Articles

Farber SJ, Kantar RS, Rodriguez ED 18(3). 62 - 66 (Journal Article)

As the United States continues to increase its use of Special Operations Forces worldwide, treatment of craniomaxillofacial (CMF) trauma must be adapted to meet the needs of the warfighter. The remoteness of Special Operations can result in potentially longer times until definitive treatment may be reached. A significant portion of Servicemembers incur injury to the CMF region (42%). Severe CMF trauma can result in substantial hemorrhage and airway compromise. These can be immediately life threatening and must be addressed expeditiously. Numerous devices and techniques for airway management have been made available to the forward provider. A thorough review of nonsurgical and surgical airway management of the patient with facial injury for the forward provider and providers at receiving facilities is provided in this article. Techniques to address flail segments of the facial skeleton are critical in minimizing airway compromise in these patients. There are many methods to control hemorrhage from the head and neck region. Hemorrhage control is critical to ensure survival in the austere environment and allow for transport to a definitive care facility. Associated injuries to the cervical spine, globe, skull base, carotid artery, and brain must be carefully evaluated and addressed in these patients. Management of vision- threatening orbital compartment syndrome is critical in patients with CMF injuries. Because the head and neck region remains relatively vulnerable in the warfighter, combat CMF trauma will continue to occur. Forward providers will benefit from a review of the acute treatment of CMF traumatic injury. Properly triaging and treating facial injuries is necessary to afford the best chance of survival for patients with a devastating combat CMF injury.

Reed JR, Carman MJ, Titch FJ, Kotwal RS 18(3). 57 - 61 (Journal Article)

Background: In the prehospital environment, nonmedical first responders are often the first to arrive on the scene of a traumatic event and must be prepared to provide initial care at the point of injury. In civilian communities, these nonmedical first responders often include law enforcement officers. Hemorrhage is a major cause of death in trauma, and many of these deaths occur in the prehospital environment; therefore, prehospital training efforts should be directed accordingly toward bleeding control. Methods: A bleeding control training program was implemented and evaluated in a rural police department in Pinehurst, North Carolina, from February to April 2017. A repeated measures observational study was conducted to evaluate the training program. Measured were self-efficacy (pre- and post-test), knowledge (pretest, post-test 1 [immediate], post-test 2 [at 4 weeks]), and limb-tourniquet application time (classroom, simulation exercise). Results: The study population was composed of 28 police officers (92.9% male) whose median age was 37 (interquartile range, 22-55) years. Mean self-efficacy scores, equating to user confidence and the decision to intervene, increased from pre- to post-training (34.54 [standard deviation (SD) 4.16] versus 35.62 [SD 4.17]; p = .042). In addition, mean knowledge test scores increased from pre- to immediately post-training (75.00 [SD 16.94] versus 85.83 [SD 11.00]; p = .006), as well as from preto 4 weeks post-training (75.00 [SD 16.94] versus 84.17 [SD 11.77]; p = .018). Lower limb-tourniquet application times were more rapid in the classroom than during the simulation exercise (23.06 seconds [SD 7.68] versus 31.91 seconds [SD 9.81]; p = .005). Conclusion: First-responder bleeding-control programs should be initiated and integrated at the local level throughout the Nation. Implementation and sustainment of such programs in police departments can save lives and enhance existing law enforcement efforts to protect and serve communities.

Auten JD, Mclean JB, Kemp JD, Roszko PJ, Fortner GA, Krepela AL, Walchak AC, Walker CM, Deaton TG, Fishback JE 18(3). 50 - 56 (Journal Article)

Background: Intraosseous (IO) access is used by military first responders administering fluids, blood, and medications. Current IO transfusion strategies include gravity, pressure bags, rapid transfusion devices, and manual push-pull through a three-way stopcock. In a swine model of hemorrhagic shock, we compared flow rates among four different IO blood transfusion strategies. Methods: Nine Yorkshire swine were placed under general anesthesia. We removed 20 to 25mL/kg of each animal's estimated blood volume using flow of gravity. IO access was obtained in the proximal humerus. We then autologously infused 10 to 15mL/kg of the animal's estimated blood volume through one of four randomly assigned treatment arms. Results: The average weight of the swine was 77.3kg (interquartile range, 72.7kg-88.8kg). Infusion rates were as follows: gravity, 5mL/min; Belmont rapid infuser, 31mL/min; single-site pressure bag, 78mL/min; double-site pressure bag, 103mL/min; and push-pull technique, 109mL/min. No pulmonary arterial fat emboli were noted. Conclusion: The optimal IO transfusion strategy for injured Servicemembers appears to be single-site transfusion with a 10mL to 20mL flush of normal saline, followed immediately by transfusion under a pressure bag. Further study, powered to detect differences in flow rate and clinical complications. is required.

