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Preparing Soldiers for the Stress of Combat

Flanagan SC, Kotwal RS, Forsten RD 12(2). 33 - 41 (Journal Article)

Protracted use of stressors during military training courses does not necessarily enhance a Soldier's ability to regulate stress on the battlefield. Extensive stress during training can be a contributing factor to suboptimal neurologic and overall long-term health. Prolonged high-stress military training programs, as well as extended duration combat deployments, should be comprehensively scrutinized for opportunities to preserve health and increase combat effectiveness. Contemporary research in neuroscience and psychology can provide insight into training techniques that can be used to control stress and optimize performance in combat. Physical fitness training programs can elevate the stress threshold. Extensive situational training can also inoculate Soldiers to specific combat stressors. Training methods such as these will enable Soldiers to achieve higher levels of performance while under enemy fire and are encouraged for units deploying to combat.

Rethinking Heat Injury in the SOF Multipurpose Canine: A Critical Review

Baker JL, Hollier PJ, Miller L, Lacy WA 12(2). 8 - 15 (Journal Article)

Heat injury is a significant concern of the Special Operations Forces Multipurpose Canine (SOF MPC). The unique athletic abilities and working environment of the SOF MPC differ from that of companion dogs or even conventional military working dogs. This should be considered in the prevention, diagnosis, and treatment of heat injury of the SOF MPC. A critical review of the literature on canine heat injury as it pertains to working dogs demonstrates limited scientific evidence on best practices for immediate clinical management of heat injury in SOF MPCs. A majority of management guidelines for heat injury in veterinary reference books and journals are based on review articles or professional opinion of the author vs. evidence from original research. In addition, guidelines are written primarily for companion animal populations vs. SOF MPCs and focus on measures to be undertaken in a clinical setting vs. point of injury. The phenomenon of "circular referencing" is also prevalent in the heat injury literature. Current guidelines supported by review articles and textbooks often provide no citation or cite other review articles for clinical standards such as normal temperature ranges, treatment methods, and recurrence of heat injury. This "circular referencing" phenomenon misrepresents anecdotal evidence and professional opinion as scientifically validated, reinforcing concepts and recommendations that are not truly supported by the evidence. Further study is needed to fully understand heat injury in SOF MPCs and how this applies to prevention, diagnosis and treatment guidelines. In order to provide SOF canine programs with best clinical advice and care, SOF Veterinarians must make clinical judgments based on evaluation of the most accurate and valid information possible. Clinical guidelines are fluid and should be reviewed regularly for relevance to the defined population in question. Clinical Guidelines should also be utilized as guiding principles in conjunction with clinical judgment vs. dictate a clinical protocol. SOF veterinarians as the veterinary support asset to SOF MPC programs should be clinically competent as well as versed in evidence based medicine practices to provide the cutting edge clinical support that is required to keep SOF MPCs operating in modern warfare environments.

Salmon Thrombin-Fibrinogen Dressing Allows Greater Survival and Preserves Distal Blood Flow Compared to Standard Kaolin Gauze in Coagulopathic Swine with a Standardized Lethal Femoral Artery Injury

Floyd CT, Rothwell SW, Risdahl J, Martin R, Olson CE, Rose N 12(2). 16 - 26 (Journal Article)

We have previously shown that lyophilized salmon thrombin and fibrinogen (STF) embedded in a dissolvable dextran dressing is as efficacious as Combat Gauze™ (CG) with regard to controlling hemorrhage and survival in non-coagulopathic swine with femoral artery lacerations. A major limitation of currently available advanced field dressings is the inability to control hemorrhage in coagulopathic casualties because of the exhaustion of host coagulation proteins. We tested the hypothesis that the STF dressing would be better able to control hemorrhage and prolong survival in coagulopathic swine compared to CG. Survival rate was 50% in CG-treated animals versus 90% in STF-treated animals. Survival time was significantly greater in STF-treated animals. Clots formed over the arterial injury in 100% of STF-treated animals compared to 0% in CG-treated animals (ρ < 0.001). STF-treated animals consumed less host coagulation factors, including platelets (ρ = 0.03). Survival after limb manipulation that simulated casualty evacuation was significantly higher with the STF dressing (ρ < 0.005). Angiographic observation of distal blood flow was seen twice as often with the STF dressing as with CG. The STF dressing allows a high survival rate, significantly greater survival time, and a significantly more stable dressing than CG in coagulopathic swine. The clot formed by the STF dressing also enables restoration of distal blood flow to the limb potentially resulting in higher limb salvage.

