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The Agitated Patient

Goldstein S 13(3). 87 - 91 (Journal Article)

Caring for an agitated patient can be a daunting task for the tactical emergency medical support (TEMS) or Special Operations Forces (SOF) medic. The cause, degree, and duration of agitation can vary among such individuals. These patients create a high-stress and disruptive environment, needing numerous people involved to control. One agitated patient can disrupt an entire tactical team or casualty evacuation. The patient's history and physical examination can give important clues to the cause, thereby directing treatment and leading to a quick and safe resolution. The variety of treatments for the agitated patient are just as numerous as the causes and range from verbal deescalation to medications and physical restraint, all of which have a risk-benefit profile to consider.

Cultural Competency and Patient-Centered Communication: A Study of an Isolated Outbreak of Urinary Tract Infections in Afghanistan

Culbertson NT, Scholl BJ 13(3). 70 - 73 (Journal Article)

Background: Personal hygiene is strongly associated with disease prevention and is especially important during prolonged patrol or combat operations. Understanding cultural variances associated with personal hygiene is critical for Special Operation Forces (SOF) medics to prevent, monitor, and treat acquired and transmitted infections while working with host nation personnel. Case Presentation: During a multiday, long-range patrol, approximately 40 male Afghan National Army troops between the ages of 22 and 49 presented for treatment of burning or pain while urinating. All patients were empirically diagnosed with urinary tract infections. Methods and Discussion: The high attack rate and isolated nature of the outbreak suggested that personal hygiene or sexual intercourse was the most likely cause of the isolated outbreak. However, the cultural sensitivity of both topics made social history gathering a difficult task. After participating in a detailed medical interview, one patient revealed that he and his comrades were blocking their urethras with clay plugs after voiding to prevent residual urine from dripping onto their clothes. Conclusions: This case study presents what might be an undocumented practice carried throughout many ethnic cultures endogenous to Afghanistan and discusses how cultural barriers can impact effective health care delivery.

Preparing for Operations in a Resource-Depleted and/or Extended Evacuation Environment

Corey G, Lafayette T 13(3). 74 - 80 (Journal Article)

The wars in Afghanistan and Iraq are the only conflicts to which many medics have ever been exposed. These mature theaters have robust medical systems that ensure rapid access to full-spectrum medical care for all combat-wounded and medically injured personnel. As current conflicts draw to a close, U.S. medics may be deployed to environments that will require the ability to stabilize casualties for longer than 1 hour. Historical mission analysis reveals the need to review skills that have not been emphasized during upgrade and predeployment training. This unit's preparation for the extended care environment can be accomplished using a 4-point approach: (1) review of specific long-term skills training, (2) an extended care lab that reviews extended care skills and then lets the medic practice in a real-time scenario, (3) introduction to the HITMAN mnemonic tool, which helps identify and address patient needs, and (4) teleconsultation.

Traumatic Brain Injury: Analysis of Functional Deficits and Posthospital Rehabilitation Outcomes

Lewis FD, Horn GJ 13(3). 56 - 61 (Journal Article)

Background: Advances in emergency medicine, both in the field and in trauma centers, have dramatically increased survival rates of persons sustaining traumatic brain injury (TBI). However, these advances have come with the realization that many survivors are living with significant residual deficits in multiple areas of functioning, which make the resumption of a quality lifestyle extremely difficult. To this point, TBI has recently been characterized as a chronic disease. As with other chronic diseases, TBI is often causative of persistent disabling symptoms in multiple organ systems. Therefore, posthospital residential rehabilitation programs have emerged to treat these symptoms with the goal of helping these individuals regain function and live more productive and independent lives. Purpose: This study examined the nature and severity of residual deficits experienced by a group of 285 brain-injured individuals and evaluate the efficacy of posthospital residential rehabilitation programs in treating those deficits. Method: Participants consisted of 285 individuals who had sustained a TBI and, due to multiple residual deficits, were unable to care for themselves, necessitating admission to residential posthospital rehabilitation programs. All participants were evaluated at admission and discharge on the Mayo-Portland Adaptability Inventory-Version 4 (MPAI-4). The MPAI-4, developed specifically for persons with acquired brain injury, measures 29 areas of function often affected by TBI. Results: From the 29 skills evaluated, the 12 most often rated as causing the greatest interference with function were identified. Of these skills, the cognitive deficits including memory, attention/concentration, novel problem solving, and awareness of deficits were highly correlated with disruption in performing everyday societal roles. The impact of treatment for reducing the level of disability in these areas was statistically significant, t(284) = 17.43, p < .0001. Improvement was significant even for participants admitted more than 1 year postinjury, t(78) = 8.05, p < .0001. Conclusions: Skill deficits interfering with reintegration into home and community are highly interrelated and should be treated with the understanding that progress in one area may be dependent on change in another area. Cognitive skills including memory, attention/ concentration, novel problem solving, and awareness of deficits were highly correlated with measures of overall functional outcome. Posthospital programs using a multidisciplinary treatment approach achieved significant reduction in disability from program admission to discharge. The benefits of these programs were realized even for the most chronically-impaired participants.