Hindorf M, Lundberg L, Jonsson A 18(3). 45 - 49 (Journal Article)

Background: The Swedish naval specialized boarding element participated in Operation Atalanta in 2013 to mitigate piracy by escorting and protecting ships included in the United Nations World Food Program in the Indian Ocean. We describe the experiences of the Swedish naval specialized boarding-element members during 4 months of international naval hostile duty. Some studies have reported experiences of naval duty for the Coast Guard or the merchant fleet; however, we did not find any studies that identified or described experiences of long-time duty onboard ship for the naval armed forces. Materials and Methods: The respondents wrote individual notes of daily events while onboard. Conventional content analysis was used on the collected data, using an inductive approach. Results: The findings revealed three broad themes: military preparedness, coping with the naval context, and handling physical and mental strain. Different categories emerged indicating that the participants need the ability to adapt to the naval environment and to real situations. Conclusion: The Swedish naval forces should train their specialized element members in coping strategies.

McKee JL, Kirkpatrick AW, Bennett BL, Jenkins DA, Logsetty S, Holcomb JB 18(3). 39 - 44 (Journal Article)

Background: Historically, hemorrhage control strategies consisted of manual pressure, pressure dressings, gauze with or without hemostatic ingredients for wound packing, or the use of tourniquets. The iTClamp is a relatively new alternative to stop external bleeding. Methods: An anonymous survey was used to evaluate the outcomes of the iTClamp in worldwide cases of external bleeding. Results: A total of 245 evaluable applications were reported. The iTClamp stopped the bleeding in 81% (n = 198) of the cases. Inadequate bleeding control was documented in 8% (n = 20) and in the remaining 11% (n = 27), bleeding control was not reported. The top three anatomic body regions for iTClamp application were the scalp, 37% (n = 91); arm, 20% (n = 49); and leg, 19% (n = 46). In 26% of the reported cases (direct pressure [23% (n = 63)] and tourniquets [3% (n = 8]), other techniques were abandoned in favor of the iTClamp. Conversely, the iTClamp was abandoned in favor of direct pressure 11 times (4.4%) and abandoned in favor of a tourniquet three times (1%). Conclusion: The iTClamp appears to be a fast and reliable device to stop external bleeding. Because of its function and possible applications, it has potential to lessen the gap between and add to the present selection of devices for treatment of external bleeding.

Adhikari S, Koirala P, Kafle D 18(3). 34 - 37 (Journal Article)

Background: Anterior shoulder dislocation is a common sports-related musculoskeletal injury. Various methods have been described for reduction of the dislocation. A method that requires less sedation without compromising the success rate is likely to be highly useful in austere and prehospital settings. This study compares scapular manipulation with external rotation method for requirement of sedation and success rates. Methods: Forty-six patients with anterior shoulder dislocation were allocated alternatively to reduction using either scapular manipulation (SMM) or external rotation (ERM) techniques. The groups were compared for sedation requirements, pain scores, and success rates. Results: Reductions using SMM had fewer requirements for sedation (13% versus 39%; p < .05) and higher first-pass success rates (87% versus 61%; p < .05) as compared with ERM for anterior shoulder dislocation reduction. The numeric rating score of pain during reduction procedures was less in SMM (mean, 1.65 [standard deviation, 1.6]) than in ERM group (mean, 4.30 [standard deviation, 1.8]; p < .01). Conclusion: The SMM required less sedation and had higher first-pass success rates than ERM for reduction of anterior shoulder dislocation. The SMM is thus likely to be of advantage in resource-limited austere settings.

Florance JM, Florance C 18(3). 28 - 32 (Journal Article)

