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Old Tricks for New Dogs? John Caddy and the Victorian Origins of TCCC

Reynolds PS 18(2). 58 - 62 (Journal Article)

The success of Tactical Combat Casualty Care (TCCC) in reducing potentially preventable combat deaths may rely on both specific interventions (such as tourniquets) and the systematized application of immediate care. Essential elements of a combat care system include clear specification of immediate care priorities, standardized methodology, and inclusion and training of all nonmedical personnel in early response. Although TCCC is fairly recent, the construct is similar to that first suggested during the mid-nineteenth century by John Turner Caddy (1822-1902), a British Royal Navy staff surgeon. Although naval warfare engagements at the time were relatively infrequent, casualties could be numerous and severe and often overwhelmed the small medical staff on board. Caddy recognized that nonmedical personnel properly trained in the fundamentals of combat injury management would result in lives saved and greatly improved morale. The novelty was in his attempt to make procedures simple enough to be performed by nonmedical personnel under stress. However, Caddy's guidelines were completely overlooked for nearly two centuries. The principles of best practice for managing combat trauma injuries learned in previous wars have often been lost between conflicts. Understanding the historical roots of combat first responder care may enable us to better understand and overcome barriers to recognition and retention of essential knowledge.

Surgery at Sea: The Effect of Simulated High Sea States on Surgical Performance

Pierce E, Rapada R, Herder PA, LaPorta AJ, Hoang TN, Pena M, Blankenship J, Kiser J, Catlin SA 18(2). 64 - 70 (Journal Article)

Background: The US Navy initiated design concepts for a Medical Mission Module Support Container (M3SC), a mobile operating room capable of rapid installation aboard maneuverable ships within proximity of active combat units. The M3SC provides an alternative echelon of care in the current trauma system by decreasing the time between point of injury, arrival, and surgical intervention. The mobile ships used as M3SC platforms, however, are more susceptible to oceanic conditions that can induce detrimental physiologic motion sickness in medical personnel and patients aboard the vessels. This study investigated the effects of different sea-state motion conditions on the performance of surgical teams. Methods: Six four-person surgical teams performed 144 procedures in an M3SC aboard a Stewart motion table that simulated motion profiles of sea states 0, 3, and 4. A modified human-worn partial- task surgical simulator was used as a surgical surrogate to simulate the four most common, wartime, improvised explosive device injuries in the past 10 years. Electroencephalographs and heart rate variability (HRV) data were collected from surgeons and surgical technologists during each procedure to assess real-time physiologic responses to motion. Two postprocedure surveys, a Surgical Task Load Index and a Motion Sickness Assessment Questionnaire, were given to assess subjective responses of workload stress and motion-induced kinetosis. Surgical subject matter experts quantified surgical performance after each procedure by measuring blood loss and orthopedic pin placement to evaluate each intervention. Results: Motion did not significantly influence overall performance (ρ = .002). Surgical procedure was the strongest predictor of performance. HRV was used to measure stress and was increased in surgical technologists; however, HRV was decreased for surgeons and technologists in motion. There was a significant interaction between role and motion (ρ = .002): Surgeons had higher workloads than did surgical technologists and neither demonstrated differences between motion and no motion. Surgeons demonstrated significantly decreased workloads under motion conditions (ρ = 0.002); however, surgeons perceived their workload to be higher. We attribute this to their increased critical thinking and physical execution of procedures. Surgeons and surgical technologists showed a trend toward HRV suppression within the motion conditions. This may indicate a coping response to the increased stress of the motion setting. Procedure and team dynamic were the strongest predictors of overall performance, suggesting a learning curve exists and that added focus on training should be enforced. Conclusion: Based on data collected in this study, similar surgical procedures should be implemented aboard these classes of ships. By doing so, injured military personnel would have more timely access to care. Surgical team members were aware of craft motion, used compensatory measures, and exhibited some physiological response.