Cultural Self-Awareness as a Crucial Component of Military Cross-Cultural Competence

Pappamihiel CJ 13(3). 62 - 69 (Journal Article)

The military forces in the United States represent a unique culture that includes many subcultures within their own military society. Acculturation into the military often deemphasizes the influence of personal narrative and thereby establishes the primacy of military culture over personal cultural influences. The authors make the argument that military personnel need to further develop an understanding and appreciation of personal cultural narrative as well as organizational culture. The increased integration of military personnel with interagency partners, along with cooperative efforts between relief organizations, and nongovernmental organizations in politically/economically unstable areas around the globe serves to make cross-cultural interaction unavoidable in the future. Military medical personnel are especially likely to interact with others who have culturally different values. These interactions can occur between organizations as easily as they can during patient care. They must be able to step outside of their military culture and develop cross-cultural competence that is grounded in cultural self-awareness. Without an appropriate level of cultural self-awareness, military and medical personnel run the risk of being unable to communicate across dissimilar cultures or worse, alienating key stakeholders in collaborative operations between military services, coalition partners, and nonmilitary organizations. It is the authors' contention that unless military personnel, especially those in the medical arena, are able to appropriately self-assess situations that are impacted by culture, both their own and the other personnel involved, the resulting cultural dissonance is more likely to derail any significant positive effect of such collaborations.

Blast Traumatic Brain Injury - What Do We Know?

Rolan T 13(3). 45 - 50 (Journal Article)

Traumatic brain injury (TBI) is a significant problem in both the civilian and military worlds. Although much is understood about the effects of TBI, relatively few diagnostic or therapeutic modalities are available. Currently, TBI treatment is in a primitive phase and other than acute lifesaving interventions, is largely relegated to rehabilitation efforts. This article discusses known aspects of neuronal injury related to blast TBI, as well as a review of the current state of diagnostic and therapeutic interventions.

Deployed Assessment and Management of mTBI Casualties

Garfin B 13(3). 51 - 55 (Journal Article)

The wars in Afghanistan and Iraq have placed a spotlight on screening, evaluation, and treatment of mild traumatic brain injury, otherwise known as concussion. The author presents a mass casualty case in which a Ranger company medical section assessed and managed 30 Servicemembers (SM) diagnosed with concussion. Through the process of treating these Servicemembers, a consolidated checklist was created based on existing Department of Defense, United States Special Operations Command (USSOCOM), and United States Army Special Operations Command (USASOC) guidelines. During this and subsequent clinical encounters, utilization of this checklist resulted in efficient identification of concussed personnel, appropriate treatment, and documentation.

MEDEVAC Use of Ketamine for Postintubation Transport

Grumbo R, Hoedebecke KL, Berry-Caban CS, Mazur A 13(3). 36 - 41 (Journal Article)

The use of traditional sedatives and analgesics in intubated patients can have undesired hemodynamic consequences with increases in sedation exacerbating hypotension and potentially avoidable morbidity and mortality. This project compared 50 intubated patients using traditional analgesics and sedatives to 20 intubated patients using ketamine with the hypothesis that there would be a significant difference in subsequent blood pressure drop between the two groups. Though the results did not prove to be statistically significant within this small study, the authors did observe a trend toward significance. Additionally, some hypotensive patients had traditional analgesics and sedatives withheld altogether, which did not occur within the ketamine group. Due to the reduced side-effect profile, deployed medical providers should have increased training with and use of ketamine in the pre-hospital setting.

