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Davis K, Oury JJ, Reed BL, Grabo DJ, Wilson A, Coleman C 99(5). 0 (Journal Article)

Needle decompression is a mainstay intervention for tension pneumothorax in trauma medicine. It is used in combat and prehospital medicine when definitive measures are often not available or ideal. It can temporarily relieve increased intrathoracic pressure and treat a collapsed lung or great vessel obstruction. However, when done incorrectly, it can result in underlying visceral organ and vessel trauma. This is a case of an adult male who presented to the emergency department after sustaining multiple stab wounds during an altercation. On arrival, the patient had a 14-gauge angiocatheter inserted at the 4th intercostal space (ICS), left of the parasternal line traversing the right ventricle and interventricular septum and terminating in the left ventricle. The case emphasizes the importance of understanding the landmarks of performing needle decompression in increasing the procedure's efficacy and reducing iatrogenic complications.

Lalli K, Charkoudian N, Moreh Y, Degroot D 99(5). 0 (Journal Article)

Exertional heat stroke (EHS) is a medical emergency characterized by elevated body temperature and central nervous system dysfunction, and it can include dizziness, confusion and loss of consciousness, as well as long-term organ and tissue damage. EHS is distinct from classic, or passive, heat stroke and is most commonly observed during intense physical activity in warfighters, athletes, and laborers. EHS is an ongoing non-combat threat that represents a risk to both the health and readiness of military personnel. Potential risk factors and their mitigation have been the subject of investigation for decades. One risk factor that is often mentioned in the literature, but not well quantified, is that of individual motivation to excel, wherein highly trained military personnel and athletes exert themselves beyond their physiological limits because of a desire to complete tasks and goals. The motivation to excel in tasks with high standards of achievement, such as those within elite military schools, appears to create an environment in which a disproportionately high number of exertional heat illness casualties occur. Here, we review existing biomedical literature to provide information about EHS in the context of motivation as a risk factor and then discuss five cases of EHS treated at Martin Army Community Hospital at Fort Moore, GA, from 2020 to 2022. In our discussion of the cases, we explore the influence of motivation on each occurrence. The findings from this case series provide further evidence of motivation to excel as a risk factor for EHS and highlight the need for creative strategies to mitigate this risk.

Leone R, Remondelli MH, Smith SS, Moore BJ, Wuss SL, D'Angelo M 99(5). 0 (Editorial)

Knapp JG, Tang N 99(5). 0 (Journal Article)

Separate evidence-based, best practice guidelines and recommendations exist for the prehospital management of traumatic injuries sustained in combat settings and those encountered during high-threat civilian operational incidents. The Bureau of Alcohol, Tobacco, Firearms and Explosives (ATF) Tactical Medic Program is a mature operational medicine asset supporting high-threat federal law enforcement operations. The ATF conducted an audit of its agency-issued tactical medic bags with regards to completeness, as defined by authorized medical protocols, which are aligned with current Tactical Combat Casualty Care and Tactical Emergency Casualty Care guidelines.

This current set of medical guidelines was developed by collaborating with Emergency Medicine professionals, experienced Flight Medics, Aeromedical Physician Assistants, Critical Care Nurses, and Flight Surgeons. There has been close coordination in developing these guidelines by the Joint Trauma System, the Committee of En Route Combat Casualty Care, and the Committee of Tactical Combat Casualty Care. The shared goal is to ensure excellent en-route care that is standard across all evacuation and emergency medical pre-hospital units. All these enhancements and improvements will advance en-route care across the services and the Department of Defense. This handbook was published in February 2024.

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US Air Force Independent Duty Medical Technician (IDMT), Medical and Dental Treatment Protocols, Ed 2.3 Handbook published in January 2021 is a resource for Air Force IDMT medical personnel with advanced skills and knowledge. These protocols are the product of a concerted effort by representatives from all major command surgeons' offices with the express goal to standardize the care  IDMTs are permitted to provide regardless of location and command affiliation. These protocols clearly define the scope of care parameters that the IDMT is expected and trained to work within. These treatment protocols are designed as a guide to accepted step-by-step treatments for medical disorders that may be encountered by IDMTs in the field. 

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Digital Flipbook and PDF versions of this handbook are available as a subscription to the JSOM. You can subscribe here.

Table of Contents

The Advanced Tactical Protocols-Paramedic (ATP-P) Handbook is an essential reference tool for tactical and combat medics, SWAT team members, and medical professionals operating in austere environments.

This handbook is printed on waterproof/tearproof paper. Please note: Do not expose this product to chemicals such as cleaning supplies, lotions, etc., as your book will be damaged.

This revision contains updates to the Airway Management protocols, Respiration / Breathing in Tactical Field Care, and K9 TCCC protocols.

