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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)

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.

Tactical Emergency Casualty Care (TECC): Guidelines For The Provision Of Prehospital Trauma Care In High Threat Environments

Callaway DW, Smith ER, Cain JS, Shapiro G, Burnett WT, McKay SD, Mabry RL 11(3). 104 - 122 (Journal Article)

Hot Dogs: Not Just Backyard Fun A K-9 Heat Injury Case Study

LeClair TG 11(3). 66 - 68 (Journal Article)

Underneath The Unconventional: Philosophies And Paradigms Of Special Operations Forces Clinical Science

Froede K 11(3). 56 - 60 (Journal Article)

Special Operations Forces (SOF) medical personnel (clinicians) directly impact their patients' outcomes, regardless if the patient is a Soldier, civilian, or indigenous person. Any health practitioner who specializes in trauma, Soldiers' healthcare, or tactical and/or operational healthcare must have a working knowledge of SOF medicine and its philosophical, political, and contextual origins. SOF clinical evidence and knowledge base is extensive and inextricably linked to SOF clinicians' underlying warrior philosophy and worldview. This submission will argue the point that SOF healthcare is a discipline and mature science in its own right, as evidenced by SOF's utilization and/or rejection of other disciplines' (nursing, medicine, conventional military) paradigms, community-wide adoption of its own specific paradigms, disciplinary matrix, and language. Peer-reviewed articles relevant to SOF and military healthcare from 2009-2011 are reviewed to determine possible philosophical frameworks, identify extant methodologies, and demonstrate underlying philosophical constructs.

Zoonotic And Infectious Disease Surveillance In Ecuador: Ehrlichia Canis, Anaplasma Phagocytophilum, Borrelia Burgdorferi, And Dirofilaria Immitis Prevalence Rates In Canines

McCown ME, Monterroso VH, Grzeszak B 11(3). 61 - 65 (Journal Article)

Vector-borne diseases (VBD) make up a large number of emerging infectious and zoonotic diseases. Ticks, fleas, and mosquitoes are effective vectors parasitizing canines, making dogs adequate reservoirs for zoonoses. The U.S. military deploys personnel and government- owned animals around the world with possible risk of exposure to VBD. Canine VBD have veterinary and public health significance for the host nations as well as for the U.S. troops and its working animals deployed in the theater of operations. These factors make disease surveillance a great importance. The objective of this work was to survey canines from the cities of Manta and Guayaquil in Ecuador to determine prevalence of heartworm disease (D. immitis), ehrlichi os is (E. canis), Lyme disease (B. burgdorf eri), and anapl asmosis (A. phagocytophilum). Canine blood samples (1-3ml) collected from the cities of Manta (n=50) and Guayaquil (n=50) were tested on site using a SNAP® 4Dx® Test Kit. Prevalence for single or multiple disease status was calculated for each city. In the city of Manta the overall prevalence of diseases was 78%; 52% for E. canis alone, and 26% for co-infection with E. canis and A. phagocytophilum. The overall prevalence for the city of Guayaquil was 88%; 40% for E. canis alone, 22% for A. phagocytophilum alone, and 26% for co-infection with E. canis and A. phagocytophilum. Neither heartworm disease nor Lyme disease was detected in any samp le. In conclusion, this study showed the extensive presence of E. canis and A. phagocytophilum in both cities in Ecuador, emphasizing the value of surveillance for zoonotic diseases to determine disease prevalence and risk assessments, as well as to implement control measures.

Parasitology Results From A Medcap In Africa

Franklin B, Swierczewski B 11(3). 48 - 51 (Journal Article)

The Medical Civil Action Program (MEDCAP) is an important tool that is utilized to support the larger missions in all areas of current operations. In Ethiopia, MEDCAPs are one of many tools commanders use to earn the trust and confidence of the local population. There are many ways to implement a MEDCAP and this paper will highlight one such successful engagement. This mission was intended in increase the medical capacity of host nation (HN) medical personnel and increase HN confidence in their government to provide for essential services. The mission was broken into four phases similar to traditional MEDCAPs, but with a significant difference.

