifying the basic qualities of the hazard, (8) strengthening the individual to make them more resistant to damage, (9) countering the damage done, and (10) stabilizing, healing, and rehabilitating the individual. Part 2 of this series will discuss the injury control process and the Army risk management process.

Keywords: injuries; injury prevention; Haddon Matrix; Counter-measure Strategies

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Keyword: course

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Cypress Creek EMS Basic Tactical Operational Medical Support Course

Godbee DC. 19(2). 34 - 39. (Journal Article)

Abstract

Keywords: Cypress Creek EMS Basic Tactical Operational Medical Support; tactical EMS; course; class

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Keyword: craniomaxillofacial trauma

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Facial Trauma Care in the Austere Environment

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

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Keyword: creatinine kinase

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Exertional Rhabdomyolysis: Attrition Through Exercise, A Case Series and Review of the Literature

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

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Keyword: Cric-Key™

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The Cric-Key™ and Cric-Knife™: A Combined Tube-Introducer and Scalpel-Hook Open Cricothyrotomy System

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™

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Keyword: Cric-Knife™

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The Cric-Key™ and Cric-Knife™: A Combined Tube-Introducer and Scalpel-Hook Open Cricothyrotomy System

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™

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Keyword: cricothyroidotomy

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Prehospital Cricothyrotomy Kits Used in Combat

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

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Survival of Casualties Undergoing Prehospital Supraglottic Airway Placement Versus Cricothyrotomy

Schauer SG, Naylor JF, Chow AL, Maddry J, 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

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Keyword: cricothyrotomy

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The Cric-Key™ and Cric-Knife™: A Combined Tube-Introducer and Scalpel-Hook Open Cricothyrotomy System

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™

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Prehospital and En Route Cricothyrotomy Performed in the Combat Setting: A Prospective, Multicenter, Observational Study

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

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Prehospital Cricothyrotomy Kits Used in Combat

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

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Concepts of Prehospital Advanced Airway Management in the Operational K9: A Focus on Cricothyrotomy

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

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Keyword: Crimea

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Old Tricks for New Dogs? John Caddy and the Victorian Origins of TCCC

Reynolds PS. 18(2). 58 - 62. (Journal Article)

Abstract

The success of Tactical Combat Casualty Care (TCCC) in reducing potentially preventable combat deaths may rely on both specific interventions (such as tourniquets) and the systematized application of immediate care. Essential elements of a combat care system include clear specification of immediate care priorities, standardized methodology, and inclusion and training of all nonmedical personnel in early response. Although TCCC is fairly recent, the construct is similar to that first suggested during the mid-nineteenth century by John Turner Caddy (1822-1902), a British Royal Navy staff surgeon. Although naval warfare engagements at the time were relatively infrequent, casualties could be numerous and severe and often overwhelmed the small medical staff on board. Caddy recognized that nonmedical personnel properly trained in the fundamentals of combat injury management would result in lives saved and greatly improved morale. The novelty was in his attempt to make procedures simple enough to be performed by nonmedical personnel under stress. However, Caddy's guidelines were completely overlooked for nearly two centuries. The principles of best practice for managing combat trauma injuries learned in previous wars have often been lost between conflicts. Understanding the historical roots of combat first responder care may enable us to better understand and overcome barriers to recognition and retention of essential knowledge.

Keywords: combat casualty care; Crimea; hemorrhage; military medicine; tourniquet; wounds and injuries

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Keyword: Crimean-Congo hemorrhagic fever

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Crimean-Congo Hemorrhagic Fever

Burnett MW. 15(4). 96 - 98. (Journal Article)

Abstract

In mid-September 2009, a 22-year-old critically ill Soldier was medically evacuated from a treatment facility in southern Afghanistan to Landstuhl Regional Medical Center in Germany. Despite the efforts of the team at Landstuhl, this patient died and became the US military's first known victim of Crimean-Congo hemorrhagic fever (CCHF). CCHF is caused by a virus, which bears the same name. Because a vaccine is lacking, as well as an effective antiviral treatment, prevention is key.

Keywords: Crimean-Congo hemorrhagic fever; infectious disease

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Keyword: critical care

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Resuscitation During Critical Care Transportation in Afghanistan

Tobin JM, Nordmann GR, Kuncir EJ. 15(3). 72 - 75. (Journal Article)

Abstract

Objective: These data describe the critical care procedures performed on, and the resuscitation markers of, critically wounded personnel in Afghanistan following point of injury (POI) transports and intratheater transports. Providing this information may help inform discussion on the design of critical care transportation platforms for future conflicts. Methods: The Department of Defense Trauma Registry (DoDTR) was queried for descriptive data on combat casualties with Injury Severity Score (ISS) greater than 15 who were transported in Operation Enduring Freedom (OEF) from 1 January 2010 to 31 December 2010. Both POI transportation events and interfacility transportation events were reviewed. Base deficit (BD) was evaluated as a maker of resuscitation, and international normalized ratio (INR) was evaluated as a measure of coagulopathy. Results: There were 1198 transportation events that occurred during the study period - 634 (53%) transports from the POI and 564 (47%) intratheater transports. Critical care interventions were performed during 147 (12.3%) transportation events, including intubation, cricothyrotomy, double-lumen endotracheal tube placement, needle or tube thoracostomy, central venous access placement, and cardiopulmonary resuscitation. The mean BD on arrival in the emergency department was -5.4 mEq/L for POI transports and 0.68 mEq/L intratheater transports (ρ < .001). The mean INR on arrival in the emergency department was 1.48 for POI transports and 1.21 for intratheater transports (ρ < .001). Conclusions: Critical care interventions were needed frequently during evacuation of severely injured personnel. Furthermore, many troops arrived acidotic and coagulopathic following initial transport from POI. Together, these data suggest that a platform capable of damage control resuscitation and critical care interventions may be warranted on longer transports of more critically injured patients.

Keywords: transportation; critical care; resuscitation, trauma; damage control; emergency medical services; care, out-of-hospital

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Telemedicine to Reduce Medical Risk in Austere Medical Environments: The Virtual Critical Care Consultation (VC3) Service

Powell D, McLeroy RD, Riesberg JC, Vasios WN,