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The Future of Prehospital Critical Care

Johnson A, Dodge M, Fisher AD 22(2). 116 - 118 (Journal Article)

As technology improves, the capabilities of prehospital providers increase. Innovations and realizations from military counterparts are being transitioned to civilian emergency care with the same hopes of increasing survivability of patients. Looking to the future, the incorporation of drone aircraft in the critical care field will likely impact the way medicine is practiced. Education is the key to improving outcomes in the prehospital setting.

Coagulopathy Associated With Trauma: A Rapid Review for Prehospital Providers

Friedman J, Ditzel RM, Fisher AD 22(2). 110 - 115 (Journal Article)

The coagulopathy associated with trauma is a complex and convoluted process that is still poorly understood. However, there are recognized contributors to acute traumatic coagulopathy (ATC) and trauma induced coagulopathy (TIC) that are universal. They are hypothermia, acidosis, and coagulopathy, also known as the lethal triad. Recently, with new understanding of hypocalcemia's role in trauma mortality, the term lethal diamond has been coined to underscore calcium's importance. Prehospital providers often unknowingly exacerbate ATC and TIC with excessive crystalloid administration and poor hypothermia prevention. This article will serve as an overview of the physiologic and iatrogenic drivers of ATC and TIC, and will discuss how they can be prevented, assessed, and treated.

Management of Acute Lung Injuries and Acute Respiratory Distress Syndrome in the Tactical and Prolonged Field Care Setting

Bagley GF, Ciochirca C 22(2). 104 - 109 (Journal Article)

The authors examine two acute lung injuries (ALI) that can occur in the tactical setting - positive pressure pulmonary edema and inhalation injury - as well as acute respiratory distress syndrome (ARDS), all of which can quickly progress in a prolonged field care (PFC) environment. These conditions present complex problems to emergency department (ED) and intensive care unit (ICU) teams worldwide, requiring intimate knowledge of their distinct disease pathophysiology and advanced critical care equipment. These challenges are compounded in the world of the Special Operations Forces (SOF) medic who often operates as the sole provider in environments with both limited resources and prolonged evacuation times. It is the hope of the authors that by breaking down these complex critical care topics and providing concrete guidance and treatment recommendations that we can ultimately improve the care SOF medics provide overseas in an austere operational environment.

Mechanical Ventilation: A Review for Special Operations Medical Personnel

Friedman J, Assar SM 22(2). 97 - 102 (Journal Article)

Mechanical ventilation is machine-delivered flow of gases to both oxygenate and ventilate a patient who is unable to maintain physiological gas exchange, and positive-pressure ventilation (PPV) is the primary means of delivering invasive mechanical ventilation. The authors review invasive mechanical ventilation to give the Special Operations Force (SOF) medic a comprehensive conceptual understanding of a core application of critical care medicine.

Airway Management With Noninvasive Positive Pressure Ventilation

Papalski W, Siedler J, Callaway DW 22(2). 93 - 96 (Journal Article)

Noninvasive positive-pressure ventilation (NPPV) is a form of ventilatory support that does not require the placement of an advanced airway. The authors discuss the use of NPPV on patients who will likely benefit. The use of NPPV has reduced the need for patients to require intubation and/or mechanical ventilation in some cases, as well as benefits.

Pathophysiology and Treatment of Burns

Payne R, Glassman E, Turman ML, Cancio LC 22(2). 87 - 92 (Journal Article)

Management of burn patients in the prehospital and prolonged field care environments presents complex patient care and logistical challenges. The authors discuss the pathophysiology, diagnostics, longitudinal concerns, and treatment involved in the care of such patients.

Prehospital Electrolyte Care: A Review of Symptoms, Evaluation, and Management

Painter A, Carius BM 22(2). 80 - 86 (Journal Article)

Ongoing evolution of prehospital medical care continues to advance beyond tactical field care scenarios in the consideration of prolonged field care. This is even more important to consider in theaters with extended evacuation times and limited local medical assets. The critical regulatory functions of electrolytes such as sodium, potassium, calcium, and glucose require medics operating in these environments to have a strong, fundamental knowledge of the principles, manifestations, and initial stabilization measures to aid their patients prior to, or in lieu of evacuation. Continued development and access to point of care testing in increasingly forward deployed settings further enables medics to perform these tasks. Here, we provide a brief review of these vital electrolytes, as well as additional kidney function evaluation considerations, to assist medics in their treatment efforts. Specific concerns for battlefield and atraumatic presentations are addressed.

