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Pressures Under 3.8cm, 5.1cm, and Side-by-Side 3.8cm-Wide Tourniquets

Wall PL, Weasel J, Rometti MR, Birkholz S, Gildemaster Y, Grulke L, Sahr SM, Buising CM 16(2). 28 - 35 (Journal Article)

Background: Applications of wider tourniquet are expected to occlude arterial flow at lower pressures. We examined pressures under 3.8cm-wide, 5.1cm-wide, and side-by-side-3.8cm-wide nonelastic strap-based tourniquets. Methods: Ratcheting Medical Tourniquets (RMT) were applied mid-thigh and mid-arm for 120 seconds with Doppler-indicated occlusion. The RMTs were a Single Tactical RMT (3.8cm-wide), a Wide RMT (5.1cm-wide), and Paired Tactical RMTs (7.6cm-total width). Tightening completion was measured at one-tooth advance past arterial occlusion, and paired applications involved alternating tourniquet tightening. Results: All 96 applications on the 16 recipients reached occlusion. Paired tourniquets had the lowest occlusion pressures (ρ < .05). All pressures are given as median mmHg, minimum-maximum mmHg. Thigh application occlusion pressures were Single 256, 219-299; Wide 259, 203-287; Distal of Pair 222, 183-256; and Proximal of Pair 184, 160-236. Arm application occlusion pressures were Single 230, 189-294; Wide 212, 161-258; Distal of Pair 204, 193-254, and Proximal of Pair 168, 148-227. Pressure increases with the final tooth advance were greater for the 2 teeth/cm Wide than for the 2.5 teeth/cm Tacticals (ρ < .05). Thigh final tooth advance pressure increases were Single 40, 33-49; Wide 51, 37-65; Distal of Pair 13, 1-35; and Proximal of Pair 15, 0-30. Arm final tooth advance pressure increases were Single 49, 41-71; Wide 63, 48-77; Distal of Pair 3, 0-14; and Proximal of Pair 23, 2-35. Pressure decreases occurred under all tourniquets over 120 seconds. Thigh pressure decreases were Single 41, 32-75; Wide 43, 28-62; Distal of Pair 25, 16-37; and Proximal of Pair 22, 15-37. Arm pressure decreases were Single 28, 21-43; Wide 26, 16-36; Distal of Pair 16, 12-35; and Proximal of Pair 12, 5-24. Occlusion losses before 120 seconds occurred predominantly on the thigh and with paired applications (ρ < .05). Occlusion losses occurred in six Paired thigh applications, two Single thigh applications, and one Paired arm application. Conclusions: Side-by-side tourniquets achieve occlusion at lower pressures than single tourniquets. Additionally, pressure decreases under tourniquets over time; so all tourniquet applications require reassessments for continued effectiveness.

Field Sterilization in the Austere and Operational Environment A Literature Review of Recommendations

Will JS, Alderman SM, Sawyer RC 16(2). 36 - 43 (Journal Article)

Special Operations Forces medical providers are often deployed far beyond traditional military supply chains, forcing them to rely on alternative methods for field sterilization of medical equipment. This literature review proposes several alternative methods for both sterilization and disinfection of medical instruments after use and cleaning of skin and wounds before procedures. This article reviews recommendations from sources like the United Nations, the World Health Organization, the Special Operations Forces Medical Handbook, and the Centers for Disease Control and Prevention.

Preliminary Measures of Instructor Learning in Teaching Junctional Tourniquet Users

Kragh JF, Aden JK, Shackelford S, Dubick MA 16(2). 13 - 15 (Journal Article)