A New Plan For The 800-pound Guerrilla: Perinatal Mortality. A 21st Century Medical Counterinsurgency Model For Afghanistan

Johnson TC 11(3). 52 - 55 (Journal Article)

Afghanistan has the highest perinatal mortality rate in the entire world. One Afghani woman dies every 30 minutes from perinatal- related event. One of eight Afghani women will die from perinatal events. Maternal mortality is (use percentage, not fractions) 1600/100,000 vs 13 /100,000 in the United States. Afghanistan is one of the only countries in the world in which the average woman's life expectancy is shorter than a males- despite the active, nationwide combat fought primarily by Afghani males. Meaning, women in Afghanistan are not routinely involved in combat, yet are more likely to die than a man of the same age. This article presents an alternative model Medical Seminar (MEDSEM) for a successful Special Forces (SF) medical counterinsurgency (COIN) plan that can obtain real results by addressing the mission of the Afghan Ministry of Health versus clinging to old notions. This model forms around the medical capabilities of the SF Operational Detachment (ODA)- Alpha (A) and preventinmaternal- infant complications.

Fresh Whole Blood Transfusions In The Austere Environment

Bowling F, Kerr W 11(3). 3 - 37 (Journal Article)

The use of Fresh Whole Blood (FWB) transfusions can be a powerful tool for the Special Operations Forces (SOF) medic to treat uncontrolled hemorrhage. In fact, it may be the only tool currently available for hemostatic resuscitation, which along with hypotensive resuscitation, forms the basis for Damage Control Resuscitation (DCR). Until now, no comprehensive protocol has existed for conducting FWB transfusions in austere environments. The United States Special Operations Command (USSOCOM) sponsored Curriculum Evaluation Board (CEB), which is responsible for authoring the Tactical Emergency Medical Protocols (TMEPs) has produced a protocol. This article serves as its introduction.

Mild Traumatic Brain Injury Literature Review and Proposed Changes To Classification

Krainin BM, Forsten RD, Kotwal RS, Lutz RH, Guskiewicz KM 11(3). 38 - 47 (Journal Article)

Mild traumatic brain injury (mTBI) reportedly occurs in 8-22% of U.S. servicemembers who conduct combat operations in Afghanistan and Iraq. The current definition for mTBI found in the medical literature, to include the Department of Defense (DoD) and Veterans Administration (VA) clinical practice guidelines is limited by the parameters of loss of consciousness, altered consciousness, or post-traumatic amnesia, and does not account for other constellations of potential symptoms. Although mTBI symptoms typically resolve within seven days, some servicemembers experience symptoms that continue for weeks, months, or years following an injury. Mild TBI is one of few disorders in medicine where a benign and misleading diagnostic classification is bestowed on patients at the time of injury, yet still can be associated with lifelong complications. This article comprehensively reviews the clin ical literature over the past 20 years and proposes a new classification for TBI that addresses acute, sub-acute, and chronic phases, and includes neurocognitive, somatic, and psychological symptom presentation.

Military Static Line Parachuting Injuries Seen By The Airborne Battalion Provider

Healy ML 11(2). 45 - 51 (Journal Article)

Military static line parachuting exposes jumpers to a variety of novel methods of injury. Providers assigned to Airborne units need to develop and maintain a high index of suspicion when dealing with jump-related injuries. Understanding the incident rate and the mechanism of injury can help a provider better identify injuries based on the history of the incidence and develop that index of suspicion. Injuries can happen at almost any point during the jump process and each step has both common and unique injuries associated with it. In addition to identifying, managing, and treating the injuries involved, providing information on estimated time until return to duty can be beneficial for the commander. In the end, a provider's best tools for managing Airborne-related injuries are an understanding of Airborne operations, quality orthopedic skills, and a high index of suspicion.

Case Report: Acute Intermittent Porphyria In A 21-year-old Active Dutymale

Thompson WD 11(2). 52 - 56 (Journal Article)

Acute Intermittent Porphyria (AIP) is one of a group of rare metabolic disorders arising from reduced activity of any of the enzymes in the heme biosynthetic pathway. The porphyrias can be very difficult for the practitioner to understand. There are several types of porphyrias, which have been known by various different names and are classified from different perspectives1 based on where the defective synthesis site is, or what the clinical manifestations are. Since practitioners rarely encounter this disease process, it is commonly not considered in the differential diagnoses. AIP can be confused with other causes of acute abdominal disorders such as appendicitis with peritonitis or nephrolithiasis. Patients with AIP typically give a history of constipation, fatigue, irritability, and insomnia that precede their acute attack. Symptoms occur intermittently in some patients with acute attacks lasting for several days or longer and were usually followed by complete recovery. This case report deals with an initial presentation of AIP in an otherwise healthy 21-year-old active duty male Soldier. Clinical presentation, diagnosis and treatment are discussed as is a brief historical anecdote.