Since When is a Calorie a Calorie?

Reshel R 12(1). 71 - 72 (Journal Article)

Exertional Heat Stroke: Clinical Significance and Practice Indications for Special Operations Medics and Providers

Johnston J, Donham B 12(2). 2 - 7 (Journal Article)

Exertional heat stroke is an acute injury associated with high morbidity and mortality, and is commonly encountered within military and Special Operations environments. With appropriate planning, rapid diagnosis, and aggressive treatment significant mortality reduction can be obtained. Planning for both training and real world operations can decrease the patient's morbidity and mortality and increase the chances of successful handling of a patient with exertional heat stroke. The mainstay of treatment is rapid reduction of the core body temperature. This is paramount both at the field level of care as well as in a clinical setting. Diligent surveillance for commonly encountered complications includes anticipating electrolyte abnormalities, rhabdomyolysis, acute renal failure, and hepatic injuries. Treatment with dantrolene may be indicated in patients with continued hyperthermia despite aggressive traditional treatment.

Medical Provider Ballistic Protection at Active Shooter Events

Stopyra JP, Bozeman WP, Callaway DW, Winslow J, McGinnis HD, Sempsrott J, Evans-Taylor L, Alson RL 16(3). 36 - 40 (Journal Article)

There is some controversy about whether ballistic protective equipment (body armor) is required for medical responders who may be called to respond to active shooter mass casualty incidents. In this article, we describe the ongoing evolution of recommendations to optimize medical care to injured victims at such an incident. We propose that body armor is not mandatory for medical responders participating in a rapid-response capacity, in keeping with the Hartford Consensus and Arlington Rescue Task Force models. However, we acknowledge that the development and implementation of these programs may benefit from the availability of such equipment as one component of risk mitigation. Many police agencies regularly retire body armor on a defined time schedule before the end of its effective service life. Coordination with law enforcement may allow such retired body armor to be available to other public safety agencies, such as fire and emergency medical services, providing some degree of ballistic protection to medical responders at little or no cost during the rare mass casualty incident. To provide visual demonstration of this concept, we tested three "retired" ballistic vests with ages ranging from 6 to 27 years. The vests were shot at close range using police-issue 9mm, .40 caliber, .45 caliber, and 12-gauge shotgun rounds. Photographs demonstrate that the vests maintained their ballistic protection and defeated all of these rounds.

Evaluation of Two Junctional Tourniquets Used on the Battlefield: Combat Ready Clamp® versus SAM® Junctional Tourniquet

Meusnier J, Dewar C, Mavrovi E, Caremil F, Wey P, Martinez J 16(3). 41 - 46 (Journal Article)

Background: Junctional hemorrhage (i.e., between the trunk and limbs) are too proximal for a tourniquet and difficult to compress. These hemorrhages are responsible for 20% of preventable deaths by bleeding on the battlefield. The majority of these involve the groin area. Devices allowing a proximal compression for arterial axes have been recently developed. Objective: The purpose of this study was to compare the use of two junctional- tourniquet models, the Combat Ready Clamp (CRoC®) and the SAM® Junctional Tourniquet (SJT), in simulated out-of-hospital trauma care when tourniquets were ineffective to stop the arterial flow. Methods: During our clinical study, 84 healthy volunteers wearing battle dress performed a physical exercise to come approximate the operational context. The volunteers were randomly divided into two groups according to the device (the CRoC or SJT) used as supplement to a tourniquet self-applied to the root of the thigh. The primary study end point was the complete interruption of popliteal arterial flow, measured with Doppler auscultation. Time to effectiveness and subjective questionnaire data to evaluate the devices' application were also collected. Results: Junctional device effectiveness was almost 90% for both the CRoC and the SJT, and did not differ between them, either used with a tourniquet (ρ = .36) or alone (ρ = .71). The time to effectiveness of the SJT was significantly shorter than that of the CRoC (ρ = .029). Conclusion: The SJT and the CRoC were equally effective. The SJT was faster to apply and preferred by the users. Our study provides objective evidence to the French Tactical Casualty Care Committee for improving junctional hemorrhage treatment.

