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Burnett MW 14(4). 129 - 130 (Journal Article)

Chikungunya is a rapidly emerging infectious disease caused by a virus of the genus Alphavirus, family Togaviridae. Most commonly, patients have an acute onset of fever with often debilitating symmetric joint discomfort that can relapse months after the initial infection. This infection is typically transmitted by the bite of an infected Aedes aegypti or Aedes albopictus mosquito, vectors that also transmit dengue and yellow fever. Special Operations Forces Medical Providers should be aware of this disease, which is currently being diagnosed worldwide.

Force Health Protection Support Following a Natural Disaster: The 227th Medical Detachment's Role in Response to Superstorm Sandy

Stanley SE, Faulkenberry JB 14(4). 106 - 112 (Journal Article)

On 3 November 2012, in the wake of Superstorm Sandy, the 227th Preventive Medicine Medical Detachment deployed to support relief operations in New Jersey and New York State. The unit was on the severe weather support mission (SWRF) and ordered to provide preventive medicine support to relief personnel within the affected area. In addition, teams from the 227th conducted environmental surveillance in the two-state region where Army Corps of Engineers were pumping floodwaters from affected neighborhoods. The 227th rapid deployment highlights the complexities associated with defense support to civil authorities and provides excellent teaching points that may enhance units' expeditionary posture, regardless of mission.

This Is Africa. Bites, Stings, and Rigors: Clinical Considerations in African Operations

Lynch JH, Verlo AR, Givens ML, Munoz CE 14(4). 113 - 121 (Journal Article)

The natural health threats in Africa pose daunting clinical challenges for any provider, as evidenced by the current Ebola epidemic in West Africa, but the threat is multiplied for the Special Operations provider on the continent who faces these challenges with limited resources and the tyranny of distance. The majority of operationally significant health risks can be mitigated by strict adherence to a comprehensive force health protection plan. The simplest, yet most effective, technique for preventing mosquito-borne diseases is the prevention of mosquito bites with repellent, bed nets, and appropriate clothing in addition to chemoprophylaxis. Some of the more likely or lethal infectious diseases encountered on the continent include malaria, Chikungunya, dengue, human immunodeficiency virus, and Ebola. Venomous snakes pose a particular challenge since the treatment can be as deadly as the injury. Providers supporting African operations should educate themselves on the clinical characteristics of possible envenomations in their area while promoting snake avoidance as the primary mitigation measure. To succeed in Africa, the Special Operations provider must consider how to meet these challenges in an environment where there may not be reliable evacuation, hospitalization, or logistics channels.

Erythema Nodosum

Vigilante JA, Scribner J 14(4). 122 - 123 (Journal Article)

An active duty female Sailor reports to your clinic complaining of tender nodules to her legs beginning 1.5 weeks ago. She is diagnosed with erythema nodosum (EN), a painful disorder of the subcutaneous fat that is usually self-limited but may be a clue to an additional underlying medical diagnosis. This article reviews the pathophysiology, causes, course, diagnosis, and management of EN.

Pilot Ejection, Parachute, and Helicopter Crash Injuries

McBratney CM, Rush SC, Kharod C 14(4). 92 - 94 (Journal Article)

USAF Pararescuemen (PJs) respond to downed aircrew as a fundamental mission for personnel recovery (PR), one of the Air Force's core functions. In addition to responding to these in Military settings, the PJs from the 212 Rescue Squadron routinely respond to small plane crashes in remote regions of Alaska. While there is a paucity of information on the latter, there have been articles detailing injuries sustained from helicopter crashes and while ejecting or parachuting from fixed wing aircraft. The following represents a new chapter added to the Pararescue Medical Operations Handbook, Sixth Edition (2014, editors Matt Wolf, MD, and Stephen Rush, MD, in press). It was designed to be a quick reference for PJs and their Special Operations flight surgeons to help with understanding of mechanism of injury with regard to pilot ejection, parachute, and helicopter accident injuries. It outlines the nature of the injuries sustained in such mishaps and provides an epidemiologic framework from which to approach the problem.

