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Prehospital Use of Hemostatic Bandages and Tourniquets: Translation From Military Experience to Implementation in Civilian Trauma Care

Zietlow JM, Zietlow SP, Morris DS, Berns KS, Jenkins DH 15(2). 48 - 53 (Journal Article)

Background: While the military use of tourniquets and hemostatic gauze is well established, few data exist regarding civilian emergency medical services (EMS) systems experience. Methods: A retrospective review was performed of consecutive patients with prehospital tourniquet and hemostatic gauze application in a single ground and rotor-wing rural medical transport service. Standard EMS registry data were reviewed for each case. Results: During the study period, which included 203,301 Gold Cross Ambulance and 8,987 Mayo One Transport records, 125 patients were treated with tourniquets and/or hemostatic gauze in the prehospital setting. Specifically, 77 tourniquets were used for 73 patients and 62 hemostatic dressings were applied to 52 patients. Seven patients required both interventions. Mechanisms of injury (MOIs) for tourniquet use were blunt trauma (50%), penetrating wounds (43%), and uncontrolled hemodialysis fistula bleeding (7%). Tourniquet placement was equitably distributed between upper and lower extremities, as well as proximal and distal locations. Mean tourniquet time was 27 minutes, with 98.7% success. Hemostatic bandage MOIs were blunt trauma (50%), penetrating wounds (35%), and other MOIs (15%). Hemostatic bandage application was head and neck (50%), extremities (36%), and torso (14%), with a 95% success rate. Training for both interventions was computer-based and hands-on, with maintained proficiency of > 95% after 2 years. Conclusion: Civilian prehospital use of tourniquets and hemostatic gauze is feasible and effective at achieving hemostasis. Online and practical training programs result in proficiency of skills, which can be maintained despite infrequent use.

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)

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.

Saving Lives on the Battlefield (Part II) - One Year Later: A Joint Theater Trauma System and Joint Trauma System Review of Prehospital Trauma Care in Combined Joint Operations Area-Afghanistan (CJOA-A)

Sauer SW, Robinson JB, Smith MP, Gross K, Kotwal RS, Mabry RL, Butler FK, Stockinger Z, Bailey JA, Mavity ME, Gillies DA 15(2). 25 - 41 (Journal Article)

The United States has achieved unprecedented survival rates, as high as 98%, for casualties arriving alive at the combat hospital. Our military medical personnel are rightly proud of this achievement. Commanders and Servicemembers are confident that if wounded and moved to a Role II or III medical facility, their care will be the best in the world. Combat casualty care, however, begins at the point of injury and continues through evacuation to those facilities. With up to 25% of deaths on the battlefield being potentially preventable, the prehospital environment is the next frontier for making significant further improvements in battlefield trauma care. Strict adherence to the evidence-based Tactical Combat Casualty Care (TCCC) Guidelines has been proven to reduce morbidity and mortality on the battlefield. However, full implementation across the entire force and commitment from both line and medical leadership continue to face ongoing challenges. This report on prehospital trauma in the Combined Joint Operations Area - Afghanistan (CJOA-A) is a follow-on to the one previously conducted in November 2012 and published in January 2013. Both assessments were conducted by the US Central Command (USCENTCOM) Joint Theater Trauma System (JTTS). Observations for this report were collected from December 2013 to January 2014 and were obtained directly from deployed prehospital providers, medical leaders, and combatant leaders. Significant progress has been made between these two reports with the establishment of a Prehospital Care Division within the JTTS, development of a prehospital trauma registry and weekly prehospital trauma conferences, and CJOA-A theater guidance and enforcement of prehospital documentation. Specific prehospital trauma-care achievements include expansion of transfusion capabilities forward to the point of injury, junctional tourniquets, and universal approval of tranexamic acid.

Role of the Windlass in Improvised Tourniquet Use on a Manikin Hemorrhage Model

Altamirano MP, Kragh JF, Aden JK, Dubick MA 15(2). 42 - 46 (Journal Article)

Background: In emergencies when commercially designed tourniquets are unavailable, hemorrhage may need to be controlled with improvised tourniquets. In the aftermath of the Boston Marathon bombing, no improvised strap-and-windlass tourniquets were used to treat casualties; tourniquets without windlasses were used. The purpose of the present study is to determine the effectiveness of improvised tourniquets with and without a windlass to better understand the role of the windlass in tightening the tourniquet strap. Methods: An experiment was designed to test the effectiveness of improvised strap-and-windlass tourniquets fashioned out of a tee shirt on a manikin thigh. Two users conducted 40 tests each with and without the use of a windlass. Results: Without a windlass, improvised tourniquets failed to stop bleeding in 99% of tests (79 of 80 tests). With a windlass, improvised tourniquets failed to stop bleeding in 32% of tests (ρ < .0001). In tests with no windlass, attempts to stop the pulse completely failed (100%, 80 of 80 tests). With a windlass, however, attempts to stop the pulse failed 31% of the time (25 of 80 tests); the difference in proportions was significant (ρ < .0001). Conclusions: Improvised strap-and-windlass tourniquets were more effective than those with no windlass, as a windlass allowed the user to gain mechanical advantage. However, improvised strap-and-windlass torniquets failed to control hemorrhage in 32% of tests.