Nursing Interventions in Prolonged Field Care

Ostberg D, Loos PE, Mann-Salinas EA, Creson C, Powell D, Riesberg JC, Keenan S, Shackelford S 18(2). 123 - 132 (Journal Article)

Ether Anesthesia in the Austere Environment: An Exposure and Education

Morgans LB, Graham N 18(2). 142 - 146 (Journal Article)

Medical services in the austere and limited environment often require therapeutics and practices uncommon in modern times due to a lack of availability, affordability, or expertise in remote areas. In this setting, diethyl ether, or simply ether anesthesia, still serves a role today as an effective inhalation agent. An understanding of ether as an anesthetic not only illustrates the evolution in surgical anesthesia but also demonstrates ether's surviving function and durable use as a practical agent in developing nations. Although uncommon, it is not unseen, so a working knowledge should be understood if observation and advocacy for patients receiving this method of anesthesia are experienced.

Picture This: Management of Canine Pyotraumatic Dermatitis (a.k.a., Hot Spot)

Palmer LE 18(2). 105 - 109 (Journal Article)

Pyotraumatic dermatitis (a.k.a., hot spot) is a rapidly developing, superficial, moist, exudative dermatitis commonly induced by self-inflicted trauma. Although not acutely life threatening, these lesions are extremely pruritic and distracting and significantly interfere with the canine's operational effectiveness and ability to stay on task. The review discusses a case, including clinical presentation, diagnosis, treatment, and prognosis.


Burnett MW 18(2). 115 - 116 (Journal Article)

Arthropod Borne and Zoonotic Infections Among Military Personnel in Georgia

Chitadze N, Gureshidze N, Rostiaschvili N, Danelia N, Dalakishvili K, Durglishvili L, Kuchukhidze R, Imnadze P, Chlikadze R, Betashvili M, Kuchuloria T, Akhvlediani N, Rivard R, Nikolich M, Bautista CT, Washington MA, Akhvlediani T 18(2). 136 - 140 (Journal Article)

Military personnel are at an increased risk for exposure to arthropod- borne and zoonotic pathogens. The prevalence of these pathogens has not been adequately described in the country of Georgia. As the Georgian military moves toward an increased level of capability and the adoption of European Union and North Atlantic Treaty Organization standards, international field exercises will become more frequent and will likely involve an increasing number of international partners. This study was undertaken with the goal of defining the arthropod-borne and zoonotic pathogen threat in Georgia so force health protection planning can proceed in a rational and data-driven manner. To estimate disease burden, blood was taken from 1,000 Georgian military recruits between October 2014 and February 2016 and screened for previous exposure to a set of bacterial and viral pathogens using a antibody-based, serologic procedure. The highest rate of exposure was to Salmonella enterica serovar Typhi, and the lowest rate of exposure was to Coxiella burnettii (the causative agent of Q fever). These data provide insight into the prevalence of arthropod-borne infections in Georgia, fill a critical knowledge gap, will help guide future surveillance efforts, and will inform force health protection planning.

Prehospital Administration of Antibiotic Prophylaxis for Open Combat Wounds in Afghanistan: 2013-2014

Schauer SG, Fisher AD, April MD, Stolper KA, Cunningham CW, Carter R, Fernandez JD, Pfaff JA 18(2). 53 - 56 (Journal Article)

Background: Military operations place injured Servicemembers at high risk for open wounds. Austere environments and initial wound contamination increase the risk for infection. Wound infections continue to cause significant morbidity among injured Servicemembers. Limited evidence suggests that early antibiotic therapy for open wounds reduces infection rates. Methods: We obtained data from the Prehospital Trauma Registry (PHTR) from January 2013 through September 2014. This database includes data from Tactical Combat Casualty Care (TCCC) cards, Department of Defense 1380 forms, and after-action reports to provide near-real-time feedback to units on prehospital medical care. We evaluated whether patients with open wounds received antibiotics in accordance with TCCC guidelines. Low adherence was defined at less than 80%. Results: In this data set, overall, prefixed facility providers administered antibiotics to 54.0% of patients with an open combat wound. Of the antibiotics given, 11.1% were within TCCC guidelines. The relatively low administration and adherence rates persisted across subgroup analyses. Conclusion: Overall, relatively few patients with open combat wounds receive antibiotic administration as recommended by TCCC guidelines. In the group that received antibiotics, few received the specific antibiotics recommended by TCCC guidelines. The development of strategies to improve adherence to these TCCC recommendations is a research priority.