Performance Psychology as a Key Component of Human Performance Optimization

Herzog TP, Deuster PA 14(4). 99 - 105 (Journal Article)

The degree of psychological fitness will ultimately impact mission outcomes, so approaches to enhancing it are critical. Performance psychology is one important aspect of psychological fitness that fits into the holistic model of human performance optimization. This article delves into one component of performance psychology: how mental skill training can be applied to improve performance on mission-related tasks. Mental skills training provides added internal resources to help meet the extraordinary external demands that Special Operations Forces personnel can face. Relevance in terms of the demand-resource model and the positive psychology concept of flow are explained. The application of two specific mental skills-executing a goal-setting process and using mental imagery to rehearse technical, tactical, and strategic tasks-will be discussed by using the example of how to enhance performance when entering and clearing rooms.

Point Prevalence Survey for Tick-Borne Pathogens in Military Working Dogs, Shelter Animals, and Pet Populations in Northern Colombia

McCown ME, Alleman A, Sayler KA, Chandrashekar R, Thatcher B, Tyrrell P, Stillman B, Beall M, Barbet AF 14(4). 81 - 85 (Journal Article)

Background: Based on the high tick-borne pathogen results from a 2011 surveillance study in three Colombian cities, an in-depth point prevalence survey was conducted to determine the seroprevalence of tick-borne pathogens at a specific point in time in 70 working dogs, 101 shelter dogs, and 47 client-owned dogs in Barranquilla, Colombia. Results: Of the 218 serum samples, 163 (74%) were positive for Ehrlichia canis and 116 (53%) for Anaplasma platys. Exposure to tick-borne pathogens was highest in shelter and working dogs where more than 90% of the samples were seropositive or positive on polymerase chain reaction for one or more organisms as compared to 51% in client-owned animals. Conclusion: Surveillance for exposure to tickborne pathogens provides vital information necessary to protect and conserve the health of local humans and animals, deployed military service members, and working dogs in various parts of the world. This study and resultant data demonstrate the value of following a broadbased surveillance study with a more specific, focused analysis in an area of concern. This area's high levels of exposure warrant emphasis by medical planners and advisors on precautionary measures for military dogs, Special Operations Forces personnel, and the local public.

Review of Canine Deaths While in Service in US Civilian Law Enforcement (2002-2012)

Stojsih SE, Baker JL, Les CM, Bir CA 14(4). 86 - 91 (Journal Article)

Background: Working dogs have been proven effective in multiple military and law enforcement applications. Similar to their human counterparts, understanding mortality while still in service can help improve treatment of injuries, and improve equipment and training, to potentially reduce deaths. This is a retrospective study to characterize mortality of working dogs used in civilian law enforcement. Methods: Reported causes of death were gathered from two working dog and law enforcement officer memorial websites. Results: Of the 867 civilian law enforcement dogs reported to these memorial websites from 2002 to 2012 with reported causes of death while in service, the deaths of 318 were categorized as traumatic. The leading reported causes of traumatic death or euthanasia include trauma as a result of a vehicle strike, 25.8% (n = 82); heatstroke, 24.8% (n = 79); and penetrating ballistic trauma, 23.0% (n = 73). Conclusion: Although the information gathered was from online sources, this study casts some light on the risks that civilian law enforcement dogs undergo as part of the tasks to which they are assigned. These data underscore the need for a comprehensive database for this specialized population of working dogs to provide the robust, reliable data needed to develop prevention and treatment strategies for this valuable resource.

Special Forces Medical Sergeants' Perceptions and Beliefs Regarding Their Current Medical Sustainment Program: Implications for the Field

Wilson RL, DeZee KJ 14(4). 59 - 69 (Journal Article)

Background: Special Forces Medical Sergeants (SFMS) are trained to provide trauma and medical care in support of military operations and diplomatic missions throughout the world with indirect physician oversight. This study assessed their perceptions of the current program designed to sustain their medical skills. Methods: An Internet-based survey was developed using the constructs of the Theory of Reasoned Action/Planned Behavior and validated through survey best practices. Results: Of the 334 respondents, 92.8% had deployed at least once as an SFMS. Respondents reported spending 4 hours per week sustaining their medical skills and were highly confident that they could perform their duties on a no-notice deployment. On a 5-point, Likerttype response scale, SFMS felt that only slight change is needed to the Special Operations Medical Skills Sustainment Course (mean: 2.17; standard deviation [SD]: 1.05), while moderate change is needed to the Medical Proficiency Training (mean: 2.82; SD: 1.21) and nontrauma modules (mean: 3.02; SD: 1.22). Respondents desire a medical sustainment program that is provided by subject matter experts, involves actual patient care, incorporates new technology, uses hands-on simulation, and is always available. Conclusions: SFMS are challenged to sustain their medical skills in the current operational environment, and barriers to medical training should be minimized to facilitate sustainment training. Changes to the current medical sustainment program should incorporate operator-level perspectives to ensure acceptability and utility but must be balanced with organizational realities. Improving the medical sustainment program will prepare SFMS for the challenges of future missions.

