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An Inventory of the Combat Medics' Aid Bag

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.

Expression of High Mobility Group Box 1 Protein in a Polytrauma Model During Ground Transport and Simulated High-Altitude Evacuation

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.

Decontamination of Toxic Industrial Chemicals and Fentanyl by Application of the RSDL® Kit

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.

Successful Placement of REBOA in a Rotary Wing Platform Within a Combat Theater: Novel Indication for Partial Aortic Occlusion

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.

Case Report Stimulant-Induced Atrial Flutter in a Remote Setting

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.

Rapid Ketamine Infusion at an Analgesic Dose Resulting in Transient Hypotension and Bradycardia in the Emergency Department

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.

Powassan Virus: Centers for Disease Control and Prevention

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

Surgical Airway in a Tactical Environment: A Case Report

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.

Measuring Special Operations Forces Readiness

Berry KG, Sakallaris B, Deuster PA 19(4). 100 - 104 (Journal Article)

Special Operations Force (SOF) Operators, spouses, and component representatives were asked to describe what readiness looks like to them and what is needed to achieve it. Their views informed a broad and deep dive into the academic and gray literature for believable measures relevant to operational readiness. This commentary is a synthesis of that work and provides recommendations for ways to improve "readying" strategies, practices, and outcomes to better achieve human- based mission performance. The key modifiers of Operator readiness are family, SOF culture and leadership, and time. Recommendations are to measure SOF mission performance to define premission Operator readiness; conceptualize mission readiness in terms of assets and not just deficits; combine experiential wisdom with that gained from the study of in-mission performance and premission readiness data; establish SOF phenotypes for use by all components; address emerging fields (doping, sleep, mental toughness, spiritual readiness, moral injury); and develop a simple readiness index.

Leprosy (Hansen's Disease)

Crecelius EM, Burnett MW 19(4). 105 - 107 (Journal Article)

The Good, the Bad, and the Future of Drones in Tactical/Operational Medicine

Bradley KD 19(4). 91 - 93 (Journal Article)

Unmanned aerial vehicles (UAVs) have seen expansion with their applications in many fields, including the opportunity these tools offer to improve medical care. Drones have significant potential for use in the tactical setting. New, unique possibilities for these drones are emerging constantly, but there is no standardized inclusion specifically with tactical medicine operations. This article is a review of the future possibilities of drones, the associated risks that drones present, and the current application of drone technology in the field of civilian operational/tactical medicine.

The Rise of the Stop the Bleed Campaign in Italy

Valsecchi D, Sassi G, Tiraboschi L, Bonetti M, Lagazzi E, Michelon AM, Nicolussi T, Stevan A, Bonasera-Vincenti NM, Guelfi-Pulvano R, Tripodi R 19(4). 95 - 99 (Journal Article)

Background: The B-Con Basic 1.0 protocol is a medical training designed to teach how to control massive external haemorrhages in emergency conditions. Spread throughout the United States since 2013, thanks to the Stop the Bleed campaign, it has seen a progressive international spread during 2016-2018. We report here data from the first 18 months of our training in Italy. Methods: Since January 2017, military Operators enlisted to the Volunteer Military Corps of the Italian Red Cross and registered to the ACS B-Con instructor database have provided B-Con courses. These instructors have provided extensive training, involving learners among military and civilian populations, especially health professionals and students. Further, they have obtained a formal adhesion to the National Stop the Bleed Day 2018. Results: Through August 2018, we trained 1186 learners in Italy on the B-Con protocol. The learners were mainly military personnel and law enforcement agents (620 [52%]) but also students and civilian health personnel (566 [48%]). Conclusion: The B-Con protocol has been very well received in Italy by military and police personnel. Good results have been assessed among civilian health professionals and medical students, especially by those operators involved in the field of emergency medicine.