Methods for Early Control of Abdominal Hemorrhage: An Assessment of Potential Benefit

Cantle PM, Hurley MJ, Swartz MD, Holcomb JB 18(2). 98 - 104 (Journal Article)

Background: Noncompressible truncal hemorrhage (NCTH) after injury is associated with a mortality increase that is unchanged during the past 20 years. Current treatment consists of rapid transport and emergent intervention. Three early hemorrhage control interventions that may improve survival are placement of a resuscitative endovascular balloon occlusion of the aorta (REBOA), injection of intracavitary self-expanding foam, and application of the Abdominal Aortic Junctional Tourniquet (AAJT™). The goal of this work was to ascertain whether patients with uncontrolled abdominal or pelvic hemorrhage might benefit by the early or prehospital use of one of these interventions. Methods: This was a single-center retrospective study of patients who received a trauma laparotomy from 2013 to 2015. Operative reports were reviewed. The probable benefit of each hemorrhage control method was evaluated for each patient based on the location(s) of injury and the severity of their physiologic derangement. The potential scope of applicability of each control method was then directly compared. Results: During the study period, 9,608 patients were admitted; 402 patients required an emergent trauma laparotomy. REBOA was potentially beneficial for hemorrhage control in 384 (96%) of patients, foam in 351 (87%), and AAJT in 35 (9%). There was no statistically significant difference in the potential scope of applicability between REBOA and foam (ρ = .022). There was a significant difference between REBOA and AAJT (ρ < .001) and foam and AAJT™ (ρ < .001). The external surface location of signs of injury did not correlate with the internal injury location identified during laparotomy. Conclusion: Early use of REBOA and foam potentially benefits the largest number of patients with abdominal or pelvic bleeding and may have widespread applicability for patients in the preoperative, and potentially the prehospital, setting. AAJT may be useful with specific types of injury. The site of bleeding must be considered before the use of any of these tools.

The Role of Magnetic Resonance Imaging in Optimizing Injury Management in Air Force Pararescuemen, Combat Rescue Officers, and Survival Specialists

Rush SC, Foresto C, Hewitt CW, Grossman MG, Petersen CD, Gallo I, Staak BP, Rush JT 18(2). 86 - 89 (Journal Article)

Operators perform physically demanding jobs associated with a variety of overuse and acute musculoskeletal injuries. The current management of musculoskeletal complaints in the Air Force includes plane radiographs and 6 weeks of physical therapy (PT) before consideration of orthopedic consultation and magnetic resonance imaging (MRI); however, MRI shows a clear advantage compared with plane radiographs. We conducted a performance improvement project and conclude that (1) MRI allowed for definitive diagnosis as well as definitive triage for care in a timely manner, (2) guidelines for ordering lumbosacral MRIs should be followed and not ordered for pain that is not progressive and severe or not associated with a neurological finding, and (3) because of the risk of X-ray exposure in patients in their 20 and 30s, X-rays should be avoided in this setting unless definitely indicated.

Are the King LTS Laryngeal Tube and the Ambu AuraOnce Laryngeal Mask Useful Airway Adjuncts for Military Medics?

Regner D, Frykholm P 18(2). 90 - 96 (Journal Article)

