Articles

20(1). 125 - 140 (Journal Article)

Achilles tendinopathy (AT) is a clinical term describing a nonrupture injury of the Achilles tendon where the patient presents with pain, swelling, and reduced performance and symptoms exacerbated by physical activity. About 52% of runners experience AT in their lifetime and in the United States military the rate of clinically diagnosed AT cases was 5/1000 person-yr in 2015. The pathophysiology can be viewed on a continuum proceeding from reactive tendinopathy where tenocytes proliferate, protein production increases, and the tendon thickens; to tendon disrepair in which tenocytes and protein production increase further and there is focal collagen fiber disruption; to degenerative tendinopathy involving cell death, large areas of collagen disorganization, and areas filled with vessels and nerves. Inflammation may be present, especially in the early phases. Some evidence suggests AT pain may be due to neovascularization and the ingrowth of new nerve fibers in association with this process. Prospective studies indicate that risk factors include female sex, black race, higher body mass index, prior tendinopathy or fracture, higher alcohol consumption, lower plantar flexion strength, greater weekly volume of running, more years of running, use of spiked or shock absorbing shoes, training in cold weather, use of oral contraceptives and/ or hormone replacement therapy, reduced or excessive ankle dorsiflexion range of motion, and consumption of antibiotics in the fluoroquinolone class. At least 10 simple clinical tests are available for the diagnosis of AT, but based on accuracy and reproducibility, patient self-reports of morning stiffness and/or pain in the tendon area, pain on palpation of the tendon, and detection of Achilles tendon thickening appear to be the most useful. Both ultrasound and magnetic resonance imaging (MRI) are useful in assisting in diagnosis with MRI providing slightly better sensitivity and specificity. Conservative treatments that have been researched include: (1) nonsteroidal anti-inflammatory medication, (2) eccentric exercise, (3) stretching, (4) orthotics, (5) bracing, (6) glyceryl trinitrate patches, (7) injection therapies (corticosteroids, hyaluronic acid, platelet-rich plasma injections), (8) shock wave therapy, and (9) low-level laser therapy. Nonsteroidal anti-inflammatory medication and corticosteroid injections may provide short-term relief but do not appear effective in the longer term. Eccentric exercise and shock wave therapies are treatments with the highest evidence- based effectiveness. Prevention strategies have not been well researched, but in specific populations balance training (soccer players) and shock-absorbing insoles (military recruits) may be effective. Ultrasound scans might be useful in predicting future AT occurrences.

20(1). 141 - 144 (Journal Article)

Battlefield medicine is constantly evolving. Wound patterns, terrain, weapons, and medical evacuation change, so surgical capabilities must adapt. With the changing environment, we must evolve by adapting to offer the best practical care, closest to the frontline. The golden hour has never been a magical number, and the most successful care is provided by the most advanced practitioners as close to the point of injury as possible. The proper placement and access of surgical teams are a key factor in access to a casualty within minutes. NATO Special Operations combat medics (NSOCMs) are highly trained medical Operators who can work as a force multiplier, not only to the Special Operations elements in which they serve but also as members of a Special Operations surgical team (SOST), and these Soldiers can provide the essential skills necessary to best employ and support the surgical asset.

20(1). 120 - 122 (Journal Article)

Scrub typhus, also known as tsutsugamushi disease, is caused by Orientia sp. and approximately 1 million new cases are reported annually. This article discusses the importance of scrub typhus and its clinical presentation, diagnosis, treatment, and prevention.

20(1). 123 (Journal Article)

20(1). 113 - 119 (Journal Article)

The Special Operations Forces (SOF) community represents an impressive degree of diversity in talents, culture, mission essential tasks, and occupational risk exposures across Service branches, their career fields, and units. Sustaining the capabilities of the SOF Operator across a career lifespan requires collaboratively addressing the current gap between medical readiness and mission readiness with support services and their SOF end users. Given the diverse needs of SOF Operators and their units, realigning performance and health (P&H) service delivery to meet their specific needs will require the adoption of an alternative business framework, operationally focused metrics, and retargeting to ensure SOF Operators are not just medically ready, but mission ready. With restructuring of P&H service delivery occurring across the Department of Defense at all levels to support the 2018 National Defense Strategy, there is a greater need for collaborative synchronization, targeting, and validating operational return on investment with SOF Operators and SOF stakeholders. Here, we present the Human Performance Optimization (HPO) and Total Force Fitness (TFF) Capabilities-Based Blueprint (CBB) and Targeting System as an initial step to realigning service delivery. We examine the use of CBB as a translational tool to bridge the divide between P&H services and SOF Operator communities, and demonstrate how the CBB has significant applications to help construct appropriate programming and program evaluation, align resources and needs, and provide culturally appropriate services that should sustainably preserve SOF Operators' unique capabilities and their mission.

