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Laboratory Model of a Collapsible Tube to Develop Bleeding Control Interventions

Griffin LV, Kragh JF, Dubick MA 18(1). 47 - 52 (Journal Article)

Background: To develop knowledge of mechanical control of bleeding in first aid, a laboratory model was set up to simulate flow through a blood vessel. A collapsible tube was used to mimic an artery in two experiments to determine (1) the extent of volumetric flow reduction caused by increases in the degree of compression of the vessel and (2) the extent of flow reduction caused by increases in the length of compression. Methods: Water was used in vertical tubing. Gravity applied a pressure gradient of about 100mmHg to cause flow. A silicone tube (10mm-diameter lumen [the inner opening], 1mm-thick wall, 150mm length) was used. Tests of no compression of the external wall constituted the control group for both experiments. For all groups, flow volume was sampled over a period of time, and six samples were averaged. In both experiments, the study group consisted of tests with compression that was measured as the reduced area of the luminal cross section. In the first experiment, six groups with luminal area reductions of 0% (control), 74%, 81%, 91%, 94%, and 97% were tested. In the second experiment at 74% luminal area reduction, the three lengths of compression were 5mm, 20mm, and 70mm. The measured data were compared with calculated data by applying established mathematical equations. Results: In the first experiment, flow decreased with decreasing area due to luminal compression, but the association was a parabolic curve such that 94% or greater reduction in luminal area was required to reduce flow by greater than 50%. A reduction in luminal area of 97% reduced flow by 95%. In the second experiment, mean flow rates were not significantly different among the three lengths of compression. Measured data and calculated data were in good agreement. Conclusions: Compared with an uncompressed vessel, volumetric flow of water through a single, unsupported collapsible tube in steady, nonpulsatile conditions with compression applied to its external wall to produce a reduction in luminal area of 97% reduced flow by 95%. Flow was affected by the degree of compression but not by the length of compression.

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The Myth of Hyperresilience Evolutionary Concept Analysis of Resilience in Special Operations Forces

Rocklein Kemplin K, Paun O, Sons N, Brandon JW 18(1). 54 - 60 (Journal Article)

Despite many resilience studies and resilience-building initiatives in the military, resilience as a concept remains granularly unexamined, vague, and inconsistently interpreted throughout military-specific research literature. Specifically, studies of military suicide and related mental health constructs assert that Servicemembers in Special Operations Forces (SOF) possess higher levels of resilience without providing an empirical basis for these statements. To provide rigorous evidence for future studies of resilience in SOF, a concept analysis was performed via Rodgers' evolutionary method to contextualize resilience in the SOF community and provide accurate redefinitions on which theoretical and methodological frameworks can be constructed reliably.

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Editorial Response

Keenan S 18(1). 139 - 140 (Editorial)

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Feasibility and Proposed Training Pathway for Austere Application of Resuscitative Balloon Occlusion of the Aorta

Ross EM, Redman TT 18(1). 37 - 43 (Case Reports)

Background: Noncompressible junctional and truncal hemorrhage remains a significant cause of combat casualty death. Resuscitative endovascular balloon occlusion of the aorta (REBOA) is an effective treatment for many junctional and noncompressible hemorrhages. The current hospital standard for time of placement of REBOA is approximately 6 minutes. This study examined the training process and the ability of nonsurgical physicians to apply REBOA therapy in an austere field environment. Methods: This was a skill acquisition and feasibility study. The participants for this experiment were two board-certified military emergency medicine physicians with no prior endovascular surgery exposure. Both providers attended two nationally recognized REBOA courses for training. A perfused cadaver model was developed for the study. Each provider then performed REBOA during different phases of prehospital care. Time points were recorded for each procedure. Results: There were 28 REBOA catheter placement attempts in 14 perfused cadaver models in the nonhospital setting: eight placements in a field setting, eight placements in a static ambulance, four placements in a moving ambulance, and eight placements inflight on a UH-60 aircraft. No statistically significant differences with regard to balloon inflation time were found between the two providers, the side where the catheter was placed, or individual cadaver models. Successful placement was accomplished in 85.7% of the models. Percutaneous access was successful 53.6% of the time. The overall average time for REBOA placement was 543 seconds (i.e., approximately 9 minutes; median, 439 seconds; 95% confidence interval [CI], 429-657) and the average placement time for percutaneous catheters was 376 seconds (i.e., 6.3 minutes; 95% CI, 311-44 seconds) versus those requiring vascular cutdown (821 seconds; 95% CI, 655-986). Importantly, the time from the decision to convert to open cutdown until REBOA placement was 455 seconds (95% CI, 285-625). Conclusion: This study demonstrated that, with proper training, nonsurgical providers can properly place REBOA catheters in austere prehospital settings at speeds