Background: The objective of the present study was to assess the effect of instructor learning on student performance in use of junctional tourniquets. Methods: From a convenience sample of data available after another study, we used a manikin for assessment of control of bleeding from a right groin gunshot wound. Blood loss was measured by the instructor while training users. The data set represented a group of 30 persons taught one at a time. The first measure was a plot of mean blood loss volumes for the sequential users. The second measure was a plot of the cumulative sum (CUSUM) of mean blood loss (BL) volumes for users. Results: Mean blood loss trended down as the instructor gained experience with each newly instructed user. User performance continually improved as the instructor gained more experience with teaching. No plateau effect was observed within the 30 users. The CUSUM plot illustrated a turning point or cusp at the seventh user. The prior portion of the plot (users 1-7) had the greatest improvement; performance did not improve as much thereafter. The improvement after the seventh user was the only change detected in the instructor's trend of performance. Conclusions: The instructor's teaching experience appeared to directly affect user performance; in a model of junctional hemorrhage, the volume of blood loss from the manikin during junctional tourniquet placement was a useful metric of instructor learning. The CUSUM technique detected a small but meaningful change in trend where the instructor learning curve was greatest while working with the first seven users.

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)

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.

Preliminary Comparison of Pneumatic Models of Tourniquet for Prehospital Control of Limb Bleeding in a Manikin Model

Gibson R, Aden JK, Dubick MA, Kragh JF 16(2). 21 - 27 (Journal Article)

Background: Emergency tourniquet use has been associated with hemorrhage control and improved survival during the wars since 2001, but little is known of the differential performance of pneumatic tourniquet models. The purpose of this study was to compare the performance of three models of pneumatic tourniquets in a laboratory setting to aid a possible decision to field test suitable models for medic preference. Methods: A laboratory experiment was designed to test the effectiveness of tourniquets on a manikin thigh. Three models (one Emergency and Military Tourniquet [EMT] and two Tactical Pneumatic Tourniquets differing in width: 2 in. and 3 in. [TPT3]) were compared with the standard-issue Combat Application Tourniquet of a strap-and-windlass design. Two users conducted 40 tests each on a right-thigh manikin (HapMed Leg Tourniquet Trainer) with a simulated above-knee amputation injury. Measurements included effectiveness in hemorrhage control, pulse stoppage distal to the tourniquet, time to stop bleeding, blood loss, and pressure. Results: All four models were 100% effective in both hemorrhage control and pulse stoppage distal to the tourniquet. The TPT3 had the slowest mean time to stop bleeding and the highest mean blood loss. The EMT had the least mean pressure. An interuser difference was found only for mean pressure. Conclusions: All models of tourniquet performed equally well for both the critical outcome of effectiveness and the important outcome of pulse stoppage, whereas results for secondary outcomes (time, pressure, and blood loss) differed by model. The EMT had best performance for every type of measurement.

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)

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.

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)

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.

Progress Of Tactical Emergency Medical Support In Japan

Fuse A, Schwartz RB, Saitoh D, Agawa S, Ohnishi M, Okumura T 16(1). 140 - 141 (Journal Article)

A Herpes Zoster Outbreak on the Sinai Peninsula

Acierto D, Savioli S, Studer NM 16(2). 1 - 4 (Case Reports)

Background: Infection with the varicella zoster virus, a type of herpesvirus, causes chickenpox in children and herpes zoster (commonly known as shingles) in adults. Case Presentation: Two 20-year-old male Soldiers returned from an outpost with a rash consistent with herpes zoster. Two other Soldiers with whom they were in close had had a similar rash 2 weeks earlier, which had since resolved at the time of initial presentation. Management and Outcome: Both Soldiers were started on an antiviral regimen and released to duty. They reported progressive relief, but both Soldiers redeployed to the United States before complete resolution. Conclusion: Herpes zoster cannot be transmitted from person to person. It is rare for young healthy people to become afflicted with it, let alone for two people to get it at the same time, which initially raised concern for infections mimicking herpes zoster. However, herpes zoster may be triggered by acute stress. Providers in deployed areas should consider the diagnosis in personnel who have had childhood varicella zoster infection (chickenpox).

Prolonged Field Care Working Group Fluid Therapy Recommendations

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

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.

