Articles

Wall PL, Buising CM, Hingtgen E, White A, Jensen J 21(1). 11 - 17 (Journal Article)

Background: Limb position changes are likely during transport from injury location to definitive care. This study investigated passive limb position change effects on tourniquet pressure and occlusion. Methods: Triplicate buddy-applied OMNA® Marine Tourniquet applications to Doppler-based occlusion were done to sitting and laying supine mid-thigh (n=5) and sitting mid-arm (n=3). Tourniqueted limb positions were bent/straight/bent and straight/bent/straight (randomized first position order, 5 seconds/position, pressure every 0.1 second, two-way repeated measures ANOVA). Results: Sitting thigh occlusion pressures leg bent were higher than straight (median, minimum-maximum; 328, 307-403mmHg versus 312, 295-387mmHg, p = .013). In each recipient, the pressure change for each position change for each limb had p < .003. In each recipient, when sitting, leg bent to straight increased pressure (326, 276-415mmHg to 371, 308-427mmHg bent first and 275, 233-354mmHg to 311, 241-353mmHg straight first), and straight to bent decreased pressure (371, 308-427mmHg to 301, 262-388mmHg bent first and 312, 265-395mmHg to 275, 233-354mmHg straight first). When laying, position changes from leg bent first resulted in pressure changes in each recipient but not in the same directions in each recipient. From laying leg straight first, in each recipient changing to bent increased the pressure (295, 210-366mmHg to 328, 255-376mmHg) and to straight decreased the pressure (328, 255-376 mmHg to 259, 210-333 mmHg). Sitting arm bent occlusion pressures were lower than straight (230, 228-252mmHg versus 256, 250-287mmHg, p = .026). Arm position changes resulted in pressure changes in each recipient but not in the same directions in each recipient. Changes in pressure trace character (presence or absence of rhythmically pulsatile traces) and Doppler-based occlusion were consistent with limb position-induced changes in tourniquet pressure (each p ≤ .001 leg, p = .071 arm traces, and p = .188 arm occlusion). Conclusions: Passive limb position changes can cause significant changes in tourniquet pressure. Therefore, tourniquet adequacy should be reassessed after any limb position change.

Dye C, Keenan S, Carius BM, Loos PE, Remley MA, Mendes B, Arnold JL, May I, Powell D, Tobin JM, Riesberg JC, Shackelford SA 20(3). 141 - 156 (Journal Article)

This Role 1, prolonged field care (PFC) clinical practice guideline (CPG) is intended to be used after Tactical Combat Casualty Care (TCCC) Guidelines, when evacuation to higher level of care is not immediately possible. A provider must first and foremost be an expert in TCCC, the Department of Defense standard of care for first responders. The intent of this PFC CPG is to provide evidence and experience-based solutions to those who manage airways in an austere environment. An emphasis is placed on utilizing the tools and adjuncts most familiar to a Role 1 provider. The PFC capability of airway is addressed to reflect the reality of managing an airway in a Role 1 resource-constrained environment. A separate Joint Trauma System CPG will address mechanical ventilation. This PFC CPG also introduces an acronym to assist providers and their teams in preparing for advanced procedures, to include airway management.

DuBose JJ, Stinner DJ, Baudek A, Martens D, Donham B, Cuthrell M, Stephens T, Schofield J, Conklin CC, Telian S 20(4). 47 - 52 (Journal Article)

Background: Expedient resuscitation and emergent damage control interventions remain critical tools of modern combat casualty care. Although fortunately rare, the requirement for life and limb salvaging surgical intervention prior to arrival at traditional deployed medical treatment facilities may be required for the care of select casualties. The optimal employment of a surgical resuscitation team (SRT) may afford life and limb salvage in these unique situations. Methods: Fifteen years of after-action reports (AARs) from a highly specialized SRTs were reviewed. Patient demographics, specific details of encounter, team role, advanced emergent life and limb interventions, and outcomes were analyzed. Results: Data from 317 casualties (312 human, five canines) over 15 years were reviewed. Among human casualties, 20 had no signs of life at intercept, with only one (5%) surviving to reach a Military Treatment Facility (MTF). Among the 292 casualties with signs of life at intercept, SRTs were employed in a variety of roles, including MTF augmentation (48.6%), as a transport capability from other aeromedical platforms, critical care transport (CCT) between MTFs (27.7%), or as an in-flight damage control capability directly to point of injury (POI) (18.2%). In the context of these roles, the SRT performed in-flight life and limb preserving surgery for nine patients. Procedures performed included resuscitative thoracotomy (7/9; 77.8%), damage control laparotomy (1/9; 11.1%) and extremity fasciotomy for acute lower extremity compartment syndrome (1/11; 11%). Survival following in-flight resuscitative thoracotomy was 33% (1/3) when signs of life (SOL) were absent at intercept and 75% (3/4) among patients who lost SOL during transport. Conclusion: In-flight surgery by a specifically trained and experienced SRT can salvage life and limb for casualties of major combat injury. Additional research is required to determine optimal SRT utilization in present and future conflicts.