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Versatility With Far Forward Damage Control Surgery: Successful Resuscitative Thoracotomy in an HH-60 Black Hawk

Pieper MA, Vonderharr MJ, Knutson TL, Sullivan JL, Allison CG, Englert Z 19(1). 20 - 22 (Case Reports)

The military conflicts of the past 17 years have taught us many lessons, including the evolution of the tiered trauma system with en route resuscitation. The evolution of the conflict has begun to limit the reach of this standard trauma system. Recent evidence suggests that 95% of early deaths resulting from traumatic injuries may be prevented if the patient can undergo damage control surgery within 23 minutes of injury. US Military Surgical Resuscitation Teams have been developed to shorten this time from injury to surgical care, as illustrated by this case report.

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Bringing Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) Closer to the Point of Injury

Pasley JD, Teeter WA, Gamble WB, Wasick P, Romagnoli AN, Pasley AM, Scalea TM, Brenner ML 18(1). 33 - 36 (Case Reports)

Background: The management of noncompressible torso hemorrhage remains a significant issue at the point of injury. Resuscitative endovascular balloon occlusion of the aorta (REBOA) has been used in the hospital to control bleeding and bridge patients to definitive surgery. Smaller delivery systems and wirefree devices may be used more easily at the point of injury by nonphysician providers. We investigated whether independent duty military medical technicians (IDMTs) could learn and perform REBOA correctly and rapidly as assessed by simulation. Methods: US Air Force IDMTs without prior endovascular experience were included. All participants received didactic instruction and evaluation of technical skills. Procedural times and pretest/posttest examinations were administered after completion of all trials. The Likert scale was used to subjectively assess confidence before and after instruction. Results: Eleven IDMTs were enrolled. There was a significant decrease in procedural times from trials 1 to 6. Overall procedural time (± standard deviation) decreased from 147.7 ± 27.4 seconds to 64 ± 8.9 seconds (ρ < .001). There was a mean improvement of 83.7 ± 24.6 seconds from the first to sixth trial (ρ < .001). All participants demonstrated correct placement of the sheath, measurement and placement of the catheter, and inflation of the balloon throughout all trials (100%). There was significant improvement in comprehension and knowledge between the pretest and posttest; average performance improved significantly from 36.4.6% ± 12.3% to 71.1% ± 8.5% (ρ < .001). Subjectively, all 11 participants noted significant improvement in confidence from 1.2 to 4.1 out of 5 on the Likert scale (ρ < .001). Conclusion: Technology for aortic occlusion has advanced to provide smaller, wirefree devices, making field deployment more feasible. IDMTs can learn the steps required for REBOA and perform the procedure accurately and rapidly, as assessed by simulation. Arterial access is a challenge in the ability to perform REBOA and should be a focus of further training to promote this procedure closer to the point of injury. Keywords: hemorrhage control; independent duty medical technician; resuscitative endovascular balloon occlusion of the aorta; REBOA

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Unstable Pelvic Fracture Reduction Under Ultrasonographic Control

Goudard Y, Camus D, de Landevoisin ES, Dobost C, Domos P, Balandraud P 19(1). 16 - 18 (Case Reports)

Managing acute trauma cases in military and low-resource environments usually requires adapted medicosurgical protocols to achieve best medical results with limited technical capacity. We report a case of unstable pelvic fracture that needed ultrasonographic assessment for closed reduction before external stabilization. In our opinion, ultrasonographic control should be considered as a useful technique for unstable pelvic fracture reduction and an alternative to radiographic control.