Background: Airway management is a critical skill that may be essential in the battlefield. The aim of this study was to determine if combat life savers and medics with no or limited clinical experience could provide airway control using the disposable laryngeal suction tube (LTS-D) and the Ambu® AuraOnce ™ disposable laryngeal mask (LMA). Methods: Eight military medics with limited clinical experience and no airway management experience secured the airway on 19 intrahospital anesthetized patients using the LTS-D and the LMA. Each patient was treated with both airway adjuncts in a randomized order. Each medic was studied on at least two and not more than three patients. Success of insertion, number of attempts, and time to correct placement with verified ventilation were recorded. Results: When using the LTS-D, the first-attempt success rate for the medics with the first patient was 50% (four of eight) and 75% (six of eight) on the second attempt. With the second patient, the first-attempt success rate was 87.5% (seven of eight), and on the third patient, it was 100% (three of three). For all patients, the accumulated first-attempt success rate was 73.7% (14 of 19) and 84.2% (16 or 19) for second attempts with the LTS-D. The success rate on first attempt with the LMA was 100% (19 of 19) on the first patient. On the second intervention with the LMA, there was a significant decrease in mean time to verified ventilation, from 56.4 seconds to 27.7 seconds (ρ = .043), and time to verified ventilation with no leakage, from 61.3 seconds to 32.3 seconds (ρ = .029). Insertion attempts for three LTS-Ds and one LMA failed. Conclusion: This study suggests that for the safe use of the laryngeal tube suction by inexperienced airway providers, a clinical training program is required. The LMA proved superior to the LTS-D with a 100% success rate at the first attempt, which suggests that minimal training is needed before clinical use. We therefore recommend the LMA as the primary airway adjunct for military medics, despite a hypothetically inferior protection from aspiration.

Optimizing Tactical Medical Performance: The Effect of Light Hue on Vision Testing

Van Buren JP, Wake J, McLaughlin J, LaPorta AJ, Enzenauer RW, Calvano CJ 18(2). 75 - 78 (Journal Article)

Background: Red and blue are the historical tactical lighting hues of choice to ensure light discipline and to preserve dark adaptation. As yet, no scientifically ideal hue for use in Special Operations medicine has been identified. We propose red/green polychromatic light as a superior choice that preserves visual function for tactical medical tasks in austere settings. Methods: Thirty participants were enrolled in this institutional review board-approved study. Participants completed four vision tasks in low-light settings under various lighting conditions. The Pelli-Robson Near Contrast Sensitivity test (PR), tumbling E visual acuity test, Farnsworth D-15 color-vision test (FD15), and pseudoisochromatic plate (PiP) testing was performed under white, green, or red light illumination and also red/green and red/green/yellow lights. PR and tumbling E tests were performed using blue and blue/red lights. Results: The test results for each light were compared against a white-light standard. Contrast sensitivity as measured by PR testing showed no statistical difference when white light was used compared with red/green or red/green/yellow light, and the differences between red, green, blue, and blue/red all were statistically different from when white light was used. When measuring visual acuity, blue light was the only color for which there was a statistically significant decrease in visual acuity in comparison with white. There was no reduction in visual acuity with any other lights compared with white. Performance on FD15 testing with all single-hue and multihue lights was significantly worse than with white light for measuring color-vision perception. Color discrimination as measured by PiP testing showed red and green light was significantly worse than with white light, whereas test results when green/red and green/red/yellow lights were used were not statistically different from white. Conclusion: Red/Green/yellow and red/green were superior light sources and performance results only were worse than white light on FD15 testing.

Junctional Tourniquet Use During Combat Operations in Afghanistan: The Prehospital Trauma Registry Experience

Schauer SG, April MD, Fisher AD, Cunningham CW, Gurney J 18(2). 71 - 74 (Journal Article)

Background: Hemorrhage is the leading cause of potentially preventable death on the battlefield. Although the resurgence of limb tourniquets revolutionized hemorrhage control in combat casualties in the recent conflicts, the mortality rate for patients with junctional hemorrhage is still high. Junctional tourniquets (JTQs) offer a mechanism to address the high mortality rate. The success of these devices in the combat setting is unclear given a dearth of existing data. Methods: From the Prehospital Trauma Registry (PHTR) and the Department of Defense Trauma Registry, we extracted cases of JTQ use in Afghanistan. Results: We identified 13 uses of a JTQ. We excluded one case in which an improvised pelvic binder was used. Of the remaining 12 cases of JTQ use, seven had documented success of hemorrhage control, three failed to control hemorrhage, and two were missing documentation regarding success or failure. Conclusion: We report 12 cases of prehospital use of JTQ in Afghanistan. The findings from this case series suggest these devices may have some utility in achieving hemorrhage control strictly at junctional sites (e.g., inguinal creases). However, they also highlight device limitations. This analysis demonstrates the need for continued improvements in technologies for junctional hemorrhage control, prehospital documentation, data fidelity and collection, as well as training and sustainment of the training for utilization of prehospital hemorrhage control techniques.