Prehospital Whole Blood in SOF: Current Use and Future Directions

Jones TB, Moore VL, Shishido AA 19(4). 88 - 90 (Journal Article)

The US Joint Trauma System (JTS) recommends stored whole blood (SWB) as the preferred product for prehospital resuscitation of battlefield casualties in both their Tactical Combat Casualty Care (TCCC) guidelines and their clinical practice guidelines (CPGs). Clinical data from nearly 2 decades of war during Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF) suggest that whole blood (WB) is safe, effective, and far superior to crystalloid and colloid resuscitation fluids. The JTS CPG for whole blood transfusion reflects the most recent clinical evidence but poses unique challenges for execution by Special Operations Forces (SOF) operating in austere environments. Given the limited shelf-life of 35 days, WB requires a constant steady pool of donors. Additionally, the cold-chain requirement for storage poses challenges for SOF on long missions without access to blood refrigerators. SOF operating in less-developed theaters face additional logistical challenges. To mitigate the challenges of WB delivery, US SOF have implemented various protocols to ensure optimal donor pool, awareness/education among medics and specialized equipment for tactical methods of blood-carry and delivery. In general, steps taken include the following: (1) Prior to deployment, soldiers are screened for blood type and titers in order to establish a large donor pool. Support soldiers have been found to be particularly beneficial donors as they typically are in closer proximity to the blood support detachment. (2) In units that operate in smaller teams, such as ODAs, medics are outfitted with "blood kits" to carry blood on missions for point of injury transfusion. In units with larger teams, LTOWB donors are identified on missions and deliver fresh WB in the event of casualties. (3) Medics receive a WB transfusion refresher tabletop exercise and review after action reviews from previous rotations. Additionally, prehospital WB delivery is a required component of scenario-based premission training. The expectation is that medics will administer WB on missions when tactically feasible. Using the prolonged field care framework (ruck, truck, house) as a template, medics now use different methods to store and transport the SWB depending on phase. Medic "truck" and "house" kits include the Dometic CFX™ powered coolers that run on AC, DC, or solar power and allow for constant temperature monitoring. When on foot, medics have been outfitted with tactical blood coolers including the Pelican Biomedical Medic 4™ or Combat Medical Blood Box™ along with a Belmont Buddy-Lite™ intravenous (IV) infusion warmer and IV administration kit with standard micron filter. Presently, SOF medics have the donor support, logistical framework, training, and equipment to deliver WB at the point of injury. However, widespread implementation will require expanded distribution and standardization of "blood kits." Additionally, SOF medical planners must put greater emphasis on education and the importance of WB over crystalloids or colloids-as many medics continue to carry only these products out of convenience. As SOF strive to establish tactics, techniques, and procedures (TTPs) and streamline prehospital WB delivery, we must constantly reassess and refine our procedures, incorporate the latest evidence and technology, and adapt to an evolving battlefield.

Pharmacokinetics of Tranexamic Acid via Intravenous, Intraosseous, and Intramuscular Routes in a Porcine (Sus scrofa) Hemorrhagic Shock Model

DeSoucy ES, Davidson AJ, Hoareau GL, Simon MA, Tibbits EM, Ferencz SE, Grayson JK, Galante JM 19(4). 80 - 84 (Journal Article)

Background: Intravenous (IV) tranexamic acid (TXA) is an adjunct for resuscitation in hemorrhagic shock; however, IV access in these patients may be difficult or impossible. Intraosseous (IO) or intramuscular (IM) administration could be quickly performed with minimal training. We investigated the pharmacokinetics of TXA via IV, IO, and IM routes in a swine model of controlled hemorrhagic shock. Methods: Fifteen swine were anesthetized and bled of 35% of their blood volume before randomization to a single 1g/10mL dose of IV, IO, or IM TXA. Serial serum samples were obtained after TXA administration. These were analyzed with high-pressure liquid chromatography-mass spectrometry to determine drug concentration at each time point and define the pharmacokinetics of each route. Results: There were no significant differences in baseline hemodynamics or blood loss between the groups. Peak concentration (Cmax) was significantly higher in IV and IO routes compared with IM (p = .005); however, the half-life of TXA was similar across all routes (p = .275). Conclusion: TXA administration via IO and IM routes during hemorrhagic shock achieves serum concentrations necessary for inhibition of fibrinolysis and may be practical alternatives when IV access is not available.

Shared Blood: Expeditionary Resuscitative Surgical Team (ERST-5) Use of Local Whole Blood to Improve Resuscitation of Host Nation Partner Forces

Bowman J, Ashbaucher J, Cohee B, Fisher MS, Jennette JB, Huse JD, Copeland C, Muir KB 19(4). 85 - 87 (Journal Article)

US Special Operations Forces work by, with, and through partner forces (PFs) to accomplish mutual objectives. Surgical teams support these forces directly and may assist in treating injuries sustained by PF, based on established medical rules of engagement. These surgical operations are often conducted in austere conditions, with limited access to blood products. Limited blood product availability decreases US medical capacity to resuscitate injured PFs and augment the local trauma system. We present an innovative solution used by an expeditionary resuscitative surgical team (ERST) and Special Operations civil affairs team to partner with host nation (HN) medical personnel to improve PF access to damage control resuscitation and surgery. Whole blood obtained through a local HN hospital was provided to the ERST to allow for increased capacity to resuscitate PF casualties and augment the local trauma system. The ERST subsequently used this blood to resuscitate two PF surgical casualties.