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Patella Fracture in US Servicemember in an Austere Location

Schermerhorn SM, Auchincloss PJ, Kraft K, Nelson KJ, Pamplin JC 18(1). 142 - 144 (Journal Article)

Objective: Review the management of a patient with acute patella fracture supported by telemedical consultation. Clinical Context: Regionally Aligned Forces (RAF) supporting US Army Africa/Southern European Task Force (USARAF/ SETAF) in Africa Command area of responsibility. Care was provided by a Role I facility on the compound. Organic Expertise: Three 68W combat medics; one Special Operations Combat Medic (SOCM). Closest Medical Support: Organic battalion physician assistant (PA) located in the United States; USARAF PA located in a European country; French Role II located in nearby West African country; telemedical consults via e-mail, phone, or videoteleconsultation. Earliest Evacuation: Estimated at 12 to 24 hours with appropriate clearances.

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An Unusual Wound Infection Due to Acinetobacter junii on the Island of Oahu: A Case Report

Griffin J, Barnhill JC, Washington MA 19(1). 14 - 15 (Case Reports)

The genus Acinetobacter has long been associated with war wounds. Indeed, A baumannii was responsible for so many infected wounds during Operation Iraqi Freedom that it was given the nickname "Iraqibacter." Therefore, it is important to monitor the occurrence and spread of Acinetobacter species in military populations and to identify new or unusual sources of infection. A junii is an infrequently reported human pathogen. Here, we report a case of a slow-healing wound infection with A junii in a woman on the island of Oahu. This case highlights the pathogenic potential of this organism and the need for proper wound care when dealing with slow-healing wounds of unknown etiology. It also underscores the need for identifying species of Acinetobacter that are not A baumannii to better understand the epidemiology of slow-healing wound infections.

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Adapting to Death: Clarifying the Roles of Special Operations Combat Medics in Prolonged Field Care

Jeschke EA 18(4). 153 - 156 (Journal Article)

I suggest that Special Operations Forces (SOF) medicine should explicitly acknowledge the Special Operations combat medic's role in attending death. This acknowledgment will allow researchers to evaluate and delimit the medic's needs in relationship to an expanded set of roles that move beyond life-saving care. This article comprises four sections. First, I provide background to my argument by exploring some assumptions of modern medicine and objections to exploring battlefield death care. Second, I describe how I see the medic's role expanding with the introduction of prolonged field care. Third, I address the implications of the medic's expanded role in relationship to role and function stress and strain. Fourth, I address the moral complexity related to withdrawing or withholding care. I conclude by briefly highlighting some of the implications for future research. In explicitly engaging death as a medical reality for which the medic ought to be prepared, SOF medicine could set the foundational development for seeing death as a valuable gift to be explored, not a failure to be avoided or burden to be overcome.

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Effects of Oral Glucosamine Sulfate on Osteoarthritis-Related Pain and Joint-Space Changes: Systematic Review and Meta-Analysis

Knapik JJ, Pope R, Hoedebecke SS, Schram B, Orr R, Lieberman HR 18(4). 139 - 147 (Journal Article)