Fisher AD, Naylor JF, April MD, Thompson D, Kotwal RS, Schauer SG 20(4). 53 - 59 (Journal Article)

Background: Role 1 care represents all aspects of prehospital care on the battlefield. Recent conflicts and military operations conducted on behalf of the Global War on Terrorism have resulted in medical officers (MOs) being used nondoctrinally on combat missions. We are seeking to describe Role 1 trauma care provided by MOs and compare this care to that provided by medics. Methods: This is a secondary analysis of previously described data from the Prehospital Trauma Registry and the Department of Defense Trauma Registry from April 2003 through May 2019. Encounters were categorized by type of care provider (MO or medic). If both were documented, they were categorized as MO; those without either were excluded. Descriptive statistics were used. Results: A total of 826 casualty encounters met inclusion criteria. There were 418 encounters categorized as MO (57 with MO, 361 with MO and medic), and 408 encounters categorized as medic only. The composite injury severity score (median, interquartile range) was higher for casualties treated by the medic cohort (9, 3.5-17) than for the MO cohort (5, 2-9.5; P = .006). There was no difference in survival to discharge between the MO and medic groups (98.6% vs. 95.6%; P = .226). More life-saving interventions were performed by MOs compared to medics. MOs demonstrated a higher rate of vital sign documentation than medics. Conclusion: More than half of casualty encounters in this study listed an MO in the chain of care. The difference in proportion of interventions highlights differences in provider skills, training and equipment, or that interventions were dictated by differences in mechanisms of injury.

Richer I, Frank C 20(4). 60 - 67 (Journal Article)

Special Operations Forces (SOF) personnel are required to withstand considerable physical and psychological hardship. Research examining resilience and mental health among SOF personnel is limited and has provided mixed results; in addition, minimal research has been undertaken on the subjective experiences of adversity and the process of resilience among SOF personnel. This unique qualitative study describes the lived experience of Canadian SOF personnel, the challenges they face, and the factors they believe impact their resilience. Seventy Canadian SOF personnel participated in in-depth, semistructured interviews. A thematic analysis of the interviews revealed that operational demands, paired with an organizational culture of performance, were important stressors for most participants, negatively affecting both themselves and their families. SOF organizations select members with resilient characteristics; however, the same characteristics that make these members resilient also lead to self-imposed pressure to perform and avoid taking time for proper recovery. Team members were reported to help such members process difficult or traumatic experiences and facilitate their seeking care. Findings provide insight into the adverse experiences that participants encountered while serving in an SOF organization and the intertwined individual, social, and organizational factors affecting their resilience. Results point to the importance of managing and mitigating the impact of high operational tempo and a culture of performance to protect the health and wellness of SOF personnel and their families

Schauer SG, April MD, Fairley R, Uhaa N, Hudson IL, Johnson MD, Keen DE, De Lorenzo RA 20(4). 68 - 72 (Journal Article)

Pennardt A, West M 20(4). 73 - 76 (Journal Article)

The Portland, Oregon, Bureau of Fire & Rescue (PF&R) established a tactical emergency medical support team embedded within the Police Bureau's Rapid Response Team (RRT). The authors describe the team's training and their recent work.