Closing The Gap: Improving Trauma Care On The Ukrainian Battlefield

Stacey SK, Jones PH 16(1). 122 - 124 (Journal Article)

Since early 2014, Ukraine has been involved in a violent social and political revolution that has taken more than 7,000 lives. Many of these deaths were due to limited field medical care and prolonged evacuation times because the Ukrainian military has been slow to adopt standard combat medical processes. We deployed with the US Army's 173rd Airborne Brigade to train soldiers in the National Guard of Ukraine (NGU) on combat first aid. We discovered that a major deficiency limiting the quality of trauma care and evacuation is an endemic lack of prior coordination and planning. The responsibility for this coordination falls on military leaders; therefore, we delivered medical operations training to officers of the NGU unit and observed great improvement in medical care sustainment. We recommend systematic leader education in best medical practices be institutionalized at all levels of the Ukrainian Army to foster sustained improvement and refinement of trauma care.

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)

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.

All That Swells Is Not A Bruise The Morel-Lavallée Lesion

Callahan CL, Eisenman J 16(1). 109 - 111 (Journal Article)

Frequently overlooked, Morel-Lavallée lesions are associated with a closed degloving or shearing mechanism causing a dehiscence of underlying soft tissue with formation of a potential space. This space fills with blood, lymph, and cellular debris, giving the lesion a fluctuant appearance on examination. The potential space associated with larger lesions can be a source for hemorrhage in the appropriate clinical context. However, these lesions are often diagnosed late in their clinical course or are misdiagnosed, leading to long-term complications. Management of this injury typically depends upon the size of the lesion. This article discusses a Morel-Lavallée lesion in an active-duty Servicemember requiring treatment by a plastic surgeon and includes the pathophysiology of Morel-Lavallée lesions, diagnostic strategies, and management pearls.

Zika Virus

Burnett MW 16(1). 86 - 87 (Journal Article)

Injuries And Footwear (Part 2): Minimalist Running Shoes

Knapik JJ, Orr R, Pope R, Grier T 16(1). 89 - 96 (Journal Article)

This article defines minimalist running shoes and examines physiological, biomechanical, and injury rate differences when running in conventional versus minimalist running shoes. A minimalist shoe is one that provides "minimal interference with the natural movement of the foot, because of its high flexibility, low heel to toe drop, weight and stack height, and the absence of motion control and stability devices." Most studies indicate that running in minimalist shoes results in a lower physiological energy cost than running in conventional shoes, likely because of the lower weight of the minimalist shoe. Most individuals running in conventional shoes impact the ground heel first (rearfoot strike pattern), whereas most people running in minimalist shoes tend to strike with the front of the foot (forefoot strike pattern). The rate at which force is developed on ground impact (i.e., the loading rate) is generally higher when running in conventional versus minimalist shoes. Findings from studies that have looked at associations between injuries and foot strike patterns or injuries and loading rates are conflicting, so it is not clear if these factors influence injury rates; more research is needed. Better-designed prospective studies indicate that bone stress injuries and the overall injury incidence are higher in minimalist shoes during the early weeks (10-12 weeks) of transition to this type of footwear. Longer-term studies are needed to define injury rates once runners are fully transitioned to minimalist shoes. At least one longer-term minimalist-shoe investigation is ongoing and, hopefully, will be published soon.

A Threat-based, Statewide EMS Protocol To Address Lifesaving Interventions In Potentially Volatile Environments

Levy MJ, Straight KM, Marino MJ, Alcorta RL 16(1). 98 - 102 (Journal Article)

Red Rash

Banting J, Meriano T 16(1). 76 - 80 (Journal Article)

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.

Sleep As A Strategy For Optimizing Performance

Yarnell AM, Deuster PA 16(1). 81 - 85 (Journal Article)

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.

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)

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.

SOLCUS: Update On Point-of-Care Ultrasound In Special Operations Medicine

Hampton K, Vasios WN, Loos PE 16(1). 58 - 61 (Journal Article)

Point-of-care ultrasonography has been recognized as a relevant and versatile tool in Special Operations Forces (SOF) medicine. The Special Operator Level Clinical Ultrasound (SOLCUS) program has been developed specifically for SOF Medics. A number of challenges, including skill sustainment, high-volume training, and quality assurance, have been identified. Potential solutions, including changes to content delivery methods and application of tele-ultrasound, are described in this article. Given the shift in operational context toward extended care in austere environments, a curriculum adjustment for the SOLCUS program is also proposed.

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