20(1). 94 - 100 (Journal Article)

Objective: Due to physical demands, Special Operations Forces (SOF) endure changes in body composition, work capacity, and endocrine function. These changes result in energy deficits and sleep deprivation, where sleep averaged 3 hours/ day, independently known to decrease testosterone levels. The use of exogenous testosterone shows increases in lean body mass (LBM) and muscle function in healthy males and reverses cachexia in diseased populations. Therefore, the review's primary purpose is to summarize and contrast literature in both SOF and nonmilitary personnel regarding the correlation between negative energy balance, sleep deprivation, and decreased testosterone. The secondary purpose summarizes the effects of exogenous testosterone therapy in healthy males as well as reversing the effects of muscle wasting diseases. Methods: An online literary search from 1975 to 2015 identified 46 of 71 sources addressing both purposes, and data were summarized into tables providing mean observations. Conclusions: SOF training results in decreased testosterone (-6.3%), LBM (-4.6%), and strength (-11.7%), tied to energy deficits (-3,351 kcal/day) and sleep deprivation (3 hours/ day). Exogenous testosterone therapy increases LBM (6.2%), strength (7.9-14.8%), reverses cachexia (2.0%) and increases strength (12.7%) in those with chronic diseases. Therefore, testosterone supplementation in SOF may attenuate changes in body composition and muscle function during training and sustained Special Operations (SUSOPS).

20(1). 101 - 111 (Journal Article)

First introduced in 1996, Tactical Combat Casualty Care (TCCC) redefined prehospital, point-of-injury (POI), battlefield trauma care for the human combat casualty. Today, many consider TCCC as one of the most influential interventions for reducing combat-related case fatality rates from preventable deaths in human combat casualties. Throughout history, Military Working Dogs (MWDs) have proved and continue to prove themselves as force multipliers in the success of many military operations. Since the start of the Global War on Terror in 2001, these elite canine operators have experienced an upsurge in combat-related deployments, placing them at a higher risk for combat-related injuries. Until recently, consensus- based Canine-TCCC (K9TCCC) guidelines for POI battlefield trauma care did not exist for the MWD, leaving a critical knowledge gap significantly jeopardizing MWD survival. In 2019, the Canine Combat Casualty Care Committee was formed as an affiliate of the Committee on Tactical Combat Casualty Care with the intent of developing evidence- based, best practice K9TCCC guidelines. Modeled after the same principles of the human TCCC, K9TCCC focuses on simple, evidence-based, field-proven medical interventions to eliminate preventable deaths and to improve MWD survival. Customized for the battlefield, K9TCCC uniquely adapts the techniques of TCCC to compensate for canine-specific anatomic and physiological differences.

20(1). 81 - 86 (Journal Article)

Background: Early hemorrhage control using resuscitative endovascular balloon occlusion of the aorta (REBOA) can save lives. This study was designed to evaluate the ability to train Quick Response Team Fire Fighters (QRT-FF) to gain percutaneous femoral artery access and place a REBOA catheter in a model, using a comprehensive theoretical and practical training program. Methods: Six QRT-FF participated in the training. SOF medics from a previous training served as the control group. A formalized training curriculum included basic anatomy and endovascular materials for percutaneous access and REBOA placement. Key skills included (1) preparation of an endovascular toolkit, (2) achieving vascular access in the model, and (3) placement and positioning of REBOA. Results: QRT-FF had significantly better scores compared with medics using endovascular materials (P = .003) and performing the procedure without unnecessary attempts (P = .032). Basic surgical anatomy scores for QRT-FF were significantly better than SOF medics (P = .048). QRT-FF subjects demonstrated a significantly higher overall technical skills point score than medics (P = .030). QRT-FF had a median total time from start of the procedure to REBOA inflation of 3:23 minutes, and medics, 5:05 minutes. All six QRT-FF subjects improved their procedure times-as did four of the five medics. Conclusions: Our training program using a task training model can be utilized for percutaneous femoral access and REBOA placement training of QRT-FF without prior ultrasound or endovascular experience. Training the use of advanced bleeding control options such as REBOA, as a secondary occupational task, has the potential to improve outcomes for severely bleeding casualties in the field.