Interest Survey And Guide To Medical Schooladmissions For SOF Medics

True NA, Conway AC, Landis TM, Cairns CB, Cairns BA 11(2). 30 - 34 (Journal Article)

The University of North Carolina at Chapel Hill and the Special Warfare Training Group, Airborne (SWTG)(A) at Fort Bragg, NC began a bilateral partnership in 2009 to enhance medical training, care and innovation in austere environments. As a result of this partnership, instructors from the Joint Special Operations Training Center have been completing month-long rotations in the North Carolina Jaycee Burn Center and University of North Carolina Hospitals. This rotation has been successful and prompted us to assess the interest of Special Operation Forces (SOF) medics is in pursuing careers in healthcare, especially medical school. We surveyed the Special Forces Medical Sergeant (SFMS) listserve on Army Knowledge Online (AKO) to collect these data. This article will review SFMS survey responses and offer information on how to negotiate medical school admissions.

Adaptations To A New Physical Training Program In The Combat Controller Training Pipeline

Walker TB, Lennemann LM, Anderson V, Lyons W, Zupan MF 11(2). 37 - 44 (Journal Article)

objectives: The United States Air Force combat controller (CCT) training pipeline is extremely arduous and historically has a high attrition rate of 70 to 80%. The primary objective of this study was to evaluate the impact of incorporating a 711 Human Performance Wing (HPW) / Biobehavior, Bioassessment, and Biosurveillance Branch (RHPF)-developed physical fitness-training program into the combat controller (CCT) 5-level training physical fitness program. methods: One-hundred-nine CCT trainees were tested and trained during their initial eight weeks at the 720th Special Tactics Training Squadron (STTS) at Hurlburt Field. Modifications to their physical training program were principally aimed at reducing overtraining and overuse injury, educating trainees and cadre on how to train smarter, and transitioning from traditional to "functional" PT. A battery of physiological measurements and a psychological test were administered prior to and immediately after trainees undertook an 8-week modified physical fitness training program designed to reduce overtraining and injury and improve performance. We performed multiple physical tests for cardiovascular endurance (VO2max and running economy), "anaerobic" capacity (Wingate power and loaded running tests), body composition (skinfolds), power (Wingate and vertical jump), and reaction time (Makoto eye-hand test). We used the Mental Toughness Questionnaire 48 (MTQ-48) for the psychological test. results: We observed several significant improvements in physical and physiological performance over the eight weeks of training. Body composition improved by 16.2% (p<0.05). VO2max, time-to-exhaustion, and ventilatory threshold were all significantly higher after implementation of the new program than before it. We observed strong trends towards improvement in work accomplished during loaded running (ρ = 0.07) and in average power per body mass during lower body Wingate (ρ = 0.08). Other measures of lower body power did not change significantly over the training period, but did show mild trends towards improvement. Upper body average and peak power per kilogram of body mass both improved significantly by 5.8% and 8.1%, respectively. Reaction time was significantly better posttraining as demonstrated by a 7% improvement during the reactive test. Reactive accuracy also improved significantly with the post test accuracy percentage jumping from 61% to 76%. Furthermore, overuse injuries, a major source of attrition fell by a dramatic 67%. conclusions: The modifications resulted in significant improvement in trainees' graduation rate. In the eight classes prior to implementation of these changes, average CCT graduating class size was nine trainees. For the eight classes following the changes, average CCT graduating class rose to 16.5 trainees, an increase of 83%. Due to its success, STTS leadership expanded the modifications from the eight weeks prior to CDS to include the entire second year of the pipeline.

Advanced Airwaymanagement In Combat Casualties By Medics At The Point Of Injury: A Sub-Group Analysis Of The Reach Study

Mabry RL, Cuniowski P, Frankfurt A, Adams BD 11(2). 16 - 19 (Journal Article)