Hall AB, Dixon M, Dennis AJ, Wilson RL 20(4). 92 - 94 (Journal Article)

Background: The COVID-19 pandemic has been a struggle for medical systems throughout the world. In austere locations in which testing, resupply, and evacuation have been limited or impossible, unique challenges exist. This case series demonstrates the importance of population isolation in preventing disease from overwhelming medical assets. Methods: This is a case series describing the outbreak of COVID-19 in an isolated population in Africa. The population consists of a main population with a Role 2 capability, with several supported satellite populations with a Role 1 capability. Outbreaks in five satellite population centers occurred over the course of the COVID-19 pandemic from its start on approximately 1 March 2020 until 28 April 2020, when a more robust medical asset became available at the central evacuation hub within the main population. Results: Population movement controls and the use of telehealth prevented the spread within the main population at risk and enabled the setup of medical assets to prepare for anticipated widespread disease. Conclusion: Isolation of disease in the satellite populations and treating in place, rather than immediately moving to the larger population center's medical facilities, prevented widespread exposure. Isolation also protected critical patient transport capabilities for use for high-risk patients. In addition, this strategy provided time and resources to develop infrastructure to handle anticipated larger outbreaks.

Roca G, Martin L, Borraz D, Serrano L, Lynam B 20(4). 95 - 99 (Journal Article)

The increase in global violence in recent years has changed the paradigm of emergency health care, requiring early medical response to victims in hostile settings where the usual work cannot be done safely. In Spain, this specific role is provided by the Tactical Environment Medical Support Teams (in Spanish, EMAETs). The Victoria I Consensus document defines and recognizes this role, whose main lines of work are the emergency medical response to the tactical team and to the victims in areas under indirect threat, provided that the tactical operators can guarantee their safety. To reinforce the suitability of this approach, we submitted the possible outcomes of this response model to a panel of national experts to assess this proposal in the different areas of Spain. The chosen research design is a conventional Delphi method, based on the content of the Victoria I Consensus response model. The panel of 52 expert reviewers from 11 different regions were surveyed anonymously; a high degree of accord was recognized when the congruence of the responses exceeded 75%. Consensus agreement was reached in all sections of the survey after two iterations. Specific contributions and recommendations were made to achieve unanimous consensus despite the population and resource differences in the country. Our results suggest that the EMAET approach is useful in areas with short response times. However, in more sparsely populated areas, this may not be feasible, and a more pragmatic response model may be suitable.

Cullen ML, Stephens M, Thronson E, Brillhart DB, Rizzo J 20(4). 112 - 114 (Journal Article)

Park GH, Lunasco T, Chamberlin RA, Deuster PA 20(4). 115 - 120 (Journal Article)

Human performance teams (HPTs) are highly capable and complex teams comprised of medical and performance professionals dedicated to supporting health and sustaining mission capabilities of the Special Operations Forces (SOF) warfighter community. As resources continue to be devoted to recruiting, hiring, and organizing HPTs, there is an increased need to support team-based capabilities, or their ability to work collaboratively and cooperatively across boundaries. In this article, we draw on existing evidence-based approaches to supporting team-based competencies to present a set of strategies designed to address barriers to cross-boundary teaming, catalyze innovation and precision of human performance optimization (HPO) service delivery, and maximize the impact of HPTs on warfighter medical and mission readiness. We begin by offering a conceptual paradigm shift that broadens the lens through which HPO intervention opportunities exist. We then explore how to promote a common understanding of the needs, performance demands, and occupational risks, which should clarify shared goals and targets for service delivery. We also discuss a refined strategy for hiring and recruiting members of HPTs, and finally, we propose opportunities for cultivating communication and collaboration across and within the HPO spectrum. By elevating HPT-based capabilities, the SOF community should be able to amplify the investment made in these invaluable resources.

Knapik JJ, Reynolds KL, Castellani JW 20(4). 123 - 135 (Journal Article)

Frostbite can occur during cold-weather operations when the temperature is <0°C (<32°F). When skin temperature is ≤-4°C (≤25°F), ice crystals form in the blood, causing mechanical damage, inflammation, thrombosis, and cellular death. Lower temperatures, higher wind speeds, and moisture exacerbate the process. The frozen part or area should not be rewarmed unless the patient can remain in a warm environment; repeated freeze/thaw cycles cause further injury. Treatment involves rapid rewarming in a warm, circulating water bath 37°C to 39°C (99°F-102°F) or, if this is not possible, then contact with another human body. Thrombolytics show promise in the early treatment of frostbite. In the field, the depth and severity of the injury can be determined with laser Doppler ultrasound devices or thermography. In hospital settings, bone scintigraphy with single-photon emission computed tomography (SPECT) 2 to 4 days postinjury provides detailed information on the depth of the injury. Prevention is focused primarily on covering exposed skin with proper clothing and minimizing exposure to wind and moisture. The Generation III Extended Cold Weather Clothing System is an interchangeable 12-piece clothing ensemble designed for low temperatures and is compatible with other military systems. The Extreme Cold Vapor Barrier Boot has outer and inner layers composed of seamless rubber with wool insulation between, rated for low temperatures. The Generation 3 Modular Glove System consists of 11 different gloves and mitts with design features that assist in enhancing grip, aid in the use of mobile devices, and allow shooting firearms. Besides clothing, physical activity also increases body heat, reducing the risk of frostbite.