Performance Enhancement Assessment and Coaching in US Army Special Operations: Rapidly Enhancing Performance Through Targeted, Tailored Feedback

Barry DM, DeVries M 19(4). 66 - 73 (Journal Article)

Background: Performance enhancement coaching poses significant benefits to individuals and organizations, such as improved job satisfaction and goal achievement. Given their training and experience in assessment and feedback, operational psychologists assigned to Special Operations units are uniquely positioned to provide performance enhancement coaching tailored to Operators and enablers. A preliminary program evaluation was conducted of the Performance Enhancement Assessment and Coaching (PEAC) Program. Methods: A sample of 32 Operators and enablers assigned to a US Army Special Operations Forces (ARSOF) unit voluntarily participated in the PEAC Program and completed one 90-minute coaching session. Following their coaching session, Soldiers provided qualitative and quantitative feedback on their coaching experience. Results: Soldiers overwhelmingly agreed that the PEAC Program was worth their time and helpful towards achieving their goals. Results indicate the PEAC Program enhanced Soldiers' perceived self-awareness, self-efficacy, and job performance. Results also suggest performance enhancement coaching may improve pass rates on interpersonally demanding Special Operations courses. Conclusion: Performance enhancement coaching delivers considerable value for Special Operations personnel and their organizations in relatively minimal time. Operational psychologist coaches (OPCs) assigned to Special Operations units can leverage their assessment skills to provide targeted, tailored performance enhancement coaching and increase value to their organizations.

The Potential Use of the Abdominal Aortic Junctional Tourniquet® in a Military Population: A Review of Requirement, Effectiveness, and Usability

Handford C, Parker PJ 19(4). 74 - 79 (Journal Article)

Uncontrolled hemorrhage is the leading cause of preventable prehospital death on the battlefield; 20% is junctional. This is a challenge to manage in the forward and prehospital military environment. With the widespread use of body armor, peripheral tourniquets and continued asymmetric warfare this consistent figure is unlikely to reduce. Resuscitative endovascular balloon occlusion of the aorta (REBOA) is an often-quoted potential solution; however, this invasive strategy requires a high skill level alongside a significant failure and complication rate. The Abdominal Aortic Junctional Tourniquet® (AAJT) is a noninvasive potential adjunct for the management of hemorrhage below the level of the aortic bifurcation with published case reports of successful use in prehospital blast and gunshot wounds. When placed at the level of the aortic bifurcation, alongside a pelvic binder, it can be used to control pelvic hemorrhage, buying time until definitive management. Importantly it has a low training burden and is easy to use. The AAJT has potential use as a prehospital device in the exsanguinating patient, those in traumatic cardiac arrest, as a bridging device, and as fluid conserving device in resource-limited environments. The evidence surrounding the AAJT is reviewed, and potential uses in the military setting are suggested.

Getting "SMART" on Shock Treatment: An Evidence-Based Mnemonic Acronym for the Initial Management of Hemorrhage in Trauma

Thompson P, Hudson AJ 19(4). 62 - 65 (Journal Article)

Treating hemorrhagic shock is challenging, the pathology is complex, and time is critical. Treatment requires resources in mental bandwidth (i.e., focused attention), drugs and blood products, equipment, and personnel. Providers must focus on treatment options in order of priority while also maintaining a dynamic assessment of the patient's response to treatment and considering potential differential diagnoses. In this process, the cognitive load is substantial. To avoid errors of clinical reasoning and practical errors of commission, omission, or becoming fixated, it is necessary to use evidence-based treatment recommendations that are concise, in priority order, and easily recalled. This is particularly the case in the austere, remote, or tactical environment. A simple mnemonic acronym, SMART, is presented in this article. It is a clinical heuristic that can be used as an aide-mémoire during the initial phases of resuscitation of the trauma patient with hemorrhagic shock: Start the clock and Stop the bleeding; Maintain perfusion; Administer antifibrinolytics; Retain heat; Titrate blood products and calcium; Think of alternative causes of shock.

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