background: Optimal airway management protocols for the prehospital battlefield setting have not been defined. Airway management strategies in this environment must take into account the injury patterns, the environment and training requirements of military prehospital providers. Methods: This is a post-hoc, sub-group analysis of the Registry of Emergency Airways Arriving at Combat Hospitals or REACH database. This study examines only those patients who had advanced airways placed for trauma by an enlisted military medic at the point of injury. results: Twenty (100%) of the patients had a traumatic injury, 19 (95%) were male, and 13 (65%) had a gun shot wounds (GSWs) as the mechanism of injury. The majority, 12 (60%) patients had an esophageal-tracheal airway device placed. Of the remaining patients, four (20%) underwent endotracheal intubation, three (15%) had a surgical cricothyroidotomy performed, and one (5%) had a Laryngeal Mask Airway (LMA) placed. Seventeen (85%) of the twenty patients were dead on arrival or died shortly after arrival at the Combat Support Hospital (CSH). All of the patients that died had a Glasgow Coma Scale (GCS) of three upon arrival. The Glasgow Coma Scale provides a score in the range 3-15; patients with scores of 3-8 are usually said to be in a coma. Three patients in this group survived to transfer from the CSH. Two of the transfers were lost to follow up, one with a GSW to the head and GCS of three, the other with a GCS of five from injuries sustained in an explosion. The third patient had a surgical cricothyroidotomy (SC) performed in the field for an expanding neck hematoma and recovered fully following surgery. conclusions: Casualties that tolerate invasive airway management without sedation in the context of trauma prognosticates a very high mortality. Airway management algorithms for military providers should reflect the casualties encountered on the battlefield not patients in cardiac arrest which predominate in the civilian EMS airway management practice. Further data are needed to understand the injuries encountered on the battlefield and to develop airway management solutions that optimize outcomes of patients with battlefield trauma.

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

Boedecker BH, Nicholas TA, Carpenter J, Leighton S, Bernhagen MA, Murray WB, Wadman MC 11(2). 21 - 29 (Journal Article)

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.

Medical Rules Of Engagement Negative Patients: The Dilemma Of Forward Surgical Teams In Counterinsurgency Operations

Becker T, Ray PD, Link M, Ziemba M 11(2). 12 - 15 (Journal Article)

By definition, Forward Surgical Teams (FSTs) are located far forward in the battlespace to allow for emergent treatment of life and limb threatening trauma sustained by United States and coalition forces as well as those injured according to the medical rules of engagement (MROE). While official doctrine dictates that MROE negative patients are not entitled to care by American military medical assets, experience has shown that some FSTs do not always adhere to that doctrine during counterinsurgency (COIN) operations. Medical civic action programs (MEDCAPS) have been used in modern COIN conflicts in an attempt to gain favor with and influence the host nations' local population. However, the results have frequently been counterproductive to the intended mission. The FST, by doctrine, is not equipped to take part in traditional MEDCAPS. The focus of this paper is to explore the potential role of the FST in COIN operations. Possible roles for the FST in COIN include improving the host nation medical capabilities through education and training. Further, surgery can be a useful commodity to gain positive influence with or to trade for intelligence from key local national leaders.

What Can Be Done With Expired Pharmaceuticals? A Review Of Literature As It Pertains To Special Operations Force's Medics

Culbertson NT 11(2). 1 - 6 (Journal Article)

Over the past decade, increasing evidence suggests that pharmaceuticals may continue to be potent beyond their date of expiration. Despite this evidence, we have not yet experienced a change in United States federal policy that would recommend usage of expired pharmaceuticals. While the scientific community and federal regulators continue to study the matter, the medical community is often guilty of misunderstanding the nuances of the issue. As a result, many healthcare professionals misinform their peers and their patients on either the appropriateness or inappropriateness of taking expired medications. Even though both the American Medical Association (AMA) and the Food and Drug Administration (FDA) do not recommend the dosing of expired pharmaceuticals at this time, discussion of the issue is warranted in order to understand the potential behind some expired drugs and to encourage further research. This discussion is particularly relevant to the Special Operations medical community, since Special Operations Force's (SOF) medic s frequently encounter expired medication overseas. Given thei r unique sk ill set and working environ ment, the SOF medic should be familiar with the potential applications of expired medications, including their drawbacks.

Guidelines For Implementing Medical Operations In The Counterinsurgency (COIN) Fight: A Framework For Engagement

Hamid S 11(2). 7 - 11 (Journal Article)

Several articles have been published over the last decade that describe the current role of medical operations (variously known as MEDCAPS- Medical Civic Action Programs, CMEs- Co-Operative Medical Engagements, etc.) in COIN and stability operations. Many of these articles focus on the experiences of healthcare and support personnel and their observations of inappropriately used U.S. Military healthcare resources. These medical assets were often used to provide fragmented and direct patient care to local populations. These operations were conducted in a non-sustainable fashion. Most importantly, poorly organized efforts damage COIN efforts and alienate local populations. Effective medical operations must be nested within the larger realm of overall COIN actions. In this paper, a fundamental framework is presented to align medical operations within COIN missions.

Ultrasound-Guided Triage

Dare C, Hampton K 16(4). 117 (Journal Article)

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