Evaluation of the US Army Special Forces Tactical Human Optimization, Rapid Rehabilitation, and Reconditioning Program

Grier T, Anderson MK, Depenbrock P, Eiserman R, Nindl BC, Jones BH 18(2). 42 - 48 (Journal Article)

Background: We sought to assess the rehabilitation process, training, performance, and injury rates among those participating and not participating in the Tactical Human Optimization, Rapid Rehabilitation, and Reconditioning (THOR3) program and determine injury risk factors. Methods: A survey inquiring about personal characteristics, injuries, physical performance, and THOR3 participation during the previous 12 months was administered to Army Special Operations Forces (SOF) Soldiers. Based on responses to physical training, Soldiers were categorized into three groups: a traditional physical training (TPT) group, a cross-training (CT) group, and a THOR3 group. To identify potential injury risk factors, risk ratios and 95% confidence intervals (95% CIs) were calculated. Backward- stepping multivariable logistic regression models were used to assess key factors associated with injury risk. Results: The survey was completed by 328 male Soldiers. Most of the Soldiers (62%) who scheduled an appointment with the physical therapist were seen within 1 day. Self-reported injury rates for the TPT, CT, and THOR3 groups were 70%, 52%, and 48%, respectively. When controlling for personal characteristics, unit training, and fitness, the TPT group had a marginally higher risk of being injured than the THOR3 group (odds ratio [OR], 2.72; 95% CI, 0.86-8.59; p = .09). Soldiers who did not perform any unit resistance training (ORnone/90-160 min, 3.62; 95% CI, 1.05-12.53; p = .04) or the greatest amount of resistance training (OR>160 min/90-160 min, 3.44; 95% CI, 1.64-7.20; p < .01) were more likely to experience an injury than the moderate-resistance training group. Conclusion: THOR3 appears to offer human performance optimization/injury prevention advantages over other SOF human performance programs.

Special Operations Force Risk Reduction: Integration of Expeditionary Surgical and Resuscitation Teams

Satterly S, McGrane O, Frawley T, Bynum W, Martin J, Clegg C, Pearsall N, Reilly S, Verwiebe E, Eckert M 18(2). 49 - 52 (Journal Article)

Hemorrhage in the presurgical setting has been the most significant cause of death on the battlefield. Damage control surgery (DCS) near the point of injury (POI) is not a new concept, but having conventional medical teams supporting Special Operations Forces (SOF) beyond robust military medical infrastructure is unique for the US military. The Expeditionary Resuscitative Surgical Team (ERST) was formed by the US Army Medical Command as a pilot team to fulfill a request for forces to provide DCS and personnel recovery near POI.

Management of Suspected Tension Pneumothorax in Tactical Combat Casualty Care: TCCC Guidelines Change 17-02

Butler FK, Holcomb JB, Shackelford S, Montgomery HR, Anderson S, Cain JS, Champion HR, Cunningham CW, Dorlac WC, Drew B, Edwards K, Gandy JV, Glassberg E, Gurney J, Harcke T, Jenkins DA, Johannigman J, Kheirabadi BS, Kotwal RS, Littlejohn LF, Martin M, Mazuchowski EL, Otten EJ, Polk T, Rhee P, Seery JM, Stockinger Z, Torrisi J, Yitzak A, Zafren K, Zietlow SP 18(2). 19 - 35 (Journal Article)