Background: Osteoarthritis (OA) is a disorder involving deterioration of articular cartilage and underlying bone and is associated with symptoms of pain and disability. Glucosamine is a component of articular cartilage naturally synthesized in the body from glucose and incorporated into substances contained in the cartilage. It has been suggested that consumption of glucosamine may reduce the pain of OA and may have favorable effects on structural changes in the cartilage. This article presents a systematic review and meta-analysis of the effectiveness of orally consumed glucosamine sulfate (GS) on OA-related pain and joint structural changes. Methods: PubMed and Ovid Embase were searched using specific search terms to find randomized, double-blinded, placebo-controlled trials on the effects of GS on pain and/or joint-space narrowing. The outcome measure was the standardized mean difference (SMD), which was the improvement in the placebo groups minus the improvement in the GS groups divided by the pooled standard deviation. Results: There were 17 studies meeting the review criteria for pain, and the summary SMD was -0.35, with a 95% confidence interval (95% CI) = -0.54 to -0.16 (negative SMD is in favor of GS). Of the 17 studies, 7 showed a statistically significant reduction in pain from GS use. Four studies met the review criteria for joint space narrowing with a summary SMD = -0.10 (95% CI = -0.23 to +0.04). Studies without involvement of the commercial glucosamine industry had a lower (but still significant) pain reduction efficacy (summary SMD = -0.19, 95% CI = -0.39 to -0.02) than those with industry involvement. Several smaller dosages throughout the day had larger pain reduction effects than a single daily large dose (1500 mg). Conclusion: These data indicate that GS may have a small to moderate effect in reducing OA-related pain but little effect on joint-space narrowing. Until there is more definitive evidence, healthcare providers should be cautious in recommending use of GS to their patients. Because GS dosages used in studies to date resulted in mild and transient adverse effects, and these were similar to that experienced by patients receiving placebos, larger GS doses possibly could be investigated in future studies.

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Thrown for a Loop

Urbaniak MK, Hampton K 18(4). 148 (Journal Article)

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What the SOF Community Needs to Know About Dietary Supplements

Deuster PA 18(4). 131 - 136 (Journal Article)

Dietary supplement (DS) use by military members and Special Operations Forces (SOF), in particular, is high. The "sports nutrition" market is expected to be one of the fastest growing segments because a "performance edge" is certainly desirable within the military. DS products are readily available in retail stores on military bases, over the Internet, and in niche stores near military bases. Thus, use of some DSs raises a number of unique concerns, particularly considering the potential for interactions among combinations of DS ingredients and concurrent medications taken under military operational conditions. All those who work with SOF should have a basic understanding of the DS world. This article briefly reviews selected DS regulations, identifies concerns and risks related to various DS products, and describes the purpose, functions, and resources of Operation Supplement Safety. Examples of regulatory concerns, adverse events, red flags, and tools are provided to help SOF communities sustain their health and performance.

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Tetanus

Burnett MW 18(4). 137 - 138 (Journal Article)

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Clinical Update: Concepts of Prehospital Traumatic Hemorrhage Control in the Operational K9

Palmer LE 18(4). 123 - 130 (Journal Article)

Major trauma often involves varying degrees of hemorrhage. Left unattended, any amount of trauma-induced hemorrhage may rapidly become life threatening. Similar to humans, Operational canines (OpK9s) can suffer penetrating trauma and blunt trauma that lead to compressible and noncompressible hemorrhage. Preserving organ function and saving the life of a massively bleeding OpK9 require the implementation of immediate and effective hemostatic measures. Effective hemorrhage control interventions for the exsanguinating OpK9 are similar to those for humans: direct pressure, wound packing, hemostatic agents and devices, pressure bandage, and, possibly, tourniquet application. Although tourniquet application is a life-saving intervention in humans experiencing extremity hemorrhage, it is not considered a necessary, immediate-action life-saving intervention for canines with extremity injuries. This article provides a brief description of the basic methods for identifying life-threatening hemorrhage and achieving immediate hemostasis in the bleeding OpK9 during the prehospital period.