A Call for Innovation: Reflective Practices and Clinical Curricula of US Army Special Operations Forces Medics

Rocklein K 14(4). 70 - 80 (Journal Article)

Background: Special Operations Forces (SOF) medics have written and published numerous practice reflections that intricately describe their practice environments, clinical dilemmas, and suggestions for teaching and practice. The lack of translation of SOF medics' experiential evidence to their curriculum has created a gap in evidence-based curriculum development. This study analyzed SOF medics' learning and practice patterns and compared it to the evidence in the interdisciplinary clinical literature. After framing the problem, the literature was reviewed to determine appropriate tools by which perceptions and attitudes toward reflection-centered curricula could be measured. Methods: A recognizable practice reflection was extracted from the published SOF clinical literature and presented in writing to self-identified SOF medics and medic instructors via a descriptive crossover design, to ensure possible biases were mitigated. To measure SOF medics' perceptions of reflection-based curricula, the Dundee Ready Education Environment Measure survey instrument was used, as it has validated psychometric properties and is used worldwide. Results: SOF medics' averaged scores of perceptions of their medic education indicated positive but not completely statistically significant preferences toward reflection-based curricula over traditional curriculum.

Predicting When to Administer Blood Products During Tactical Aeromedical Evacuation: Evaluation of a US Model

Le Clerc S, McLennan J, Kyle A, Mann-Salinas EA, Russell RJ 14(4). 48 - 52 (Journal Article)

The administration of blood products to battlefield casualties in the prehospital arena has contributed significantly to the survival of critically injured patients in Afghanistan over the past 5 years. Given as part of an established military "chain of survival," blood product administration has represented a step-change improvement in capability for both UK and US tactical aeromedical evacuation (TACEVAC) platforms. The authors explore current concepts, analyzing and exploring themes associated with early use of blood products (fresh frozen plasma [FFP] and red blood cells [RBCs]), and they compare and evaluate a US/UK study analyzing the differences and recommending future strategy. The subject matter expert (SME) consensus guidelines developed for use by the US Army Air Ambulance units commonly known as call sign "DUSTOFF." These TACEVAC assets in Afghanistan were validated in this retrospective study. Using statistical analysis, the authors were able to ascertain that the current DUSTOFF SME-derived guidelines offer a sensitivity of 63.04% and a specificity of 89.07%. By adjusting the indicators to include a single above-ankle amputation with a systolic blood pressure (SBP) less than 90mmHg and pulse greater than 120/min, the sensitivity could be increased to 67.39% while maintaining the specificity at 89.07%. In our data set, a single amputation above the ankle, in combination with an SBP of less than 100mmHg and a pulse of greater than 120/min, increased the sensitivity to 76% but with a slight drop in specificity to 86%. Further study of military prehospital casualty data is under way to identify additional physiological parameters that will allow simple scoring tools in the remote setting to guide the administration of prehospital blood products.

The Use of Dexamethasone in Support of High-Altitude Ground Operations and Physical Performance: Review of the Literature

O'Hara R, Serres J, Dodson W, Bruce W, Ordway J, Powell E, Wade M 14(4). 53 - 58 (Journal Article)

Objective: Military Special Operators (SOs) are exposed environmental conditions that can alter judgment and physical performance: uneven terrain, dryness of ambient air, reduction of air density, and a diminished partial pressure of oxygen. The primary purpose of this review was to determine the medical efficacy of dexamethasone as an intervention for the prevention and treatment of high-altitude illness. The secondary purpose was to determine its ability to maintain physical performance of SOs at high altitudes. Methods: A search of the literature from 1970 to 2014 was performed, locating 61 relevant articles, with 43 addressing the primary and secondary purposes of this literature review. Conclusions: The review indicates that dexamethasone is an effective prevention and treatment intervention for high-altitude illness. Commonly used dosages of either 2mg every 6 hours or 4mg every 12 hours can prevent high-altitude illnesses in adults. Currently in USSOCOM operations, there is an option to use 4mg every 6 hours (concurrently with acetazolamide 125mg bid) if ascending rapidly to or above 11,500 ft without time for acclimatization. Researchers also determined that acute exposure to high altitude, even in asymptomatic subjects, resulted in small cognitive deficits that could be reversed with dexamethasone. Dexamethasone may also help improve cognition and maximal aerobic capacity in SOs who are susceptible to high-altitude pulmonary edema.

