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Worldwide Case Reports Using the iTClamp for External Hemorrhage Control

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.

Comparison of Scapular Manipulation With External Rotation Method of Reduction of Acute Anterior Shoulder Dislocation for Sedation Requirements and Success Rates

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.

Mechanical Forces Experienced by Simulated Patients Evacuated During Dismounted Military Movement in Mountainous Terrain

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.

Your Metric Matters! Choose Wisely to Assess User Performance With Tourniquets in Simulated First Aid

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.

Study of Tourniquet Use in Simulated First Aid: User Judgment

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.

Ultramobile Surgical Set for Austere Damage Control Surgery

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.

Asclepius Snakebite Foundation Update

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

Injuries During High-Intensity Functional Training

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.

Latent TB Infection in USSOF: A Refresher and Update

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.

Centipede Bites

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.

Casualty Evacuation (CASEVAC) Platform Review and Case Series of US Military Enroute Critical Care Team With Contract Personnel Recovery Services in an Austere Environment

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.

Use of Walking Blood Bank at Point of Injury During Combat Operations: A Case Report

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.

Development of a Swine Polytrauma Model in the Absence of Fluid Resuscitation

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.

Updated Considerations for the Use of Anesthesia Gas Machines in a Critical Care Setting During the Coronavirus Disease Pandemic

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.

Emergency Medical Services Provider Self-Reported Occupational Safety

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.

Use of Topical Hemostatic Dressings in an Extended Field Care Model

Welch M, Barratt J, Peters A, Wright C 21(4). 63 - 65 (Journal Article)

Background: We sought to test whether Celox topical hemostatic dressing (Medtrade Products) would maintain hemostasis in extended use. Methods: An anesthetized swine underwent bilateral arteriotomies and treatment with topical hemostatic dressings in line with the Kheirabadi method. The dressings were covered with standard field dressings, and these were visually inspected for bleeding every 2 hours until 8 hours, when the swine was euthanized. Results: There was no evidence of rebleeding at any point up to and including 8 hours. The Celox dressings maintained hemostasis in extended use. Conclusion: Celox topical hemostatic dressing is effective for extended use and maintains hemostasis. It should be considered for use in situations in which evacuation and definitive care may be delayed.

Comprehensive Ultrasound Course for Special Operations Combat and Tactical Medics

Fatima H, Kuppalli S, Baribeau V, Wong VT, Chaudhary O, Sharkey A, Bordlee JW, Leibowitz A, Murugappan K, Pannu A, Rubenstein LA, Walsh DP, Kunze LJ, Stiles JK, Weinstein J, Mahmood F, Matyal R, Lodico DN, Mitchell J 21(4). 54 - 61 (Journal Article)

Background: Advances in ultrasound technology with enhanced portability and high-quality imaging has led to a surge in its use on the battlefield by nonphysician providers. However, there is a consistent need for comprehensive and standardized ultrasound training to improve ultrasound knowledge, manual skills, and workflow understanding of nonphysician providers. Materials and Methods: Our team designed a multimodal ultrasound course to improve ultrasound knowledge, manual skills, and workflow understanding of nine Special Operations combat medics and Special Operations tactical medics. The course was based on a flipped classroom model with a total time of 43 hours, consisting of an online component followed by live lectures and hands-on workshops. The effectiveness of the course was determined using a knowledge exam, expert ratings of manual skills using a global rating scale, and an objective structured clinical skills examination (OSCE). Results: The average knowledge exam score of the medics increased from pre-course (56% ± 6.8%) to post-course (80% ± 5.0%, p < .001). Based on expert ratings, their manual skills improved from baseline to day 4 of the course for image finding (p = .007), image optimization (p = .008), image acquisition speed (p = .008), final image quality (p = .008), and global assessment (p = .008). Their average score at every OSCE station was > 91%. Conclusion: A comprehensive multimodal training program can be used to improve military medics' ultrasound knowledge, manual skills, and workflow understanding for various applications of ultrasound. Further research is required to develop a reliable, sustainable course.

Stress Inoculation Training (SIT-NORCAL), Part 2: A Pilot Study Among Explosive Ordnance Disposal Special Warfare Enablers

Jackson SE, Baity MR, Thomas PR, Walker M, Goodkind M, Swick D, Barba D, Jacobson D, Byrd E, Ivey AS 21(4). 46 - 53 (Journal Article)

Background: Despite being a well-supported strategy, Stress Inoculation Training (SIT) has not been fully incorporated in the advancement of human performance among most military personnel. The RAND Study recommendations for maximizing SIT's potential within high-risk/ high-intensity occupational groups were used in designing the Core Training protocol targeting psychological performance, SIT-NORCAL (Part 1). Purpose: The current project (Part 2) sought to further develop the protocol as a health and human performance hybrid through quality improvement analysis of the content, process, and measurement elements for use in the human performance context. Methods: Evidence-based/evidence-driven methodologies were used in collaborative design tailored to the unique needs of special warfare enablers specializing in Explosive Ordnance Disposal (n = 17). The resultant three-phase training was conducted with a novice group (n = 10) using standardized measurements of collaboration, human performance, and adaptive capabilities on identified training targets. Results: Process elements demonstrated high feasibility, resulting in high collaboration and trainee satisfaction. Significant improvements in psychological performance targets were observed pre- to post-training, and during an Adaptive Environmental Simulation designed by unit members. Two weeks post-training, unit members (n = 5) responded to an actual crash of an F-16 aircraft; measurements indicated maintenance of skill set from training to real-world events. Conclusion: Deployment of the elements in the SIT-NORCAL protocol demonstrated early feasibility and positive training impact on occupationally relevant skills that carried over into real-world events.

Stress Inoculation Training (SIT-NORCAL), Part 1: The Development and Preliminary Evaluation of a Psychological Performance Training Protocol

Jackson SE, Baity MR, Thomas PR, Barba D, Jacobson D, Goodkind M, Swick D, Ivey AS 21(4). 37 - 45 (Journal Article)

Background: Stress inoculation training (SIT) interventions have demonstrated promise within military contexts for human performance enhancement and psychological health applications. However, lack of manualized guidance on core content selection, delivery, and measurement processes has limited their use. Purpose: The purpose of this study was to develop and evaluate a comprehensive SIT intervention protocol to enhance the performance and health of military personnel engaged in special warfare and first-response activities. Methods: Multidisciplinary teams of subject matter experts (n = 19) were consulted in protocol generation. The performance improvement/human performance technology (HPT) model was used in the selection, refinement, and measurement of core skills. The protocol was trialed and refined (44 cohorts, n = ≥300; 2013-2020) to generate the results. Results: Four primary aims were achieved: (1) The generation of a flexible, evidence-based/evidence-driven psychological performance and health sustainment hybrid, SIT-NORCAL. (2) Manualized content and process guidance. (3) The creation of multimedia materials using evidence-based methodologies. (4) The design of initial measurement systems. Preliminary quality improvement analysis demonstrated positive results using standard-of-care and performance enhancement assessments. Conclusion: Hybridized human performance and psychological health sustainment protocols represent a paradigm shift in the delivery of psychological performance training with the potential to overcome barriers to success in traditional care. Further study is needed to determine the effectiveness and reach of SIT-NORCAL.

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