Background: Given a denied or resource-limited area of operations, when air medical evacuation would require extended delay, should dismounted movement through difficult terrain dissuade an attempt of immediate ground evacuation? Understanding the magnitude of external forces during dismounted movement would inform planning in such circumstances. Objectives: We assessed the mechanical impact experienced during dismounted evacuation from mountainous terrain. We also describe a protocol using a portable accelerometer to evaluate evacuation. Materials and Methods: A triaxial accelerometer and a semiflexible litter were used to collect data during the Army Mountain Warfare School Rough Terrain Evacuation Course. We used the generalized extreme value (GEV) distribution, using maximum likelihood estimation, to model maximum acceleration values. Results: It was determined that the accelerometer should be mounted directly onto a mannequin when using semiflexible litters. GEV analysis from a mannequin-mounted trial revealed that for 1-minute evacuation intervals, 10% would have a maximum acceleration over a value between 2.4g and 3.7g. This interval encompasses the maximum acceleration from evacuation using a Mine-Resistant Ambush Protected (MRAP) vehicle, measured by the US Army Aeromedical Research Laboratory. The peak acceleration from a 75-minute, mannequin-mounted trial was 5.5g, approximately twice as large as the MRAP maximum. Conclusion: For the evacuee, the acceleration experienced during dismounted evacuation in mountainous terrain can be comparable to MRAP evacuation, especially with sufficient planning that avoids points of maximum impact. Leaders can consider this comparison during planning.

Zhao NO, Kragh JF, Aden JK, Jordan BS, Parsons DL, Dubick MA 18(3). 22 - 27 (Journal Article)

Background: Readiness to perform lifesaving interventions during emergencies is based on a person's preparation to proficiently execute the skills required. Graphically plotting the performance of a tourniquet user in simulation has previously aided us in developing our understanding of how the user actually behaves. The purpose of this study was to explore performance assessment and learning curves to better understand how to develop best teaching practices. Methods: These were retrospective analyses of a convenience sample of data from a prior manikin study of 200 tourniquet uses among 10 users. We sought to generate hypotheses about performance assessments relevant to developing best teaching practices. The focus was on different metrics of user performance. Results: When one metric was chosen over another, failure counts summed cumulatively over 200 uses differed as much as 12-fold. That difference also indicated that the degree of challenge posed to user performance differed by the metric chosen. When we ranked user performance with one metric and then with another, most (90%; nine of 10) users changed rank: five rose and four fell. Substantial differences in performance outcomes resulted from the difference in metric chosen, which, in turn, changed how the outcome was portrayed and thus interpreted. Hypotheses generated included the following: The usefulness of a specific metric may vary by the user's level of skill from novice to expert; demonstration of the step order in skill performance may suffice for initial training of novices; a mechanical metric of effectiveness, like pulse stoppage, may aid in later training of novices; and training users how to practice on their own and self-assess performance may aid their self-development. Conclusion: The outcome of the performance assessments varied depending on the choice of metric in this study of simulated use of tourniquets.

Kragh JF, Tan AR, Newton NJ, Aden JK, Dubick MA 18(3). 15 - 21 (Journal Article)

Background: The purpose of this study was to survey the judgments of tourniquet users in simulation to discern opportunities for further study. Methods: The study design constituted two parts: questions posed to four tourniquet users and then their tourniquet use was surveyed in simulated first aid, where the users had to decide how to perform among five different cases. The questions addressed judged confidence, blood volumes, a reason bleeding resumes, regret of preventable death, hemorrhage assessment, need for side-by-side use of tourniquets, shock severity, predicting reliability, and difference in blood losses. The mechanical performance was tested on a manikin. Case 1 had no bleeding. Case 2 had limb-wound bleeding that indicated tourniquet use in first aid. Case 3 was like case 2, except the patient was a child. Case 4 was like case 2, except caregiving was under gunfire. Case 5 was like case 4, but two tourniquets were to be used side by side. Each user made tests of the five cases to constitute a block. Each user had three blocks. Case order was randomized within blocks. The study had 60 tests. Results: In answering questions relevant to first-aid use of limb tourniquets, judgments were in line with previous studies of judgment science, and thus were plausibly applicable. Mechanical performance results on the manikin were as follows: 38 satisfactory, 10 unsatisfactory (a loose tourniquet and nine incorrect tourniquet placements), and 12 not applicable (case 1 needed no mechanical intervention). For cases 1 to 5, satisfactory results were: 100%, 83%, 100%, 75%, and 58%, respectively. For blocks 1 to 3, satisfactory results were 50%, 83%, and 83%, respectively. Conclusion: For tourniquet use in simulated first aid, the results are plausibly applicable because user judgments were coherent with those in previous studies of judgment science. However, the opportunities for further studies were noted.

Lundy JB, Sparkman BK, Sleeter JJ, Steinberger Z, Remick KN 21(4). 118 - 123 (Journal Article)

The authors describe an equipment list for an ultramobile, surgeon-carried equipment set that is specifically designed for missions that require the extremes of constraints on personnel and resources conducted outside the ring of golden hour access to damage control surgery (DCS) capabilities.