20(1). 87 - 93 (Journal Article)

There is growing concern that military breaching and training and firing artillery and mortars, grenades, and shoulder-fired weapons may have some type of cumulative deleterious effects. There are anecdotal reports of those with repetitive exposure to low-level blast complaining of various symptoms, as well as increasing empirical evidence. The purpose of this report is to provide a systematic review of the literature on repetitive lowlevel blast as it pertains to military and police training protocols. An extensive literature search was conducted, resulting in detailed review of 18 studies. Results suggest few consistent findings, likely due to the heterogeneity of methods, high risk of bias, and lack of reliance on objective blast-exposure data. Adverse effects, when present, dissipated over time. All studies that used blast gauges found significant associations, though only a subset actually reported using the blast-gauge data (to correlate objective exposure with outcomes). When comparing studies within an outcome domain (e.g., cognitive), findings were largely inconsistent. Research with larger sample sizes, followed longitudinally, is needed.

20(1). 72 - 80 (Journal Article)

Purpose: To review the current literature investigating if performance of tactical athletes under multitask paradigms is different than performance under single-task paradigms. Methods: The authors completed a search of the literature published from January 01, 2000, to June 01, 2018, using key search terms in PubMed, Web of Science, SPORTDiscus, and Defense Technical Information Center (DTIC) databases. Studies that met inclusion and exclusion criteria were assessed for quality. Results: Fourteen articles were identified as eligible to be included in the review. Compared with single-task, two studies reported better motor performance, six reported poorer motor performance, and three reported no difference in motor performance under multitask. Compared with single- task, two studies reported better cognitive performance, seven studies reported poorer cognitive performance, and three studies reported no difference in cognitive performance under multitask. Conclusion: As occupational duties become increasingly demanding, it is crucial to modify and adapt performance assessments to meet the needs required of tactical athletes to guide training and injury management programs. Motor and cognitive assessments are an integral part of performance evaluations to train, prepare, and rehabilitate tactical athletes. To meet the modern demands of tactical athletes, varying levels of difficulty in multitask paradigms that include both motor and cognitive tasks should be investigated to understand fundamental performance under operational settings to better translate across training paradigms and rehabilitation programs.

20(1). 61 - 64 (Journal Article)

Introduction: Tactical Combat Casualty Care (TCCC) recommends life-saving interventions; however, these interventions can only be implemented if military prehospital providers carry the necessary equipment to the injured casualty. Combat medics primarily use aid bags to transport medical materiels forward on the battlefield. We seek to assess combat medic materiel preparedness to employ TCCC-recommended interventions by inventorying active duty, combat medic aid bags. Methods: We sought combat medics organic to combat arms units stationed at Joint Base Lewis McChord. Medics volunteered to complete a demographic worksheet and have the contents of their aid bag photographed and inventoried. We spoke with medic unit leadership prior to their participation and asked that the medics bring their aid bags in the way they would pack for a combat mission. We categorized medic aid bag contents in the following manner: (1) hemorrhage control; (2) airway management; (3) pneumothorax treatment, or (4) volume resuscitation. We compared the items found in the aid bags against the contemporary TCCC guidelines. Results: In January 2019, we prospectively inventoried 44 combat medic aid bags. Most of the medics were male (86%), in the grade of E4 (64%), and had no deployment experience (64%). More medics carried a commercial aid bag (55%) than used the standard issue M9 medical bag (45%). Overall, the most frequently carried medical device was an NPA (93%). Overall, 91% of medics carried at least one limb tourniquet, 2% carried a junctional tourniquet, 31% carried a supraglottic airway (SGA), 64% carried a cricothyrotomy setup/kit, 75% carried a chest seal, and 75% carried intravenous (IV) fluid. The most commonly stocked limb tourniquet was the C-A-T (88%), the airway kit was the H&H cricothyrotomy kit (38%), the chest injury set were prepackaged needle decompression kits (81%), and normal saline was the most frequently carried fluid (47%). Most medics carried a heating blanket (54%). Conclusions: Most medics carried materiels that address the common causes of preventable death on the battlefield. However, most materiels stowed in aid bags were not TCCC-preferred items. Moreover, there was a small subset of medics who were not prepared to handle the major causes of death on the battlefield based on the current state of their aid bag.