Prehospital and En Route Cricothyrotomy Performed in the Combat Setting: A Prospective, Multicenter, Observational Study

Barnard EB, Ervin AT, Mabry RL, Bebarta VS 14(4). 35 - 39 (Journal Article)

Introduction: Airway compromise is the third most common cause of potentially preventable combat death. Surgical cricothyrotomy is an infrequently performed but lifesaving airway intervention. There are limited published data on prehospital cricothyrotomy in civilian or military settings. Our aim was to prospectively describe the survival rate and complications associated with cricothyrotomy performed in the military prehospital and en route setting. Methods: The Life-Saving Intervention (LSI) study is a prospective, institutional review boardapproved, multicenter trial examining LSIs performed in the prehospital combat setting. We prospectively recorded LSIs performed on patients in theater who were transported to six combat hospitals. Trained site investigators evaluated patients on arrival and recorded demographics, vital signs, and LSIs performed. LSIs were predefined and include cricothyrotomies, chest tubes, intubations, tourniquets, and other procedures. From the large dataset, we analyzed patients who had a cricothyrotomy performed. Hospital outcomes were cross-referenced from the Department of Defense Trauma Registry. Descriptive statistics or Wilcoxon test (nonparametric) were used for data comparisons; statistical significance was set at ρ < .05. The primary outcome was success of prehospital and en route cricothyrotomy. Results: Of the 1,927 patients enrolled, 34 patients had a cricothyrotomy performed (1.8%). Median age was 24 years (interquartile range [IQR]: 22.5-25 years), 97% were men. Mechanisms of injury were blast (79%), penetrating (18%), and blunt force (3%), and 83% had major head, face, or neck injuries. Median Glasgow Coma Scale score (GCS) was 3 (IQR: 3-7.5) and four patients had GCS higher than 8. Cricothyrotomy was successful in 82% of cases. Reasons for failure included left main stem intubation (n = 1), subcutaneous passage (n = 1), and unsuccessful attempt (n = 4). Five patients had a prehospital basic airway intervention. Unsuccessful endotracheal intubation preceded 15% of cricothyrotomies. Of the 24 patients who had the provider type recorded, six had a cricothyrotomy by a combat medic (pre-evacuation), and 18 by an evacuation helicopter medic. Combat-hospital outcome data were available for 26 patients, 13 (50%) of whom survived to discharge. The cricothyrotomy patients had more LSIs than noncricothyrotomy patients (four versus two LSIs per patient; ρ < .0011). Conclusion: In our prospective, multicenter study evaluating cricothyrotomy in combat, procedural success was higher than previously reported. In addition, the majority of cricothyrotomies were performed by the evacuation helicopter medic rather than the prehospital combat medic. Prehospital military medics should receive training in decision making and be provided with adjuncts to facilitate this lifesaving procedure.

Evaluation of NuStat®, a Novel Nonimpregnated Hemostatic Dressing, Compared With Combat Gauze™ in Severe Traumatic Porcine Hemorrhage Model

Hillis GR, Yi CJ, Amrani DL, Akers TW, Schwartz RB, Wedmore I, McManus JG 14(4). 41 - 47 (Journal Article)