Benjamin JM 21(4). 116 - 117 (Journal Article)

Knapik JJ 21(4). 112 - 115 (Journal Article)

High-intensity functional training (HIFT) involves high-volume and high-intensity physical activities with short rest periods between movements and the use of multiple-joint exercises. This paper analyzes narrative and systematic reviews covering studies of injuries sustained during HIFT. Two narrative and six systematic reviews on injuries during HIFT were identified. Seven reviews concluded that the injury incidences or injury rates during HIFT were similar to those of comparable sports and exercise programs. The most often injured anatomic locations were shoulders, backs, and knees. The most comprehensive and recent review involved 21 retrospective and three prospective studies. In this review, mean ± standard deviation (SD) injury prevalence was 35% ± 15%, the injury rate was approximately 3 ± 5 injuries/1,000 hours of training, and the prevalence of injuries requiring surgery was 6% ± 5%. Most injuries were associated with weightlifting exercises, especially deadlifts, snatches, clean and jerks, and overhead presses. Other risk factors included participation time in HIFT, participation in competition, prior injuries, weekly training frequency, male sex, older age, and alternating training loads. Although most studies included in these reviews were of lower methodologic quality, current evidence suggests that injury rates in HIFT are similar to those of other exercise activities. More high-quality prospective studies are needed to fully evaluate HIFT safety.

Tang SH, Evans JD, Vostal A, Shishido AA 21(4). 108 - 111 (Journal Article)

Tuberculosis (TB) causes approximately 2 million deaths annually worldwide, with 2 billion persons estimated to be actively infected with TB. While rates of active TB disease in the US military are low, military service in TB-endemic countries remains an uncommon, but important source of infection. United States Special Operations Forces (USSOF) and enablers often operate in TB-endemic countries and, as an inherent risk of their mission sets, are more likely to have high-risk exposure to TB disease. Military medical authorities have provided excellent diagnostic guidance; the Centers for Disease Control and Prevention (CDC) recently updated preferred regimens for the treatment of latent TB infection (LTBI). This review serves as a refresher and update to the management of LTBI in USSOF to optimize medical readiness through targeted testing and short treatment regimens.

Randich HB, Burnett MW 21(4). 106 - 107 (Journal Article)

The genus Scolopendra includes large centipedes that inhabit tropical regions of Southeast Asia and the Pacific Islands as well as South America and the Southwestern US. They are capable of inflicting a clinically significant venomous bite. These multilegged arthropods may enter tents or buildings at night in search of prey and tend to hide in bedding and clothing. Presentation and management are discussed.

Anonymous A 21(4). 104 - 105 (Journal Article)

The Centers for Disease Control and Prevention warned that two people are dead and two have recovered after being infected with the bacterial disease melioidosis - a disease that had never before been detected on contiguous US soil. The cases occurred between March and July 2021 in Georgia, Kansas, Texas, and Minnesota. Melioidosis, also called Whitmore's disease, is an infectious disease that can infect humans or animals. The disease is caused by the bacterium Burkholderia pseudomallei. It is predominately a disease of tropical climates, especially in Southeast Asia and northern Australia where it is widespread.

Boyer NL, Mazarella JA, Thronson EE, Brillhart DB 21(4). 99 - 103 (Journal Article)

In a rapidly changing operational environment, in which there has been an emphasis on prolonged field care and limited evacuation platforms, military providers must practice to the full scope of their training to maximize outcomes. In addition to pushing military providers further into combat zones, the Department of Defense has relied on contracted personnel to help treat and evacuate servicemembers. This article is a retrospective review on the interoperability of the expeditionary resuscitative surgical team (ERST) and a contracted personnel recovery (CPR) team in a far-forward austere environment and will discuss actual patient transport case reviews that used multiple evacuation platforms across thousands of miles of terrain. To effectively incorporate CPR personnel into a military transport team model, we recommend including cross-training on equipment and formularies, familiarization with CPR evacuation platforms, and mass casualty (MASCAL) exercises that incorporate the different platforms available.

Gaddy M, Fickling A, Hannick VC, Shackelford SA 21(4). 94 - 98 (Journal Article)

The US Military Tactical Combat Casualty Care guidelines recommend blood products as the preferred means of fluid resuscitation in trauma patients;, however, most combat units do not receive blood products prior to executing combat operations. This is largely due to logistical limitations in both blood supply and transfusion equipment. Further, the vast majority of medics are not trained in transfusion protocol. For many medics, the logistical constraints for cold-stored blood products favor the use of Walking Blood Bank (WBB), however few cases have been reported of WBB implementation at the point of injury during real world combat operations. This case report reviews one case of successful transfusion using WBB procedures at point of injury during combat. It highlights not only the feasibility, but also the necessity, for implementation of this practice on a larger scale.