F-Cell World Drive 2011: Are Tactical Medicine Principles Applicable to a Civilian Scenario?

Burkert MG, Kroencke A 12(1). 62 - 70 (Journal Article)

In 2011, a Mercedes Benz (MB) conducted the F-Cell World Drive tour around the globe in 125 days. While crossing Asia from SHANGHAI (CHINA) to HELSINKI (FINLAND) by car, en route medical care was provided by embedded emergency physicians. The designated route crossed four different countries, multiple climate zones, and challenging road conditions. There was only limited information provided about hospitals and emergency medical services within different hostnations in the planning phase, so we adopted tactical medical principles for mission planning and execution, as we were facing remote conditions and limitations to equipment, staffing, and patient transport.

Evaluation of Models of Pneumatic Tourniquet in Simulated Out-of-Hospital Use

Kragh JF, Aden JK, Dubick MA 16(3). 21 - 29 (Journal Article)

Background: Pneumatic field tourniquets have been recommended for Military medics to stop bleeding from limb wounds, but no comparison of commercially available pneumatic models of tourniquet has been reported. The purpose of this study is to provide laboratory data on the differential performance of models of pneumatic tourniquets to inform decision-making of potential field assessment by military users. Methods: Models included the Emergency and Military Tourniquet (EMT), Tactical Pneumatic Tourniquet 2-inch (TPT2), and Tactical Pneumatic Tourniquet 3-inch (TPT3). One user tested the three tourniquet models 30 times each on a manikin to collect data on effectiveness (yes-no bleeding control), pulse cessation, time to stop bleeding, total time of application, after time (after bleeding was stopped), pressure applied, blood loss volume, composite outcome (whether all individual outcomes were good or not), and pump count of the bulb used to inflate the tourniquet. Results: Neither tourniquet effectiveness nor pulse cessation (ρ = 1; likelihood ratio, 0 for both) differed among tourniquet models: all three models had 100% (30 of 30 tests) for both outcomes. The EMT had the best or tied for best performance in time to stop bleeding, total time, after time, pressure blood loss, composite outcome, and pump count. Conclusion: Each of the three models of pneumatic field tourniquet was 100% effective in stopping simulated bleeding. Among the three models, the EMT showed the best or tied for best performance in time to stop bleeding, blood loss, and composite outcomes. All models are suitable for future field assessment among military users.

Fraction of Inspired Oxygen Delivered by Elisée™ 350 Turbine Transport Ventilator With a Portable Oxygen Concentrator in an Austere Environment

d'Aranda E, Bordes J, Bourgeois B, Clay J, Esnault P, Cungi P, Goutorbe P, Kaiser E, Meaudre E 16(3). 30 - 35 (Journal Article)

Background: Management of critically ill patients in austere environments is a logistic challenge. Availability of oxygen cylinders for the mechanically ventilated patient may be difficult in such a context. One solution is to use a ventilator able to function with an oxygen concentrator (OC). Methods: We tested two Elisée™ 350 ventilators paired with SeQual Integra 10-OM oxygen concentrators (OC) (Chart Industries, http://www and evaluated the delivered fraction of inspired oxygen (Fio2). Ventilators were connected to a test lung and Fio2 was measured and indicated by the ventilator. Continuous oxygen was generated by the OC from 0.5L/min to 10L/min, and administered by the specific inlet port of the ventilator. Several combinations of ventilator settings were evaluated to determine the factors affecting the delivered Fio2. Results: The Elisée 350 turbine ventilator is able to deliver a high Fio2 when functioning with an OC. However, modifications of the ventilator settings such as an increase in minute ventilation, inspiratory-to-expiratory ratio, and positive end-expiratory pressure affect delivered Fio2 despite steady-state oxygen flow from the concentrator. Conclusion: OCs provide an alternative to oxygen cylinders for delivering high Fio2 with a turbine ventilator. Nevertheless, Fio2 must be monitored continuously, since it decreases when minute ventilation is increased.