Background: Uncontrolled hemorrhage remains one of the most challenging problems facing emergency medical professionals and a leading cause of traumatic death in both battlefield and civilian environments. Survival is determined by the ability to rapidly control hemorrhage. Several commercially available topical adjunct agents have been shown to be effective in controlling hemorrhage, and one, Combat Gauze™ (CG), is used regularly on the battlefield and for civilian applications. However, recent literature reviews have concluded that no ideal topical agent exists for all injuries and scenarios. The authors compared a novel nonimpregnated dressing composed of cellulose and silica, NuStat® (NS), to CG in a lethal hemorrhagic groin injury. These dressings were selected for their commercial availability and design intended for control of massive hemorrhage. Methods: A complex penetrating femoral artery groin injury was made using a 5.5mm vascular punch followed by 45 seconds of uncontrolled hemorrhage in 15 swine. The hemostatic dressings were randomized using a random sequence generator and then assigned to the animals. Three minutes of manual pressure was applied with each agent after the free bleed. Hextend™ bolus (500mL) was subsequently rapidly infused using a standard pressure bag along with the addition of maintenance fluids to maintain blood pressure. Hemodynamic parameters were recorded every 10 minutes and additionally at critical time points defined in the protocol. Primary end points included immediate hemostasis upon release of manual pressure (T0), hemostasis at 60 minutes, and rebleeding during the 60-minute observation period. Results: NS was statistically superior to CG in a 5.5mm traumatic hemorrhage model at T0 for immediate hemostasis (ρ = .0475), duration of application time (ρ = .0093), use of resuscitative fluids (ρ = .0042) and additional blood loss after application (ρ = .0385). NS and CG were statistically equivalent for hemostasis at 60 minutes, rebleeding during the study, and the additional secondary metrics, although the trend indicated that in a larger sample size, NS could prove statistical superiority in selected categories. Conclusions: In this porcine model of uncontrolled hemorrhage, NS improved immediate hemorrhage control, stability, and use of fluid in a 60-minute severe porcine hemorrhage model. In this study, NS demonstrated equivalence to CG at achieving long-term hemostasis and the prevention of rebleed after application. NS was shown to be an efficacious choice for hemorrhage control in combat and civilian emergency medical service environments.

Prehospital Analgesia With Ketamine for Combat Wounds: A Case Series

Fisher AD, Rippee B, Shehan H, Conklin C, Mabry RL 14(4). 11 - 17 (Journal Article)

Background: No data have been published on the use of ketamine at the point of injury in combat. Objective: To provide adequate pain management for severely injured Rangers, ketamine was chosen for its analgesic and dissociative properties. Ketamine was first used in the 75th Ranger Regiment in 2005 but fell out of favor because medical providers had limited experience with its use. In 2009, with new providers and change in medic training at the battalion level, the Regiment implemented a protocol using doses of ketamine that exceed the current Tactical Combat Casualty Care recommendations. Methods: Medical after-action reports were reviewed for all Ranger casualties who received ketamine at the point of injury for combat wounds from January 2009 to October 2014. Patients and medics were also interviewed. Results: Unit medical protocols authorize ketamine for tourniquet pain, amputations, long-bone fractures, and pain refractory to other agents. Nine of the 11 patients were US Forces; two were local nationals (one female, one male). The average initial dose given intramuscularly was 183mg, about 2 to 3mg/kg and intravenously 65mg, about 1mg/kg. The patients also received an opioid, a benzodiazepine, or both. There was one episode of apnea that was corrected quickly with stimulus. Eight of the 11 patients required the application of at least one tourniquet; four patients needed between two and four tourniquets to control hemorrhage. Pain was assessed with a subjective 1-10 scale. Before ketamine, the pain was rated as 9-10, with one patient claiming a pain level of 8. Of the US Forces, seven of the nine had no pain after receiving ketamine and two had a pain level of four. Two of the eight had posttraumatic stress disorder. Conclusions: In this small, retrospective sample of combat casualties, ketamine appeared to be a safe and effective battlefield analgesic.

Tourniquet Pressures: Strap Width and Tensioning System Widths

Wall PL, Coughlin O, Rometti MR, Birkholz S, Gildemaster Y, Grulke L, Sahr SM, Buising CM 14(4). 19 - 29 (Journal Article)

Background: Pressure distribution over tourniquet width is a determinant of pressure needed for arterial occlusion. Different width tensioning systems could result in arterial occlusion pressure differences among nonelastic strap designs of equal width. Methods: Ratcheting Medical Tourniquets™ (RMTs; m2® inc., http://www.ratcheting with a 1.9cm-wide (Tactical RMT) or 2.3cmwide (Mass Casualty RMT) ladder were directly compared (16 recipients, 16 thighs and 16 upper arms for each tourniquet ® 2). Then, RMTs were retrospectively compared with the windlass Combat Application Tourniquet (C-A-T ["CAT"], with a 2.5cm-wide internal tensioning strap. Pressure was measured with an air-filled No. 1 neonatal blood pressure cuff under each 3.8cm-wide tourniquet. Results: RMT circumferential pressure distribution was not uniform. Tactical RMT pressures were not higher, and there were no differences between the RMTs in the effectiveness, ease of use ("97% easy"), or discomfort. However, a difference did occur regarding tooth skipping of the pawl during ratchet advancement: it occurred in 1 of 64 Tactical RMT applications versus 27 of 64 Mass Casualty RMT applications. CAT and RMT occlusion pressures were frequently over 300mmHg. RMT arm occlusion pressures (175-397mmHg), however, were lower than RMT thigh occlusion pressures (197-562mmHg). RMT effectiveness was better with 99% reached occlusion and 1% lost occlusion over 1 minute versus the CAT with 95% reached occlusion and 28% lost occlusion over 1 minute. RMT muscle tension changes (up to 232mmHg) and pressure losses over 1 minute (24 ± 11mmHg arm under strap to 40 ± 12mmHg thigh under ladder) suggest more occlusion losses may have occurred if tourniquet duration was extended. Conclusions: The narrower tensioning system Tactical RMT has better performance characteristics than the Mass Casualty RMT. The 3.8cmwide RMTs have some pressure and effectiveness similarities and differences compared with the CAT. Clinically significant pressure changes occur under nonelastic strap tourniquets with muscle tension changes and over time periods as short as 1 minute. An examination of pressure and occlusion changes beyond 1 minute would be of interest.