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The Benefits of Reflexology for the Chronic Pain Patient in a Military Pain Clinic

Kern C, McCoart A, Beltranm T, Martoszek M 18(4). 103 - 105 (Journal Article)

Background: Chronic pain is a major cause of disability across the military, especially for the combat Soldier. More than twothirds of Americans with chronic pain are now using complementary medicine. Methods: Patients with chronic pain opting for reflexology as part of their treatment plan received bilateral therapy. Alternating pressure was applied to the individual patient's reflex points corresponding to their pain sites. Following a single treatment session, patients were asked to complete a short survey. Discussion: There is evidence that reflexology is therapeutic for many conditions, to include sleep and anxiety, both of which can be comorbidity in the patient with chronic pain. There is a lack of evidence on the use of reflexology with chronic pain patients receiving multidisciplinary pain care. Results: A total of 311 participants completed the survey. Posttreatment pain scored decreased by a median of 2 points (interquartile range [IQR] 1-3) on a 10-point pain scale. This represents a median 43% (IQR 25%-60%) reduction in pain for males and a 41% (IQR 30%-60%) reduction in pain for females. Conclusion: Currently research is limited on effects of reflexology in treating chronic pain, yet, like acupuncture, this is an inexpensive, reliable, teachable, and simple noninvasive treatment. Further studies are warranted.

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Efficacy of the Abdominal Aortic Junctional Tourniquet-Torso Plate in a Lethal Model of Noncompressible Torso Hemorrhage

Bonanno AM, Hoops HE, Graham T, Davis BL, McCully BH, Wilson LN, Madtson BM, Ross JD 18(4). 106 - 110 (Journal Article)

Background: The Abdominal Aortic Junctional Tourniquet, when modified with an off-label, prototype, accessory pressure distribution plate (AAJT-TP), has the potential to control noncompressible torso hemorrhage in prolonged field care. Methods: Using a lethal, noncompressible torso hemorrhage model, 24 male Yorkshire swine (81kg-96kg) were randomly assigned into two groups (control or AAJT-TP). Anesthetized animals were instrumented and an 80% laparoscopic, left-side liver lobe transection was performed. At 10 minutes, the AAJT-TP was applied and inflated to an intraabdominal pressure of 40mmHg. At 20 minutes after application, the AAJT-TP was deflated, but the windlass was left tightened. Animals were observed for a prehospital time of 60 minutes. Animals then underwent damage control surgery at 180 minutes, followed by an intensive care unit-phase of care for an additional 240 minutes. Survival was the primary end point. Results: Compared with Hextend, survival was not significantly different in the AAJT-TP group (ρ = .564), nor was blood loss (3.3L ± 0.5L and 3.0L ± 0.5L, respectively; p = .285). There was also no difference in all physiologic parameters between groups at the end of the study or end of the prehospital phase. Three of 12 AAJT-TP animals had an inferior vena cava thrombus. Conclusion: The AAJT-TP did not provide any survival benefit compared with Hextend alone in this model of noncompressible torso hemorrhage.

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Effect of Spearmint Extract Containing Rosmarinic Acid on Physical and Executive Functioning After a Tactical Operation

Ostfeld I, Ben-Moshe Y, Hoffman MW, Shalev H, Hoffman JR 18(4). 92 - 96 (Journal Article)

We examined the effect of a proprietary spearmint extract containing rosmarinic acid (PSE) on physical, cognitive, and executive functioning of study participants after a high-risk tactical operation while sleep deprived for 24 hours. Ten Operators (mean ± standard deviation: age, 35.1 ± 5.2 years; height, 177.6 ± 5.3cm; weight, 81.3 ± 9.3kg) from an elite counterterrorism unit volunteered to participate in this randomized, double-blind, parallel-design study. Participants were randomly assigned into either the PSE or placebo (PL) group and ingested 900mg/day PSE or an equivalent amount of PL for 17 days. Physical, cognitive, and executive functioning was tested before PST supplementation (PRE) and within 1 hour of the operation's conclusion (POST). Magnitude-based inferences indicated that differences between PSE and PL in jump power, reactive agility, eye-hand coordination, and cognition were unclear. However, subjective feelings of energy, alertness, and focus were very likely, likely, and possibly better for PSE than PL, respectively. There was no difference (ρ = .64) between groups in identifying the correct target; however, all participants in the PSE group correctly identified the target, whereas 60% of participants in the PL group correctly identified the target at POST. Although the results of this study do not provide conclusive evidence regarding the efficacy of PSE, they do suggest additional research is warranted in a larger sample of participants.

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