Rapp J, Keenan S, Taylor D, Rapp A, Turconi M, Maves R, Kavanaugh M, Makati D, Powell D, Loos PE, Sarkisian S, Sakhuja A, Mosely DS, Shackelford SA 20(4). 27 - 39 (Journal Article)

Kragh JF, Le TD, Dubick MA 20(4). 40 - 46 (Journal Article)

Background: We sought to gather data about the effects of personal protective equipment (PPE) use on tourniquet interventions by preliminarily developing a way to simulate delay effects, particularly on time and blood loss. Such knowledge might aid readiness. Field calls to emergency departments may indicate donning of PPE before patient arrival. The purpose of this study was to investigate (1) delay effects of donning the PPE studied on field-tourniquet control of hemorrhage and (2) delay effects of wearing the PPE on application of a field tourniquet and its conversion to a pneumatic tourniquet. Methods: The experiment simulated 30 tests of nonpneumatic field tourniquet use (http://www.combattourniquet.com/wp -content). The research intervention was the use of PPE. Data were grouped. The control group had no PPE (PPE0). PPE1 and PPE2 groups had mostly improvised and off-the-shelf equipment, respectively. PPE1 included donning a coat, goggles, face covering, cap, booties, and gloves. PPE2 had analogous items. The group order was randomized. A test included paired trials: field tourniquet, followed by conversion. An investigator simulated the caregiver. A task trainer simulated a thigh amputation. Donning delays were evaluated as differences in mean times to stop bleeding compared with PPE0. Blood loss results from donning PPE were calculated as the delay multiplied by its bleeding rate, 500mL/min. Results: PPE0 had no delay: its mean blood loss was 392mL. PPE1 had 805mL more blood loss than PPE0 did. PPE2 exceeded PPE0 by 1004mL. Donning time (blood loss) for PPE1 and PPE2 were 1.4 minutes (712mL) and 1.7 minutes (863mL), respectively. The wearing of PPE did not slow down field tourniquet application or its conversion. Conclusions: How long it took to don PPE delayed the time to stop bleeding and increased blood loss, but wearing PPE slowed down neither field tourniquet application nor its conversion.

Reva VA, Pochtarnik AA, Shelukhin DA, Skvortzov AE, Semenov EA, Emelyanov AA, Nosov AM, Demchenko KN, Reznik ON, Samokhvalov IM, DuBose JJ 20(4). 77 - 83 (Journal Article)

Purpose: To evaluate the feasibility of prehospital extracorporeal cardiopulmonary resuscitation (E-CPR) in the military exercise setting. Methods: Three 40kg Sus scrofa (wild swine) underwent controlled 35% blood loss and administration of potassium chloride to achieve cardiac arrest (CA). During CPR, initiated 1 minute after CA, the animals were transported to Role 1. Femoral vessels were cannulated, followed by E-CPR using a portable perfusion device. Crystalloid and blood transfusions were initiated, followed by tactical evacuation to Role 2 and 4-hour observation. Results: All animals developed sustained asystole. Chest compressions supported effective but gradually deteriorating blood circulation. Two animals underwent successful E-CPR, with restoration of perfusion pressure to 80mmHg (70-90mmHg) 25 and 23 minutes after the induction of CA. After transportation to Role 2, one animal developed abdominal compartment syndrome as a result of extensive (9L) fluid replacement. The other animal received a lower volume of crystalloids (4L), and no complications occurred. In the third animal, multiple attempts to cannulate arteries were unsuccessful because of spasm and hypotension. Open aortic cannulation enabled the circuit to commence. No return of spontaneous circulation was ultimately achieved in either of the remaining animals. Conclusion: Our study demonstrates both the potential feasibility of battlefield E-CPR and the evolving capability in the care of severey injured combat casualties.