This change to the Tactical Combat Casualty Care (TCCC) Guidelines that updates the recommendations for management of suspected tension pneumothorax for combat casualties in the prehospital setting does the following things: (1) Continues the aggressive approach to suspecting and treating tension pneumothorax based on mechanism of injury and respiratory distress that TCCC has advocated for in the past, as opposed to waiting until shock develops as a result of the tension pneumothorax before treating. The new wording does, however, emphasize that shock and cardiac arrest may ensue if the tension pneumothorax is not treated promptly. (2) Adds additional emphasis to the importance of the current TCCC recommendation to perform needle decompression (NDC) on both sides of the chest on a combat casualty with torso trauma who suffers a traumatic cardiac arrest before reaching a medical treatment facility. (3) Adds a 10-gauge, 3.25-in needle/ catheter unit as an alternative to the previously recommended 14-gauge, 3.25-in needle/catheter unit as recommended devices for needle decompression. (4) Designates the location at which NDC should be performed as either the lateral site (fifth intercostal space [ICS] at the anterior axillary line [AAL]) or the anterior site (second ICS at the midclavicular line [MCL]). For the reasons enumerated in the body of the change report, participants on the 14 December 2017 TCCC Working Group teleconference favored including both potential sites for NDC without specifying a preferred site. (5) Adds two key elements to the description of the NDC procedure: insert the needle/ catheter unit at a perpendicular angle to the chest wall all the way to the hub, then hold the needle/catheter unit in place for 5 to 10 seconds before removing the needle in order to allow for full decompression of the pleural space to occur. (6) Defines what constitutes a successful NDC, using specific metrics such as: an observed hiss of air escaping from the chest during the NDC procedure; a decrease in respiratory distress; an increase in hemoglobin oxygen saturation; and/or an improvement in signs of shock that may be present. (7) Recommends that only two needle decompressions be attempted before continuing on to the "Circulation" portion of the TCCC Guidelines. After two NDCs have been performed, the combat medical provider should proceed to the fourth element in the "MARCH" algorithm and evaluate/treat the casualty for shock as outlined in the Circulation section of the TCCC Guidelines. Eastridge's landmark 2012 report documented that noncompressible hemorrhage caused many more combat fatalities than tension pneumothorax.1 Since the manifestations of hemorrhagic shock and shock from tension pneumothorax may be similar, the TCCC Guidelines now recommend proceeding to treatment for hemorrhagic shock (when present) after two NDCs have been performed. (8) Adds a paragraph to the end of the Circulation section of the TCCC Guidelines that calls for consideration of untreated tension pneumothorax as a potential cause for shock that has not responded to fluid resuscitation. This is an important aspect of treating shock in combat casualties that was not presently addressed in the TCCC Guidelines. (9) Adds finger thoracostomy (simple thoracostomy) and chest tubes as additional treatment options to treat suspected tension pneumothorax when further treatment is deemed necessary after two unsuccessful NDC attempts-if the combat medical provider has the skills, experience, and authorizations to perform these advanced interventions and the casualty is in shock. These two more invasive procedures are recommended only when the casualty is in refractory shock, not as the initial treatment.

New and Established Models of Limb Tourniquet Compared in Simulated First Aid

Kragh JF, Newton NJ, Tan AR, Aden JK, Dubick MA 18(2). 36 - 41 (Journal Article)

Background: The performance of a new tourniquet model was compared with that of an established model in simulated first aid. Methods: Four users applied the Combat Application Tourniquet (C-A-T), an established model that served as the control tourniquet, and the new SAM Extremity Tourniquet (SXT) model, which was the study tourniquet. Results: The performance of the C-A-T was better than that of the SXT for seven measured parameters versus two, respectively; metrics were statistically tied 12 times. The degree of difference, when present, was often small. For pretime, a period of uncontrolled bleeding from the start to a time point when the tourniquet first contacts the manikin, the bleeding rate was uncontrolled at approximately 10.4mL/s, and for an overall average of 39 seconds of pretime, 406mL of blood loss was calculated. The mean time to determination of bleeding control (± standard deviation [SD]) was 66 seconds (SXT, 70 ± 30 seconds; C-A-T, 62 ± 18 seconds; p = .0075). The mean ease-of-use score was 4 (indicating easy) on a scale of 1 to 5, with 5 indicating very easy (mean ± SD: SXT, 4 ± 1; C-A-T, 5 ± 0; p < .0001). C-A-T also performed better for total trial time, manikin damage, blood loss rate, pressure, and composite score. SXT was better for pretime and unwrap time. All users intuitively self-selected the speed at which they applied the tourniquets and that speed was similar in all of the required steps. However, by time segments, one user went slowest in each segment while the other three generally went faster. Conclusions: In simulated first aid with tourniquets, better results generally were seen with the C-A-T than with the SXT in terms of performance metrics. However, the degree of difference, when present, was often small.