Principles and Considerations in the Early Identification and Prehospital Treatment of Thrombocytopenia

Nietsch KS, Roach TM, Wilson ZD, Kelly SM 22(2). 75 - 79 (Journal Article)

Thrombocytopenia is a common condition characterized by a low platelet count, typically less than 150,000/µL. This article outlines key considerations for field medical providers to effectively identify the early signs of thrombocytopenia and treat different etiologies in the prehospital environment. Following a representative case study, we present a review of basic pathophysiology to include different manifestations of thrombocytopenia as well as diagnostic methods, treatments, and other necessary interventions in this unique setting. With an adequate understanding of typical patient histories and physical presentations leading to this diagnosis, field medics and physicians can be armed with useful information to potentially improve patient outcomes.

Prehospital Anemia Care A Review of Symptoms, Evaluation, and Management

Rankin CJ, Fetherston T, Ballentine CD, Adams B, Long B, Carius BM 22(2). 69 - 74 (Journal Article)

The ongoing evolution of prehospital medical care continues to advance beyond immediate triage care. Prehospital care is even more important to consider in theaters with extended evacuation times and limited local medical assets. Although blood loss is often associated with settings of acute traumatic hemorrhage in military medicine, the possibility for other hematologic compromise necessitating urgent action requires medics operating in these environments to have a fundamental knowledge of the pathophysiology, manifestations, and stabilization measures of anemia to aid their patients prior to, or in lieu of, evacuation. Continued development of and access to point-of-care testing in increasingly forward-deployed settings further enable medics to perform these tasks. Here, we provide a brief review of hemoglobin function and composition, and presentation and management considerations of anemia, to assist medics in their treatment efforts. We also address specific concerns for battlefield and atraumatic presentations.

Shock and Vasopressors

Lampman P, Kennington K, Assar SM 22(2). 63 - 68 (Journal Article)

Shock is a life-threatening condition carrying a high mortality rate when untreated. The consequences of shock are cellular and metabolic derangements, which are initially reversible. The authors present the case of a Servicemember who sustained mortar shrapnel wounds that resulted in shock.

Prehospital Traumatic Brain Injury Management Clinical Pearls and Pathophysiology

Ditzel RM, Hwang BY, Schmid JH, Ling GS 22(2). 55 - 61 (Journal Article)

Traumatic brain injury (TBI) management is complex. The brain is a sensitive, high-maintenance organ that loses its ability to take care of itself upon injury, and our primary mission is to achieve and maintain optimal levels of cerebral blood flow (CBF) from the moment of injury until recovery. The authors provide a case and discuss prehospital patient management, including adequate oxygen saturation and blood pressure, early recognition of TBI, frequent exams, detailed charting and hand-off, and fast transport to the next echelon of care.

Analgesia and Sedation in the Prehospital Setting: A Critical Care Viewpoint

DesRosiers TT, Anderson JL, Adams B, Carver RA 22(2). 48 - 54 (Journal Article)

Pain is one of the most common complaints of battlefield casualties, and unique considerations apply in the tactical environment when managing the pain of wounded service members. The resource constraints commonly experienced in an operational setting, plus the likelihood of prolonged casualty care by medics or corpsmen on future battlefields, necessitates a review of analgesia and sedation in the prehospital setting. Four clinical scenarios highlight the spectrum of analgesia and sedation that may be necessary in this prehospital and/or austere environment.

Management of Severe Crush Injuries in Austere Environments: A Special Operations Perspective

Anderson JL, Cole M, Pannell D 22(2). 43 - 47 (Journal Article)

Crush injuries present a challenging case for medical providers and require knowledge and skill to manage the subsequent damage to multiple organ systems. In an austere environment, in which resources are limited and evacuation time is extensive, a medic must be prepared to identify trends and predict outcomes based on the mechanism of injury and patient presentation. These injuries occur in a variety of environments from motor vehicle accidents (at home or abroad) to natural disasters and building collapses. Crush injury can lead to compartment syndrome, traumatic rhabdomyolysis, arrythmias, and metabolic acidosis, especially for patients with extended treatment and extrication times. While crush syndrome occurs due to the systemic effects of the injury, the onset can be as early as 1 hour postinjury. With a comprehensive understanding of the pathophysiology, diagnosis, management, and tactical considerations, a prehospital provider can optimize patient outcomes and be prepared with the tools they have on hand for the progression of crush injury into crush syndrome.