Akhvlediani N, Walls S, Latif NH, Markhvashvili N, Javakhishvili N, Mitaishvili N, Marliani D, Hering K, Washington MA 20(4). 100 - 103 (Journal Article)

The coronavirus disease 2019 (COVID-19) pandemic has demonstrated that new and devastating respiratory pathogens can emerge without warning. It is therefore imperative that Special Operations medical personnel be aware of the presence of emerging pathogens within their area of operation. Human bocavirus (HBoV) is a newly described member of a family of viruses known as the Parvovirinae that are often associated with acute respiratory illness. The presence of HBoV in the country of Georgia has not been previously reported. Nasal and throat swabs were collected from 95 symptomatic members of the Georgian military. HBoV was detected in 11 of them (12%). To our knowledge, this is the first report of HBoV infection in the country of Georgia. This finding may have a significant impact on members of the Special Operations community who train in Georgia as more data concerning the transmission, pathogenesis, and treatment of HBoV are accumulated and the role of HBoV in human disease is more clearly defined.

Lee JD, Bowley DM, Miles JA, Muzaffar J, Poole R, Orr LE 20(4). 104 - 111 (Journal Article)

Frontline military personnel are at high risk of acute acoustic trauma (AAT) caused by impulse noise, such as weapon firing or blast. This can result in anatomic disruption of the tympanic membrane and damage to the middle and inner ear, leading to conductive, sensorineural, or mixed hearing loss that may be temporary or permanent. AAT reduces warfighters' operational effectiveness and has implications for future quality of life. Hearing protection devices can mitigate AAT but are not completely protective. Novel therapeutic options now exist; therefore, identification of AAT as soon as possible from point of injury is vital to ensure optimal treatment and fulfillment of the duty of care. Early recognition and treatment of frontline AAT can maintain the deployed team's capabilities, avoid unnecessary case evacuation (CASEVAC), and raise awareness of military occupational AAT. This will help prioritize hearing preservation, maintain the fighting force, and ultimately retain personnel in service. The UK Defence hearWELL research collaboration has developed a frontline protocol for the assessment of AAT utilizing future-facing technology developed by the US Department of Defense: the Downrange Acoustic Toolbox (DAT). The DAT has been operationally deployed since 2019 and has successfully identified AAT requiring treatment, thereby improving casualties' hearing and reducing unnecessary repatriation.

Crecelius EM, Burnett MW 20(4). 121 - 122 (Journal Article)

Leptospirosis is caused by an infection with bacteria of the Leptospira species. These spirochetes are carried by a variety of wild and domestic animals. Humans can become infected with these bacteria; leptospirosis most commonly occurs in the tropics and subtropics. Military personnel are at risk of infection through deployment in the field.

Valenzuela J, Harrison C, Barajas J, Johnston EE 20(4). 136 - 138 (Journal Article)

During the Spring 2020 COVID surge, a team primarily composed of SOF medics coalesces in New York City, rapidly establishes a field hospital within a large academic teaching hospital, then transitions to step-down and ICU care as institutional needs evolve. Empowered to work as RNs, by emergency decree, the SOF medics, remarkable performance supports the need to define a novel role within the civilian healthcare system for these valuable, highly experienced, and underused providers.

Androski CP, Bianchi W, Robinson DL, Zarow GJ, Moore CH, Deaton TG, Drew B, Gonzalez S, Knight RM 20(4). 85 - 91 (Journal Article)

Early tranexamic acid (TXA) administration for resuscitation of critically injured warfighters provides a mortality benefit. The 2019 Tactical Combat Casualty Care (TCCC) recommendations of a 1g drip over 10 minutes, followed by 1g drip over 8 hours, is intended to limit potential TXA side effects, including hypotension, seizures, and anaphylaxis. However, this slow and cumbersome TXA infusion protocol is difficult to execute in the tactical care environment. Additionally, the side effect cautions derive from studies of elderly or cardiothoracic surgery patients, not young healthy warfighters. Therefore, the 75th Ranger Regiment developed and implemented a 2g intravenous or intraosseous (IV/IO) TXA flush protocol. We report on the first six cases of this protocol in the history of the Regiment. After-action reports (AARs) revealed no incidences of post-TXA hypotension, seizures, or anaphylaxis. Combined, the results of this case series are encouraging and provide a foundation for larger studies to fully determine the safety of the novel 2g IV/IO TXA flush protocol toward preserving the lives of traumatically injured warfighters.