Pectoralis Major Injury During Basic Airborne Training

McIntire S, Boujie L, Leasiolagi J 16(3). 11 - 14 (Journal Article)

Injuries involving rupture of the pectoralis major are relatively rare. When they do occur, it is mostly frequently in a young, athletic man. The most common cause is weight lifting that results in eccentric muscle contraction (muscle contraction against an overbearing force, leading to muscle lengthening)-specifically, the bench press. Other mechanisms for this injury include forceful abduction and external rotation of the arm. Injury can occur anywhere along the pectoralis major from its medial origin on the sternum and clavicle to its lateral tendinous insertion on the humerus. At the time of injury, patients may report feeling a tearing sensation or hearing a pop, with immediate onset of pain. Physical examination findings can include a deformed appearance of the chest, ecchymosis of the chest and upper arm, pain and weakness with arm adduction and internal rotation, or noticeable asymmetry of the anterior axilla with arm abduction. Magnetic resonance imaging is the imaging study of choice to aid diagnosis. In a young and active population, such as the Special Operations community, appropriate and timely diagnosis is important because surgical intervention often is recommended. This report presents the case of an active-duty Servicemember who sustained a pectoralis major injury while exiting an aircraft during the Basic Airborne Course.

Thrombotic Microangiopathy Syndrome in a Basic Underwater Demolition/SEAL Student

Croom D, Tracy H 16(3). 16 - 19 (Journal Article)

Thrombotic microangiopathy (TMA) syndromes represent a spectrum of illnesses that share common clinical and pathologic features of microangiopathic hemolytic anemia, thrombocytopenia, and organ injury from pathologic small-vessel thrombosis. At least nine primary TMA syndromes have been described and classified based on common probable etiologies, diagnostic criteria, and treatments. The most recognized of the TMA syndromes include thrombotic thrombocytopenic purpura (TTP) and hemolytic-uremic syndrome (HUS). Advanced laboratory techniques are required to distinguish between these syndromes; however, all patients should initially be treated with plasma exchange for presumed ADAMTS13 deficiency-mediated TMA. The authors present a case of a TMA syndrome in a Navy SEAL (Sea, Air, Land) candidate.

A Skeletal Traction Technique for Proximal Femur Fracture Management in an Austere Environment

Lidwell D, Meghoo CA 16(3). 1 - 4 (Case Reports)

Skeletal traction is a useful technique for managing proximal femur fractures in austere environments where fracture stabilization for this injury is difficult. We present a technique and a construct appropriate for field use that facilitates patient evacuation, and we provide guidelines for the use of this technique by an advanced medical provider managing these injuries. The objectives of this article are to enable to reader to (1) recognize the role of skeletal traction in managing proximal femur fractures in an austere environment, (2) identify the key steps in placing transfemoral skeletal traction pins, and (3) identify options and requirements for building a traction construct in resource-limited environments.

Lower Extremity Compartment Syndrome From Prolonged Limb Compression and Immobilization During an Airborne Operation

Smedick BC, van Wyck D 16(3). 5 - 9 (Journal Article)

Acute compartment syndrome (ACS) involving the leg can occur in association with various traumatic and nontraumatic conditions, and it can have serious longterm consequences when unrecognized or untreated. Nontraumatic causes of ACS, such as those associated with cases of prolonged immobilization and/or extremity compression, can be easily overlooked, and several cases of ACS occurring with prolonged surgical positioning can be found in the literature. We present the case of a 19-year-old Army paratrooper who developed acute anterior and lateral compartment syndrome of the lower extremity after being immobilized in an aircraft for hours with several hundred pounds of equipment compressing his lower extremities. To our knowledge, this is the first documented case of ACS occurring as a result of prejump conditions. It demonstrates a potentially serious complication that could result in medical separation and/or permanent disability of the service member. ACS of the extremity should be considered in any Soldier who is required to bear heavy loads, is immobilized for several hours at a time, and complains of symptoms such as extremity pain, numbness, and weakness.