A Comprehensive Method of Assessing Body Composition Using Kinanthropometry in Human Performance Training

Wentz LM, Webb PS, Burks K 22(2). 37 - 41 (Journal Article)

Nutrition is an essential component of Human Performance Optimization in Special Operations Forces (SOF) to enhance physical and mental performance, unit readiness, and mission success. Body composition is frequently used to monitor individual nutrition progress; however, using body fat percentage is limited both by the accuracy of the assessment method and its association with SOF relevant performance outcomes. Lower body fat and/or body mass index have generally, but not universally, been correlated with higher levels of physical performance, yet they poorly predict performance in military relevant tasks. As a complement to body fat, many performance dietitians in the SOF Human Performance Programs utilize the International Society for Advanced Kinanthropometry (ISAK) profile to assess body composition, proportionality, ratio of muscle to bone, and somatotype in combat Operators. Kinanthropometry is the study of human size, shape, proportion, composition, maturation, and gross function, and it is a helpful tool for monitoring nutrition and training progress in athletes and active individuals. The ISAK profile has been well established as an international method for talent identification, distinguishing characteristics between athletes across and within elite sports, and identifying predictors of sport performance that can be applied in the military setting. While some SOF dietitians are utilizing the ISAK profile, the challenge lies in translating sport data to military relevant outcomes. We present a series of four case studies demonstrating the utility of this method as a portable comprehensive assessment for cross-sectional and longitudinal body composition tracking in a military setting.

Collaboration of a Medical School With a Special Forces Group on Annual Training: A Blueprint

Brisson PA, McGregor DW, Murphy Z 22(2). 35 - 36 (Journal Article)

Collaboration on annual training between a medical school and a National Guard Special Forces Group can be accomplished with great benefit to both parties. The authors describe the involvement by the Edward Via College of Osteopathic Medicine in providing training for the 20th Special Forces Group Medical Sergeants of the Alabama Army National Guard.

20th SFG(A) Non-Trauma Module (NTM) Course

Walker LH, Godbee DC, Palmer LE, Share MP, Mouri M 22(2). 29 - 34 (Journal Article)

The authors describe the 20th Special Forces Group-Airborne Non-Trauma Module refresher training for Special Forces medical sergeants and Special Operations combat medics.

Tactical Combat Casualty Care Maritime Scenario: Shipboard Missile Strike

Butler FK, Burkholder T, Chernenko M, Chimiak J, Chung J, Cubano M, Gurney J, Hall AB, Holcomb JB, Kotora J, Lenart M, Long A, Papalski W, Rich TA, Tripp M, Shackelford SA, Tadlock MD, Timby JW, Drew B 22(2). 9 - 28 (Journal Article)

The types of injuries seen in combat action on a naval surface ship may be similar in many respects to the injuries seen in ground combat, and the principles of care for those injuries remain in large part the same. However, some contradistinctions in the care of combat casualties on a ship at sea must be highlighted, since this care may entail a number of unique challenges and different wounding patterns. This paper presents a scenario in which a guided missile destroyer is struck by a missile fired from an unmanned aerial vehicle operated by an undetermined hostile entity. Despite the presence of casualties who require care, the primary focus of a naval vessel that has just been damaged by hostile action is to prevent the ship from sinking and to conserve the fighting force on board the ship to the greatest extent possible. The casualties in this scenario include sailors injured by both blast and burns, as well as a casualty with a non-fatal drowning episode. Several of the casualties have also suffered the effects of a nearby underwater explosion while immersed. Challenges in the care of these casualties include delays in evacuation, the logistics of obtaining whole blood for transfusion while at sea, and transporting the casualties to the next higher level of care aboard a Casualty Receiving and Treatment Ship. As the National Defense Strategy pivots to a focus on the potential for maritime combat, the medical community must continue to maintain readiness by preparing fo

Winter 2021 Journal (Vol 21 Ed 4)

Vol 21 Ed 4
Winter 2021 Journal of Special Operations Medicine
ISSN: 1553-9768

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Veterans and Suicide: An Integrative Review of Risk Factors and Suicide Reduction Services

Crawford S, Duffey JM, Doss KM 22(1). 134 - 140 (Journal Article)

Suicide has quickly risen to be among the top threats to humanity the world over, which is most certainly the case for American veterans. Literature has well documented that veterans are at increased suicide risk due to numerous factors associated with military culture. This article examines veterans' suicide reduction services by addressing the identification of veterans at elevated risk of suicide and assessing public-private partnership models that promote effective collaborative outreach and treatment. Essentially, this work appraises the development and procedures of multi-organization systems collaborating to impart novel and effective processes to eliminate suicide as intended by Past-President Trump's Executive Order No. 13,861.1 The essential risk factors associated with the identification of veterans at elevated risk of suicide are reviewed. Public-private partnership models that encourage collaborative and effective outreach and treatment are examined. The implications of this literature review will support mental health providers, researchers, and policymakers in innovative, collaborative, and effective suicide prevention and intervention practices for veterans. Directions for future research are identified to further contribute to efforts to empower veterans and eliminate suicide.

Standardized Patient Methodology in Tactical Medical Education

Tang N, Jones KD, Kemp SJ, Knapp JG 22(1). 130 - 132 (Journal Article)

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