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A Case Study of MEDCANGRO Relative to RAND Conceptual Framework*

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

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.

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Monitoring Training for Human Performance Optimization

Austin KG, Deuster PA 15(2). 102 - 108 (Journal Article)

Physical fitness can significantly impact the mission success of Special Operations Forces (SOF). Much like athletes, Operators have multiple training components including technical, tactical, physical and mental conditioning, which must simultaneously be developed for mission success. Balancing multiple physical stressors to ensure positive results from training can be achieved through periodization-the intentional planning for success. Monitoring the training load can assist SOF in managing training stress and designing periodization that minimizes fatigue. The present article provides an overview of modern technology developed to quantify the stress of training. The training load maintained by SOF consists of external loads created through physical work and internal units of load determined by the rate of perceived effort during training that must be integrated in a manner that minimizes the accumulation of fatigue. Methods for determining training load are discussed in this article and examples are provided for determining training load, developing conditioning sessions and utilizing training load to maintain physical fitness, and improve return from injury.

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Q Fever

Burnett MW 15(2). 109 - 111 (Journal Article)

Q fever is a zoonotic disease found throughout the world. It is caused by the intracellular gram-negative bacterium Coxiella burnetii. Infection by C. burnetii occurs primarily by inhalation of the aerosolized bacteria from birthing animals or contaminated dust. The bacterium is very resistant to drying and heat, and is considered highly endemic in the Middle East, where it is likely underdiagnosed. Special Operations Forces medical providers should be aware of this disease, which must be in the differential diagnosis of a patient who has a history of fever, elevated liver enzymes, pneumonia in its acute form, and endocarditis, especially in those with existing valvular heart disease in its chronic form.

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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)

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.

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"It's What Color?"

Banting J, Meriano T 15(2). 97 - 101 (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.

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Emergency Department Patients Support the Use of Combat Medics in Their Clinical Care

Schauer SG, Mabry RL, Varney SM, Howard JT 15(2). 74 - 78 (Journal Article)

Background: As US military combat operations draw down in Afghanistan, the military health system will shift focus to garrison- and hospital-based care. Maintaining combat medical skills while performing routine healthcare in military hospitals and clinics is a critical challenge for Combat medics. Current regulations allow for a wide latitude of Combat medic functions. The Surgeon General considers combat casualty care a top priority. Combat medics are expected to provide sophisticated care under the extreme circumstances of a hostile battlefield. Yet, in the relatively safe and highly supervised setting of contiguous US-based military hospitals, medics are rarely allowed to perform the procedures or administer medications they are expected to use in combat. This study sought to determine patients' opinions on the use of combat medics in their healthcare. Methods: Patients in hospital emergency department (EDs) were offered anonymous surveys. Examples of Combat medic skills were provided. Participants expressed agreement using the Likert scale (LS), with scores ranging from "strongly agree" (LS score, 1) to "strongly disagree" (LS score, 5). The study took place in the ED at Bayne-Jones Army Community Hospital, Fort Polk, Louisiana. Surveys were offered to adult patients when they checked into the ED or to adults with other patients. Results: A total of 280 surveys were completed and available for analysis. Subjects agreed that Combat medic skills are important for deployment (LS score, 1.4). Subjects agreed that Combat medics should be allowed to perform procedures (LS score, 1.6) and administer medications (LS score, 1.6). Subjects would allow Combat medics to perform procedures (LS score, 1.7) and administer medications (LS score, 1.7) to them or their families. Subjects agreed that Combat medic activities should be a core mission for military treatment facilities (MTFs) (LS score, 1.6). Conclusion: Patients support the use of Combat medics during clinical care. Patients agree that Combat medic use should be a core mission for MTFs. Further research is needed to optimize Combat medic integration into patient healthcare.

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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)

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.

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Injuries, Medical Conditions, and Changes in Blood Levels in German Special Operations Forces Selection

Lechner R, Tausch B, Unkelbach U, Tannheimer M, Neitzel C 15(2). 64 - 70 (Journal Article)

Background: Medical conditions often develop during military training. The aim of this study was to compile medical conditions and injuries sustained during a 5-day military exercise, compare them with incidences at similar civilian events, and subsequently identify differences between those who finished the exercise (Finishers) and those who did not (Nonfinishers) to identify preventable causes for not finishing and to reduce unnecessary health risks. Methods: Fifty-one soldiers had their blood parameters (creatine kinase [CK], aspartate transaminase [AST], alanine transaminase [ALT], gamma-glutamyl transferase [GGT], C-reactive protein [CRP], leukocytes, sodium), weight loss, and body temperature determined after the exercise. Additionally, the injuries and conditions that led the Nonfinishers to drop out were recorded. Results: The main reasons why Nonfinishers did not complete the exercise were physical exhaustion and minor injuries. After exercise, the Finishers showed only slightly increased incidence of hyponatremia, higher levels of CK, and significantly higher levels of AST, ALT, and CRP, and body weight loss. The Nonfinishers' results were significant for an elevated leukocyte count and lower mean temperatures. Conclusion: The specifics of military training did not influence the kind or the number of exertion-related medical conditions compared to similar civilian events. Both Finishers and Nonfinishers are at risk of developing exertion-related medical conditions such as rhabdomyolysis and hyponatremia. However, plain water did not increase the risk of exertional hyponatremia. Leukocytosis found in the Nonfinisher group could have been due to acute excessive exertion and, therefore, may be an indicator of general systemic fatigue. This could be used to differ between physical and psychological reasons for not finishing.

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Rationale for Use of Intravenous Acetaminophen in Special Operations Medicine

Vokoun ES 15(2). 71 - 73 (Journal Article)

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.

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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.

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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)

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.

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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.

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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.

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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.

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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.

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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)

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.

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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.

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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.

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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.

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