View the Table of Contents

The Advanced Tactical Protocols-Paramedic (ATP-P) Handbook is an essential reference tool for tactical and combat medics, SWAT team members, and medical professionals operating in austere environments.

This handbook is printed on standard paper and is NOT waterproof or tearproof.

View the Table of Contents

Brandt M, Liccardi C, Heidle J, Woods TD, White C, Mullins JR, Blackwell J, Le L, Brantley K 23(2). 44 (Journal Article)

Background: Recent data published by the Special Operations community suggest the Lethal Triad of Trauma should be changed to the Lethal Diamond, to include coagulopathy, acidosis, hypothermia, and hypocalcemia. The purpose of this study is to determine the prevalence of trauma-induced hypocalcemia in level I and II trauma patients. Methods: This is a retrospective cohort study conducted at a level I trauma center and Special Operations Combat Medic (SOCM) training site. Adult patients were identified via trauma services registry from September 2021 to April 2022. Patients who received blood products prior to emergency department (ED) arrival were excluded from the study. Ionized calcium levels were utilized in this study. Results: Of the 408 patients screened, 370 were included in the final analysis of this cohort. Hypocalcemia was noted in 189 (51%) patients, with severe hypocalcemia identified in two (<1%) patients. Thirty-two (11.2%) patients had elevated international normalized ratio (INR), 34 (23%) patients had pH <7.36, 21 (8%) patients had elevated lactic acid, and 9 (2.5%) patients had a temperature of <35°C. Conclusion: Hypocalcemia was prevalent in half of the trauma patients in this cohort. The administration of a calcium supplement empirically in trauma patients from the prehospital environment and prior to blood transfusion is not recommended until further data prove it beneficial.

Powell E, Betzold R, Kundi R, Anderson D, Haase D, Keville M, Galvagno S 24(1). 32 (Journal Article)

Background: Veno-venous extracorporeal membrane oxygenation (VV ECMO) is a low-frequency, high-intensity procedure used for severe lung illness or injury to facilitate rapid correction of hypoxemia and respiratory acidosis. This technology is more portable and extracorporeal support is more frequently performed outside of the hospital. Future conflicts may require prolonged causality care and more specialized critical care capabilities including VV ECMO to improve patient outcomes. We used an expert consensus survey based on a developed bifemoral VV ECMO cannulation checklist with an operational focus to establish a standard for training, validation testing, and sustainment. Methods: A 36-item procedural checklist was provided to 14 experts from multiple specialties. Using the modified Delphi method, the checklist was serially modified based on expert feedback. Results: Three rounds of the study were performed, resulting in a final 32-item checklist. Each item on the checklist received at least 70% expert agreement on its inclusion in the final checklist. Conclusion: A procedural performance checklist was created for bifemoral VV ECMO using the modified Delphi method. This is an objective tool to assist procedural training and validation for medical providers performing VV ECMO in austere environments.

Hetzler MR, Fogarty JA, Frament C 24(1). 95 (Journal Article)

This paper is designed to introduce, propose, inform, and advocate enhanced relationships between the medical communities of special operations and space. Although each provides service support in different roles and functions, similarities in both the operational context and in medical care are notable. During a recent interaction, significant relationship potential was discovered by both communities, and recommendations for greater engagement are proposed herein. By identifying and appreciating similarities and understanding history, key actors, and authorities to analyze and realize opportunities will enable us to find synergy for the development of like efforts and goals. Collaboration in research on the limits of human performance and medical support to the most austere and challenging operational environments may benefit both communities in different but productive ways. Establishing and increasing cooperation will also meet command strategic intent, explore and advance a policy concept, initiate a relationship between unique medical communities, and provide a tangible success for the advancement of operational support.

Jeschke EA, Wyma-Bradley J, Baker JB, Dorsch J, Huffman SL 24(1). 90 (Journal Article)

Building upon our strategic framework and operational model, we will discuss findings from our ethnographic study, entitled: "The Impact of Catastrophic Injury Exposure on Resilience in Special Operations Surgical Teams (SOSTs)," to explain the tactical nature and importance of social determinants within our new characterization of unconventional resilience. Our fourth paper in this series, will explain how bonding patterns establish the quality of intra- and interpersonal connections that create a tensive conduit for the pressure of performance within our operational model, allowing for dynamic freedom of maneuver to take place in ambiguity. We will use qualita- tive quotes to illustrate various ways SOST medics relate to themselves, other people, and the Special Operations Forces (SOF) culture. To achieve our goals, we will: 1) provide an in- troduction to social determinants as tactical engagement with unconventional resilience; 2) define the social determinant of bonding patterns as extrapolated from qualitative data as well as use qualitative data to thematize various types of bonding patterns; and 3) relate tactical engagement with bonding pat- terns to our metaphor of bag sets. We conclude by gesturing to the importance of bonding patterns in orienting SOF medics' proprioception and kinesthesia in the SOF performance space.