Garlic Burn to the Face

Oberle M, Wachs T, Brisson P 16(4). 80 - 81 (Journal Article)

Topical burns from the use of garlic have been reported rarely in the medical literature. Most cases have resulted from the use of naturopathic or home remedy treatments. A 20-year-old male military Servicemember presented to a military wound care clinic 7 days after applying a homemade topical preparation of garlic to the zygomatic region of the right side of his face. The patient had consulted the Internet for treatment of a minor skin lesion in that area. He created a garlic paste, applied it to the affected area, and covered it with a dressing. Twelve hours later, he noted an intense burning sensation where he had applied the garlic paste. After the initial blistering, the patient recovered without any additional treatment. Second-degree burns were an unintended consequence of the use of garlic as a home remedy.

Searching for Sustainability: How Niger's CASEVAC Success Is Leading the African Continent and Educating the GHE/IHS Community

Flatau P 16(2). 111 - 114 (Journal Article)

Against all odds and despite significant challenges and scarce resources, Niger's Armed Forces (FAN) continues to lead a successful casualty evacuation (CASEVAC) program. This program and the Special Operations Command Africa (SOCAFR) model that influenced it has become a template for the Global Health Engagement (GHE)/International Health Specialist (IHS) community. This article provides a summary of the overall CASEVAC mission, outlines the final phase sustainable execution of this program, and provides the reader with critical lessons learned for best practice GHE approaches.

A Case of Prehospital Traumatic Arrest in a US Special Operations Soldier: Care From Point of Injury to Full Recovery

McKenzie MR, Parrish EW, Miles EA, Spradling JC, Littlejohn LF, Quinlan MD, Barbee GA, King DR 16(3). 93 - 96 (Journal Article)

During an assault on an extremely remote target, a US Special Operations Soldier sustained multiple gunshot and fragmentation wounds to the thorax, resulting in a traumatic arrest and subsequent survival. His care, including care under fire, tactical field care, tactical evacuation care, and Role III, IV, and V care, is presented. The case is used to illustrate the complex dynamics of Special Operations care on the modern battlefield and the exceptional outcomes possible when evidence-based medicine is taken to the warfighter with effective, farforward, expeditionary medical-force projection.

Load Carriage-Related Paresthesias: Part 1: Rucksack Palsy and Digitalgia Paresthetica

Knapik JJ, Reynolds K, Orr R, Pope R 16(4). 74 - 79 (Journal Article)

This is the first of a two-part article discussing loadcarriage- related paresthesias, including brachial plexus lesions (rucksack palsy), digitalgia paresthetica, and meralgia paresthetica. Paresthesias are sensations of numbness, burning, and/or tingling, usually experienced as a result of nerve injury, compression, traction, or irritation. Rucksack palsy is a traction or compression injury to the brachial plexus, caused by the shoulder straps of the rucksack. The patient presents with paresthesia, paralysis, cramping with pain, and muscle weakness of the upper limb. Muscle-strength losses appear to be greater in those carrying heavier loads. Hypothetical risk factors for rucksack palsy include improper load distribution, longer carriage distances, and load weight. Nerve traction, compression, and symptoms may be reduced by use of a rucksack hip belt; wider, better-padded, and proper adjustment of the shoulder straps; reduction of weight in the rucksack; a more symmetric distribution of the load; and resistance training to improve the strength and hypertrophy of the shoulder muscles. Assessment and neck joint and nerve mobilization may relieve brachial plexus tension and reduce symptoms. Another load-carriage-related disorder is digitalgia paresthetica, likely caused by compression of the sensory digital nerves in the foot during load carriage. Patients have paresthesia in the toes. Although no studies have demonstrated effective prevention measures for digitalgia paresthetica, reducing loads and march distances may help by decreasing the forces and repetitive stress on the foot and lower leg. Specialty evaluations by a physical therapist, podiatrist, or other healthcare provider are important to rule out entrapment neuropathies such as tarsal tunnel syndrome. Part 2 of this article will discuss meralgia paresthetica.

Urban Shield 2016

Mattison D 16(3). 76 - 77 (Journal Article)

Management of Crush Syndrome Under Prolonged Field Care

Walters TJ, Powell D, Penny A, Stewart I, Chung K, Keenan S, Shackelford S 16(3). 79 - 85 (Journal Article)

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