Imaging Comparison of Pelvic Ring Disruption and Injury Reduction With Use of the Junctional Emergency Treatment Tool for Preinjury and Postinjury Pelvic Dimensions: A Cadaveric Study With Computed Tomography

Gary JL, Kumaravel M, Gates K, Burgess AR, Routt ML, Welch T, Podbielski JM, Beeler AM, Holcomb JB 14(4). 30 - 34 (Journal Article)

Objective: Complex dismounted blast injuries from (improvised) explosive devices have caused amputations of the lower extremities associated with open injuries to the pelvic ring, resulting in life-threatening hemorrhage from disruption of blood vessels near the pelvic ring. Provisional stabilization of the skeletal pelvis by circumferential pelvic compression provides stability for intrapelvic clots and reduces the volume of the pelvis, thereby limiting the amount of hemorrhage. The Junctional Emergency Treatment Tool™ (JETT™; North American Rescue Products, http://www.narescue .com) is a junctional hemorrhage control device developed to treat pelvic and lower extremity injuries sustained in high-energy trauma on the battlefield and in the civilian environment. Our purpose was to evaluate the compressive function of the JETT in the reduction of pelvic ring injuries in a cadaveric model. Methods: Radiographic comparison of pre (intact) and post pelvic ring disruption and injury was compared with radiographic measurements post reduction with the JETT device in two cadavers. The device's ability to reduce pelvic disruption and injury in a human cadaver model was assessed through measurements of the anteroposterior (AP) and transverse diameters obtained at the inlet and outlet of the pelvis. Results: Computed tomography (CT) scans demonstrated that JETT application effectively induced circumferential soft tissue compression that was evoked near anatomic reduction of the sacroiliac joint and symphysis pubis. Conclusions: The JETT is capable of effectively reducing an AP compression type III injury (APC III) pelvic ring disruption and injury by approximating the inlet and outlet dimensions toward predisruption measurements. Such a degree of reduction suggests that the JETT device may be suitable in the acute setting for provisional pelvic stabilization.

Management of Anaphylaxis in an Austere or Operational Environment

Ellis BC, Brown SG 14(4). 1 - 5 (Case Reports)

We present a case report of a Special Operations Soldier who developed anaphylaxis as a consequence of a bee sting, resulting in compromise of the operation. We review the current literature as it relates to the pathophysiology of the disease process, its diagnosis, and its management. An evidence-based field treatment algorithm is suggested.

Tactical Hemorrhage Control Case Studies Using a Point-of-Care Mechanical Direct Pressure Device

Kirkpatrick AW, McKee JL 14(4). 7 - 10 (Journal Article)

In 2012, a new hemorrhage control device entered the market, and by May 2013, the iTClamp™ 50 had acquired US Food and Drug Administration approval. The authors describe the use of the iTClamp 50 and present two case studies in which the iTClamp 50 was successfully used in the military environment to control potentially fatal hemorrhage.

Special Forces Medicine in Israel

Ostfeld I, Paran H, Chen J, Barneis Y, Dreyfuss U, Kedem H, Glassberg E 14(3). 116 - 120 (Journal Article)

The Special Forces (SF) of the Israel Defense Force (IDF) have a long and pioneering history in tactical and medical aspects. Moreover, the importance of medical assistance is highly regarded in the Israeli SF community. Consequently, as current military challenges of Israel increase, the need for SF activity and for its medical support increases as well. Therefore, the authors anticipate that further development of SF medicine (SFM), as a specific branch of military medicine in Israel, will continue.

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