Abdou H, Patel N, Edwards J, Richmond MJ, Elansary N, Du J, Poliner D, Morrison JJ 21(4). 77 - 82 (Journal Article)

Background: In locations in which access to resuscitative therapy may be limited, treating polytraumatized patients present a challenge. There is a pressing need for adjuncts that can be delivered in these settings. To assess these adjuncts, a model representative of this clinical scenario is necessary. We aimed to develop a hemorrhage and polytrauma model in the absence of fluid resuscitation. Materials and Methods: This study consisted of two parts: pulmonary contusion dose-finding (n = 6) and polytrauma with evaluation of varying hemorrhage volumes (n = 6). We applied three, six, or nine nonpenetrating captive bolt-gun discharges to the dose-finding group and obtained computed tomography (CT) images. We segmented images to assess contusion volumes. We subjected the second group to tibial fracture, pulmonary contusion, and controlled hemorrhage of 20%, 30%, or 40% and observed for 3 hours or until death. We used Kaplan-Meier analysis to assess survival. We also assessed hemodynamic and metabolic parameters. Results: Contusion volumes for three, six, and nine nonpenetrating captive bolt-gun discharges were 24 ± 28, 50 ± 31, and 63 ± 77 cm3, respectively (p = .679). Animals receiving at least six discharges suffered concomitant parenchymal laceration, whereas one of two swine subjected to three discharges had lacerations. Mortality was 100% at 12 and 115 minutes in the 40% and 30% hemorrhage groups, respectively, and 50% at 3 hours in the 20% group. Conclusion: This study characterizes a titratable hemorrhage and polytrauma model in the absence of fluid resuscitation. This model can be useful in evaluating resuscitative adjuncts that can be delivered in areas remote to healthcare access.

Wickens CD, Delmonaco BL, Pelleg T 21(4). 71 - 76 (Journal Article)

The latest surge of the coronavirus disease 2019 (SARS-CoV-2 virus) pandemic continues to create an unprecedented need for mechanical ventilation in critically ill patients. The U.S. Food and Drug Administration (FDA) recognized that the additional need for ventilators, on March 22, 2020 and issued guidance outlining a policy intended to help increase availability of relevant technologies. The FDA included guidance for healthcare facilities facing shortages of mechanical ventilators to consider alternative devices capable of delivering breaths or pressure support including anesthesia machines. Anesthesia machine manufacturers have published guidelines for the off-label use of anesthesia machines in critical care settings. Capable of providing mechanical ventilation, anesthesia machines do not deliver ventilation modes and flow capabilities commonly used outside the operating room (OR). A paucity of published information exists to describe the operation of anesthesia machines, their technological and practical limitations, and special considerations to prevent harm when re-purposed. We provide technical information and practical guidance for the safe use of anesthesia machines in critically ill patients outside the OR.

Luk JH, Chang BF, Albus ML, Morgan SA, Szymanski TJ, Hamid OS, Keller L, Daher AF, Sheele JM 21(4). 66 - 70 (Journal Article)

Background: Emergency medical services (EMS) providers are at high risk for occupational violence, and some tactical EMS providers carry weapons. Methods: Anonymous surveys were administered to tactical and nontactical prehospital providers at 180 prehospital agencies in northeast Ohio between September 2018 and March 2019. Demographics were collected, and survey questions asked about workplace violence and comfort level with tactical EMS carrying weapons. Results: Of 432 respondents, 404 EMS providers (94%) reported a history of verbal or physical assault on scene, and 395 (91%) reported working in a setting with a direct active threat at least rarely. Of those reporting a history of assault on scene, 46.5% reported that it occurred at least sometimes. Higher rates of assault on scene were associated with being younger, white, or an emergency medical technician-paramedic, working in an urban environment, having more frequent direct active threats, and having more comfort with tactical EMS carrying firearms (p ≤ .03). Most respondents (306; 71%) reported that they were prepared to defend themselves from someone who originally called for help. Most (303; 70%) reported a comfort level of 8 or higher (from 1, not comfortable to 10, completely comfortable) with tactical EMS providers carrying weapons. Comfort with tactical EMS providers carrying weapons was associated with being white, not having a bachelor's degree, and feeling prepared to defend oneself from a patient (p ≤ .02). Conclusion: EMS providers in the survey report high rates of verbal and physical violence while on scene and are comfortable with tactical EMS providers carrying weapons.