Digital Intubation: The Two-Fingered Solution to Securing an Airway

Cashwell MJ, Wilcoxen AC, Meghoo CA 13(3). 42 - 44 (Journal Article)

Digital intubation is a useful technique that is rarely taught in conventional airway management courses. With limited equipment and minimal training, a Special Operations Forces (SOF) medic can use this technique to intubate an unconscious patient with a high degree of success. The objectives of this report are to (1) learn the sequence of events for successful digital intubation, (2) recognize and appreciate the advantages and limitations of this technique, and (3) appreciate the requirements for establishing a unit-level training program.

Rigid Eye Shields: A Critical Gap in the Individual First Aid Kit

Brunstetter T, Diaz GY, Wasner C, Hart S, Burrows S 13(3). 26 - 28 (Journal Article)

From 5% to 22% of all U.S. Department of Defense combat casualties between 2001 and 2010 suffered some form of ocular trauma. Ocular injuries have an inordinately dramatic impact on return to duty, retention, and reintegration; only 25% of warfighters with severe ocular trauma return to duty. After a traumatic ocular event, the likelihood of saving an eye and preserving vision depends on several factors, especially the treatment quality at the point of injury. Every major organization associated with combat casualty care (e.g., the U.S. Army Institute of Surgical Research, the Committee on Tactical Combat Casualty Care, and the Department of Defense/VA Vision Center of Excellence) emphasizes the importance of placing a rigid eye shield on known/suspected eye injuries at point of injury. On the battlefield, there is no better way to protect an injured eye from further damage than with an eye shield, but shields are not readily available in individual first aid kits. Therefore, it is highly recommended that each Service rapidly integrate at least one rigid eye shield into every individual first aid kit, making them immediately available to every warfighter.

Design and Demonstration of a Battery-Less Fluid Warmer for Combat

Ndao S, Jensen KF, Velmahos GC, King DR 13(3). 31 - 36 (Journal Article)

Background: Prehospital battlefield hypothermia remains an issue, with cold fluid resuscitation likely being a significant contributor. Currently, no prehospital battlefield technology exists to warm intravenous resuscitation fluids. Existing commercial fluid-warming technologies are either inadequate or unreliable or have an unacceptable weight and size, making them inappropriate for the austere combat environment. We propose the creation of a battery-less, flameless, portable, low- weight, small, chemically powered fluid warmer for the battlefield. Methods: A magnesium-based exothermic chemical reaction was used as the sole heating source. A low-weight, small insulated container was created to contain the reaction. The chemical reaction was manipulated to sustain fluid heating as long as required. Results: The exothermic reaction was used to boil a Fluorinert ™ liquid within an insulated container that heats resuscitation fluid passing through the heat exchanger. A working prototype device, 9 inches in length and 4 inches in diameter, was engineered and tested. Warming was maintained over a variety of clinically relevant flow rates. Conclusion: A chemically based, safe, battery-less, flameless, lightweight fluid warmer was created. This technology could represent a significant remote capability currently unavailable on the battlefield.

Abdominal Aortic Tourniquet Controls Junctional Hemorrhage From a Gunshot Wound of the Axilla

Croushorn J, McLester J, Thomas G, McCord SR 13(3). 1 - 4 (Journal Article)

Junctional hemorrhage, bleeding from the areas at the junction of the trunk and its appendages, is a difficult problem in trauma. These areas are not amenable to regular tourniquets as they cannot fit to give circumferential pressure around the extremity. Junctional arterial injuries can rapidly lead to death by exsanguination, and out-of-hospital control of junctional bleeding can be lifesaving. The present case report describes an offlabel use of the Abdominal Aortic Tourniquet™ in the axilla and demonstrates its safety and effectiveness of stopping hemorrhage from a challenging wound. To our knowledge, the present report is the first human use of a junctional tourniquet to control an upper extremity junctional hemorrhage.