Tadlock MD, Kitchen LK, Brower JJ, Tripp MS 24(1). 88 (Journal Article)

The current United States Navy and North Atlantic Treaty Organization (NATO) maritime strategy is coalescing around the concept of Distributed Maritime Operations (DMOs) to prepare for future large-scale combat operations with peer or near-peer competitors. As a result, individual components of naval forces will be more geographically dispersed and oper- ating at a significant time and distance from higher levels of medical care. We developed a series of educational scenarios informed by real-world events to enhance the ability of Role 1 medical caregivers to apply the principles of Prolonged Ca- sualty Care during current routine, crisis, and contingency DMOs.

Smith S, Hilsden R, Patton P, Vogt K, Beckett A, Ball IM 24(1). 85 (Journal Article)

Rib fractures in combat casualties are an under-appreciated injury, and their treatment may become more common as more patients survive because of modern body armor and point-ofinjury care. The combat environment has challenges such as equipment availability and sterility. A simple and thoughtful rib fracture treatment algorithm may be useful to reduce the morbidity and mortality of rib fractures in the combat environment. Intravenous lidocaine infusions for patients with traumatic rib fractures may have important combat applications. We propose an algorithm for the management of combat casualties with traumatic rib fractures.

Schauer S, Fisher AD, April MD 24(1). 81 (Journal Article)

Background: The U.S. Military needs fast-acting, non-opioid solutions for battlefield pain. The U.S. Military recently used morphine auto-injectors, which are now unavailable. Off-label ketamine and oral transmucosal fentanyl citrate use introduces challenges and is therefore uncommon among conventional forces. Sublingual suftentanil is the only recent pain medication acquired to fill this gap. Conversely, methoxyflurane delivered by a handheld inhaler is promising, fast-acting, and available to some partner forces. We describe methoxyflurane use reported in the Department of Defense Trauma Registry (DODTR). Methods: We requested all available DODTR encounters from 2007 to 2023 with a documented intervention or assessment within the first 72 hours of care. We analyzed casualties who received methoxyflurane in the prehospital setting using descriptive statistics. Results: There were 22 encounters with documented methoxyflurane administration. The median patient age was 23 (range 21-31) years. All were men. The largest proportion was partner force (50%), followed by U.S. Military (27%). Most (64%) sustained battle injuries. Explosives were the most common mechanism of injury (46%), followed by firearms (23%). The median injury severity score was 5 (range 1-17). The most frequent injuries were serious injuries to the extremities (27%), and 23% of patients (5) received a tourniquet. One-half of the casualties received concomitant pain medications. Only three casualties had multiple pain scores measured, with a median pain score change of -3 on a scale of 10. Conclusion: Methoxyflurane use in deployed combat shows both feasibility and usability for analgesia.

Lanham N, Belyea CM, Marcello D, Wataka AB, Musila L 24(1). 77 (Journal Article)

Background: Recommendations for optimal temperature and humidity for sterile instrument storage vary according to different sources. Furthermore, there are limited data comparing methods of packing smaller, lightweight, low-profile instruments. The purpose of this study was to compare sterile peel packaging and sterile cellulose wrapping for sterile instrument storage in an austere environment characterized by elevated temperature and humidity. Methods: Stainless steel screws were sterilized and stored in either sterile peel packaging, sterile cellulose wrapping, or no packaging. Four groups were evaluated. Group 1 consisted of four screws in a sterile peelpack envelope and served as a time-zero control. Group 2 consisted of two groups of five screws, each packaged with blue sterilization cellulose wrap. Group 3 consisted of two groups of five screws, each packaged in sterile peel-pack envelopes. Group 4 consisted of 10 non-sterile unpackaged screws, which served as controls. Screws from groups 2, 3, and 4 were then cultured for 6 and 12 weeks. Temperature and humidity values were recorded in the instrument storage area. Results: Average temperature was 21.3°C (SD 1.2°C; range 18.9°C-27.2°C) and average humidity was 51.7% (SD 3.9%; range 39%- 70%). Groups 1 (time-zero control) and 2 (sterile cellulose wrapping) demonstrated no growth. After 6 and 12 weeks, groups 3 (sterile peel packaging) and 4 (control) demonstrated bacterial growth. Conclusion: The most common culture isolates were gram-positive rods and two common nosocomial Staphylococcius species. Sterile peel packaging was not found to be equivalent to sterile cellulose wrapping in austere environmental conditions.