Treatment of Psoriasis in the Deployed Setting

Bongiorno MA, Rivard SC, Meyerle JH 15(2). 12 - 15 (Journal Article)

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.

Replacement of Promethazine With Ondansetron for Treatment of Opioid- and Trauma-Related Nausea and Vomiting in Tactical Combat Casualty Care

Onifer DJ, Butler FK, Gross K, Otten EJ, Patton R, Russell RJ, Stockinger Z, Burrell E 15(2). 17 - 24 (Journal Article)

The current Tactical Combat Casualty Care (TCCC) Guidelines recommend parenteral promethazine as the single agent for the treatment of opioid-induced nausea and/or vomiting and give a secondary indication of "synergistic analgesic effect." Promethazine, however, has a well-documented history of undesired side effects relating to impairment and dysregulation of the central and autonomic nervous systems, such as sedation, extrapyramidal symptoms, dystonia, impairment of psychomotor function, neuroleptic malignant syndrome, and hypotension. These may be particularly worrisome in the combat casualty. Additionally, since 16 September 2009, there has been a US Food and Drug Administration (FDA) black box warning for the injectable form of promethazine, due to "the risk of serious tissue injury when this drug is administered incorrectly." Conversely, ondansetron, which is now available in generic form, has a well-established favorable safety profile and demonstrated efficacy in undifferentiated nausea and vomiting in the emergency department and prehospital settings. It has none of the central and autonomic nervous system side effects noted with promethazine and carries no FDA black box warning. Ondansetron is available in parenteral form and an orally disintegrating tablet, providing multiple safe and effective routes of administration. Despite the fact that it is an off-label use, ondansetron is being increasingly given for acute, undifferentiated nausea and vomiting and is presently being used in the field on combat casualties by some US and Allied Forces. Considering the risks involved with promethazine use, and the efficacy and safety of ondansetron and ondansetron's availability in a generic form, we recommend removing promethazine from the TCCC Guidelines and replacing it with ondansetron.

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)

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.

Oral Steroids for Dermatitis

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

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.

The Importance of Physical Fitness for Injury Prevention: Part 1

Knapik JJ 15(1). 123 - 127 (Journal Article)

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.

Cutaneous Leishmaniasis

Burnett MW 15(1). 128 - 129 (Journal Article)

Cutaneous leishmaniasis is the most common form of leishmaniasis, which also appears in mucosal and visceral forms. It is a disease found worldwide, caused by an intracellular protozoan parasite of which there are more than 20 different species. The disease is transmitted by the bite of an infected, female, phlebotomine sand fly, causing skin lesions that can appear weeks to years after a bite. A typical lesion will start out in a papular form, progressing to a nodular plaque and, eventually, to a persistent ulcerative lesion. Special Operations Forces medical providers should be aware of this disease, which must be in the differential diagnosis of a patient who has lived in endemic areas and who has a persistent skin lesion nonresponsive to typical therapies.

A Painful Rash in an Austere Environment

Hellums JS, Klapperich K 15(1). 113 - 117 (Journal Article)

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.

Abdominal Pain

Banting J, Meriano T 15(1). 118 - 122 (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.

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)

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.

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)

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.

Battlefield Analgesia: TCCC Guidelines Are Not Being Followed

Schauer SG, Robinson JB, Mabry RL, Howard JT 15(1). 85 - 89 (Journal Article)

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.

Mindfulness: A Fundamental Skill for Performance Sustainment and Enhancement

Deuster PA, Schoomaker E 15(1). 93 - 99 (Journal Article)

The term "mindfulness" has become very fashionable within the military and across multiple sectors of civilian and first responder populations. Overall, the key concept of mindfulness is intentionally being acutely aware of what is going on internally as well as externally, without reacting. Mindfulness and the awareness that underlies it are inherent capabilities that can be honed through training. As such, classes in mindfulness are being offered in many venues and medical clinics are using mindfulness-based interventions for patients for a wide range of medical issues. The evidence behind the benefits of mindfulness is extensive and instructive. Importantly, evidence suggests that mindfulness can be helpful for many operational, leadership, and personal activities and is likely beneficial for enhancing resilience and overall health. Many current military leaders are using mindfulness as a tool to better prepare for a dynamic and uncertain future.

Operational Point-of-Care Ultrasound Review: Low-Cost Simulators and Resources for Advanced Prehospital Providers

Ross EM, Deaton TG, Hurst N, Siefert J 15(1). 71 - 78 (Journal Article)

Prehospital ultrasound use is a relatively new skill set. The military noted the clear advantages of this skill set in the deployed setting and moved forward with teaching their advanced combat trauma medics skills to perform specific examinations. The training curriculum for Special Operations-level clinical ultrasound was created and adapted from training guidelines set forth by the American College of Emergency Physicians with a focus on the examinations relevant to the Special Operations community. Once providers leave the training environment, skill sustainment can be difficult. We discuss the relevant ultrasound exams for the prehospital setting. We address opportunities to improve point-of-care ultrasound skills through hands-on experience while in a fixed medical facility. Options for simulation-based training are discussed with descriptions for creating lowcost simulation models. Finally, a list of online resources is provided to review specific ultrasound examinations.

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)

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.

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)

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.

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