Tragedy Into Drama: An American History of Tourniquet Use in the Current War

Kragh JF, Walters TJ, Westmoreland T, Miller RM, Mabry RL, Kotwal RS, Ritter BA, Hodge DC, Greydanus DJ, Cain JS, Parsons DL, Edgar EP, Harcke HT, Baer DG, Dubick MA, Blackbourne LH, Montgomery HR, Holcomb JB, Butler FK 13(3). 5 - 25 (Journal Article)

Background: Although the scientific results of recent tourniquet advances in first aid are well recorded, the process by which tourniquet use advances were made is not. The purpose of the present report is to distill historical aspects of this tourniquet story during the current wars in Afghanistan and Iraq to aid scientists, leaders, and clinicians in the process of development of future improvements in first aid. Methods: The process of how developments of this tourniquet story happened recently is detailed chronologically and thematically in a "who did what, when, where, why, and how" way. Results: Initially in these wars, tourniquets were used rarely or were used as a means of last resort. Such delay in tourniquet use was often lethal; subsequently, use was improved incrementally over time by many people at several organizations. Three sequential keys to success were (1) unlocking the impasse of enacting doctrinal ideas already approved, (2) reaching a critical density of both tourniquets and trained users on the battlefield, and (3) capturing their experience with tourniquets. Other keys included translating needs among stakeholders (such as casualties, combat medics, providers, trainers, and decision-makers) and problem-solving logistic snags and other issues. Eventually, refined care was shown to improve survival rates. From all medical interventions evidenced in the current wars, the tourniquet broke rank and moved to the forefront as the prehospital medical breakthrough of the war. Conclusion: The recorded process of how tourniquet developments in prehospital care occurred may be used as a reference for parallel efforts in first aid such as attempts to improve care for airway and breathing problems.

Medical Mission to Dominican Republic: One Dermatology Group's Experiences

Ahmed A, Peine S 13(2). 69 - 74 (Journal Article)

The intents of this article are to share our experiences during a medical mission in the Dominican Republic and to provide the reader with a cross-sectional view of conditions seen and an overview of interesting and challenging cases encountered. We also discuss treatments and techniques used and share lessons learned.

The Tactical Combat Casualty Care Casualty CardTCCC Guidelines - Proposed Change 1301

Kotwal RS, Butler FK, Montgomery HR, Brunstetter T, Diaz GY, Kirkpatrick JW, Summers NL, Shackelford S, Holcomb JB, Bailey JA 13(2). 82 - 87 (Journal Article)

Optimizing trauma care delivery is paramount to saving lives on the battlefield. During the past decade of conflict, trauma care performance improvement at combat support hospitals and forward surgical teams in Afghanistan and Iraq has increased through Joint Trauma System and DoD Trauma Registry data collection, analysis, and rapid evidence-based adjustments to clinical practice guidelines. Although casualties have benefitted greatly from a trauma system and registry that improves hospital care, still lacking is a comprehensive and integrated system for data collection and analysis to improve performance at the prehospital level of care. Tactical Combat Casualty Care (TCCC) based casualty cards, TCCC after action reports, and unit-based prehospital trauma registries need to be implemented globally and linked to the DoD Trauma Registry in a seamless manner that will optimize prehospital trauma care delivery.

Vector-Borne Disease Surveillance in Puerto Rico: Pathogen Prevalence Rates in Canines - Implications for Public Health and the U.S. Military - Applying the One Health Concept

McCown ME, Opel T, Grzeszak B 13(2). 59 - 63 (Journal Article)

Vector-borne diseases (VBDs) make up a large number of emerging infectious and zoonotic diseases. Vectors such as ticks, fleas, and mosquitoes parasitize dogs, thus making canine populations adequate reservoirs for infectious disease and zoonoses. The U.S. military deploys its personnel and Military Working Dogs (MWDs) throughout the world with possible risk of exposure to VBDs. Canine VBDs continue to have veterinary and public health significance for the host nations as well as for deployed U.S. personnel and MWDs. Thus, ongoing and consistent disease surveillance is an essential component to preserve health. The purpose of this study was to survey dogs from multiple cities and varying regions throughout Puerto Rico to determine the prevalence of ehrlichiosis (Ehrlichia canis), anaplasmosis (Anaplasma phagocytophilum), Lyme disease (Borrelia burgdorferi), and heartworm disease (Dirofilaria immitis) from May to July 2012. Canine blood samples (1-3 ml) from the cities of San Juan (n = 629), Guaynabo (n = 50), Ponce (n = 20) and Vieques Island (n = 53) were obtained and tested on-site using an IDEXX SNAP® 4Dx® (enzyme-linked immunosorbent assay) test kit. Prevalence for single or multiple disease status was calculated for each site. The overall period prevalence of VBD in Puerto Rico in the shelter population was 57.7% (71/123). In Guaynabo, the VBD prevalence was 30% (15/50); 2 (13%) of these positive dogs had VBD co-infection. In the coastal port city of Ponce, it was 60% (12/20); 6 (50%) dogs were infected by two or more VBDs. On Vieques Island, it was 83% (44/53); 27 (61%) dogs were coinfected. Conversely, samples collected at the Fort Buchanan Veterinary Clinic in the capitol city of San Juan resulted in a VBD prevalence of 8.9% (56/629). Lyme disease was not detected in any sample. This study showed the presence of D. immitis, E. canis, and A. phagocytophilum in all four sites of Puerto Rico, emphasizing the value of surveillance for VBDs to determine disease prevalence, complete risk assessments, and implement timely preventive medicine and other preventive measures. The lower VBD prevalence rate in the canine samples from Fort Buchanan demonstrates the value of responsible pet ownership and importance of preventive medicine and public health.