Medicine on the Edge of Darkness

Christensen PA 18(1). 150 - 154 (Journal Article)

Austere care of the wounded is challenging for all Western medical professionals-nurse, medic, or physician. There can be no doubt that working for the first time, either for a nongovernment organization or in the Special Forces, you will be taking care of wounded patients outside your training and experience. You must have the ability to adapt to and overcome lack of resources and equipment, and accept standards of treatment often very different and lower than that common in western hospitals. The International Committee of the Red Cross (ICRC) was asked to provide relief for the Pakistan Red Crescent in 1982 and set up the ICRC Hospital for Afghan War Wounded in Peshawar on the border to Afghanistan. This article relates how a western-trained young anesthetist on a ICRC surgical team experienced this, at the time, austere environment.

A Case of Rhabdomyolysis Caused by Blood Flow-Restricted Resistance Training

Krieger J, Sims D, Wolterstorff C 18(2). 16 - 17 (Case Reports)

Blood flow-restricted resistance (BFRR) training is effective as a means to improve muscle strength and size while enduring less mechanical stress. It is generally safe but can have adverse effects. We present a case of an active duty Soldier who developed rhabdomyolysis as a result of a single course of BFRR training. He was presented to the emergency department with bilateral lower extremity pain, was admitted for electrolyte monitoring and rehydration, and had an uncomplicated hospital course and full recovery. This is an increasingly common mode of rehabilitation in the military, and practitioners and providers should be aware of it and its possible adverse effects.

Prehospital Medicine and the Future Will ECMO Ever Play a Role?

Macku D, Hedvicak P, Quinn J, Bencko V 18(1). 133 - 138 (Journal Article)

Due to the hybrid warfare currently experienced by multiple NATO coalition and NATO partner nations, the tactical combat casualty care (TCCC) paradigm is greatly challenged. One of the major challenges to TCCC is the ad hoc extension phase in resource-poor environments, referred to as prolonged field care (PFC) and forward resuscitative care (FRC). The nuanced clinical skills with limited resources required by warfighters and auxiliary health care professionals to mitigate death on the battlefield and prevent morbidity and mortality in the PFC phase represent a balance that is still under review. The aim of our article is to describe the connection between extracorporeal membrane oxygenation (ECMO) or the extracorporeal life support (ECLS) treatment and its possible improvement in prehospital trauma care, at a Role 1 or 2 facility and, more provocatively, in the PFC phase of care in the future through innovative technology and how it connects with FRC. We report and describe here the primary components of ECMO/ECLS and present the main concept of a human extracorporeal circulation cocoon as a transitional living form for the cardiopulmonary stabilization of wounded combatants on the battlefield and their transportation to higher echelons of care and treatment facilities (to include damage control resuscitation [DCR] and damage control surgery [DCS]). As clinical governance, these matters would fall within the remit of the Committee on Surgical Combat Casualty Care (CoSCCC) and the Committee on Enroute Combat Casualty Care (CoERCCC), and it is within this framework that we propose this concept piece of ECMO in the prehospital space. We caution that this report is a proposed innovation to TCCC but also serves to push the envelope of the PFC and FRC paradigm. What we propose will not change the practice this year, but as ECMO technology progresses, it may change our practice within the next decade. We conclude with proposed novel future research to save life on the battlefield with ECMO as a major challenge and one worth the focus of further research. Medicine is controversial and constantly changing; for those who work in prehospital and battlefield medicine, change is the only constant on which we rely, and without provocative discussion that makes our systems and practice more robust, we will fail.

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