20(1). 65 - 70 (Journal Article)

Background: We investigated the expression of high mobility group box 1 (HMGB1) protein in a combat-relevant polytrauma/ acute respiratory distress syndrome (ARDS) model. We hypothesized that systemic HMGB1 expression is increased after injury and during aeromedical evacuation (AE) at altitude. Methods: Female Yorkshire swine (n =15) were anesthetized and cannulated with a 23Fr dual-lumen catheter. Venovenous extracorporeal life support (VV ECLS) was initiated via the right jugular vein and carried out with animals uninjured on day 1 and injured by bilateral pulmonary contusion on day 2. On both days, animals underwent transport and simulated AE. Systemic HMGB1 expression was measured in plasma by ELISA. Plasma-free Hb (pfHb) was measured with the use of spectrophotometric methods. Results: Plasma HMGB1 on day 1 was transiently higher at arrival to the AE chambers, increased significantly after injury, reaching highest values at 8,000 ft on day 2, after which levels decreased but remained elevated versus baseline at each time point. pfHb decreased on day 1 at 30,000 ft and significantly increased on day 2 at 8,000 ft and postflight. Conclusions: Systemic HMGB1 demonstrated sustained elevation after trauma and altitude transport and may provide a useful monitoring capability during en route care.

20(1). 40 - 42 (Editorial)

20(1). 55 - 59 (Journal Article)

Purpose: This study investigated the decontamination effectiveness of selected toxic industrial chemicals using RSDL® (Reactive Skin Decontamination Lotion Kit; Emergent BioSolutions Inc.; https://www.rsdl.com/). Materials and Methods: Quantitative analytical methods were developed for dermal toxic compounds of varying physicochemical properties: sulfuric acid, hydrofluoric acid, ammonia, methylamine, hydrazine, phenylhydrazine, 1,2-dibromoethane, capsaicin, and fentanyl. These methods were subsequently used to evaluate the decontamination effectiveness on painted metal substrates at an initial chemical contamination level of 10g/m2 (0.1g/m2 for fentanyl). Results: The decontamination effectiveness ranged from 97.79% to 99.99%. Discussion and Conclusion: This study indicates that the RSDL kit may be amenable for use as an effective decontaminant for material substrates beyond the classical chemical warfare agents and the analytical methods may be used for future decontamination assessment studies using contaminated skin or other materials.

20(1). 21 - 25 (Case Reports)

20(1). 34 - 36 (Case Reports)

Resuscitative endovascular balloon occlusion of the aorta (REBOA) is used to augment resuscitation in patients with noncompressible torso hemorrhage, which is a leading cause of death on the battlefield. However, the implementation of REBOA has resulted in considerable debate within the military medical community. We present a case of the first successful placement of an REBOA by a small surgical team within a mobile rotary wing platform.

20(1). 37 - 39 (Case Reports)

Atrial flutter and atrial fibrillation are among the most commonly encountered cardiac arrhythmias; however, there is a dearth of clinical trials or case studies regarding its occurrence in the setting of stimulants such as caffeine and nicotine in otherwise healthy young patients. Described here is a case of a 29-year-old physically fit white man without significant past medical history who presented in stable condition complaining only of palpitations. He was found to have atrial flutter without rapid ventricular response on cardiac monitoring, most likely due to concomitant presence of high levels of nicotine and caffeine via chewing tobacco and energy drinks. He was treated conservatively with vagal maneuvers and intravenous fluids with complete resolution of symptoms and electrocardiographic abnormalities within 14 hours. This demonstrates an alternate conservative treatment strategy in appropriately risk stratified patients who present in an austere field setting with limited resources.

20(1). 31 - 33 (Case Reports)

Ketamine's favorable hemodynamic and safety profile is motivating increasing use in the prehospital environment. Despite these advantages, certain side effects require advanced planning and training. We present a case of rapid intravenous administration of ketamine causing bradycardia and hypotension. A 46-year-old man presented to the emergency department for an exacerbation of chronic shoulder pain. Given the chronicity of the pain and multiple failed treatment attempts, ketamine at an analgesic dose was used. Despite the local protocol directing administration over several minutes, it was pushed rapidly, resulting in malaise, nausea, pallor, bradycardia, and hypotension. The patient returned to his baseline without intervention. This and other known side effects of ketamine, such as behavioral disturbances, altered sense of reality, and elevated heart rate and blood pressure, are well documented in the literature. With this report, the authors aim to raise awareness of transient bradycardia and hypotension associated with the rapid administration of ketamine at an analgesic dose.

Anonymous A 19(4). 108 (Journal Article)

20(1). 29 - 30 (Case Reports)

Surgical airway management should be regarded as one of many tools available to forward clinical Operators. The need for that intervention should be determined in a quick and decisive manner consistent with accepted protocols for combat care. The case presented discusses immediate surgical access to the airway required after the initial assessment of the patient and illustrates the clinical urgency of patients requiring surgical intervention in the field setting.