Dengue Infections

Burnett MW 13(2). 64 - 68 (Journal Article)

Background: Dengue fever is one of the most common mosquito-borne viral illnesses in the world. It is usually transmitted to humans through the bite of an infected Aedes aegypti or Aedes albopictus mosquito. Dengue infections are caused by four antigenically distinct but closely related viruses (DEN 1-4). Infection with any one of the viruses is thought to provide lifetime immunity to future infections from the same virus but only short-term cross-immunity to the other types, leading to the possibility of secondary infections. Dengue hemorrhagic fever/dengue shock syndrome (DHF/DSS), more severe types of dengue infections, sometimes result when an individual is subsequently infected with a second virus serotype during their lifetime. The most commonly accepted theory for the development of these more severe dengue infections is that of antibody-dependent enhancement, although other factors likely play a role. Infections complicated by DHF/DSS in areas where dengue is endemic are most often seen in the later half of the first year of life, when waning maternal antibodies may enhance the development of a more severe infection, and in young school-age children experiencing secondary infections. Widespread infections are most commonly seen during the rainy season of endemic areas when the breeding habitat of the Aedes mosquito is most favorable.

Priorities for a 21st-Century Defense: Aligning U.S. Army Environmental Science and Engineering Officer Resources with the Department of Defense Strategic Guidance

Licina D, Rufolo D, Story M 13(2). 38 - 43 (Journal Article)

The recently published Department of Defense (DoD) strategic guidance highlights the need to "shape a joint force for the future." Supporting requirements to shape the joint force while the overall DoD force structure is reduced will be challenging. Fortunately, based on its unique training and experience, the Army Environmental Science and Engineering Officer (ESEO) profession is positioned today to fill anticipated joint public health requirements. Obtaining the U.S. Army Medical Department (AMEDD) approval to meet these requirements will have near-term consequences for the ESEO profession as some existing (albeit antiquated) authorizations may go unfilled. However, long-term dividends for the Medical Service Corps (MSC), AMEDD, Army, and DoD will be achieved by realigning critical resources to future joint and interagency requirements. Assigning ESEOs now to organizations such as the Theater Special Operations Commands (TSOCs), U.S. Agency for International Development (USAID), and the North Atlantic Treaty Organization (NATO) with perceived and real joint force health protection/public health requirements through unique means will ensure our profession remains relevant today and supports the joint force of tomorrow.

CBRNE TC3: A Hybrid Approach to Casualty Care in the CBRNE Environment

Strain JE 13(2). 44 - 53 (Journal Article)

The implementation of Tactical Combat Casualty Care (TCCC) guidelines for the Operation Enduring Freedom and Operation Iraqi Freedom contingency operations has dramatically reduced preventable combat deaths. A study of these principles and their application to medical treatment in the chemical, biological, radiological, nuclear, and high-yield explosives (CBRNE), weapons of mass destruction (WMD) environment is presented as a potential readiness and force multiplier for units engaged in this area of operations. Preparing medical operators for support of WMD sampling and mitigation missions requires extensive preventive medicine and post-exposure and downrange trauma threat preparedness. Training and equipping CBRN operators with treatment skills and appropriate interventional material requires pre-implementation planning specific to WMD threats (e.g., anthrax, radiation, organophosphates, and contaminated trauma). A scenario-based study reveals the tactics, techniques, and procedures for training, resourcing, and fielding the CBRN operator of the future.

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