Articles

Smith S, Liu M, Ball I, Meunier B, Hilsden R 99(5). 33 - 39 (Journal Article)

Medical leadership must decide how prehospital airways will be managed in a combat environment, and airway skills can be complicated and difficult to learn. Evidence informed airway strategies are essential. A search was conducted in Medline and EMBASE databases for prehospital combat airway use. The primary data of interest was what type of airway was used. Other data reviewed included: who performed the intervention and the success rate of the intervention. The search strategy produced 2,624 results, of which 18 were included in the final analysis. Endotracheal intubation, cricothyroidotomy, supraglottic airways, and nasopharyngeal airways have all been used in the prehospital combat environment. This review summarizes the entirety of the available combat literature such that commanders may make an evidence-based informed decision with respect to their airway management policies.

Bryan CJ, Rush SC, Fuessel-Herrmann D, Bryan AO, Morrow CE, Haskell J, Jones MJ, Bowerfind C, Stephenson JA 99(5). 21 - 25 (Journal Article)

Background: Research among military personnel and veterans indicates that subjective appraisal of warzone stressors explains the relation of combat exposure to posttraumatic stress disorder (PTSD), but not the relation of exposure to injury and death to PTSD. Studies have primarily been limited to conventional forces using aggregate measures of warzone stressor exposure. Threat appraisal may play a different role in the emergence of PTSD among military personnel for whom dangerous deployment experiences are more closely associated with exposure to injury and death, such as US Air Force Pararescuemen and Combat Rescue officers. Materials and Methods: In a sample of 207 rescue personnel, correlations among various types of warzone stressor exposure, threat appraisal, and postdeployment PTSD symptoms were examined. Results: The relative strongest correlates of threat appraisal were stressors related to injury, death, and human remains. Although exposure to these stressors was also correlated with PTSD symptom severity, partial correlations of stressor exposure and PTSD symptoms were no longer significant when adjusting for threat appraisal. Conclusion: Results support the contributing role of threat appraisal to PTSD among military personnel whose primary duties entail exposure to injury and death under hostile and dangerous conditions.

Tekmal S, Lockett C, Long B, Schauer SG 22(4). 83 - 86 (Journal Article)

Background: The Department of State has the primary responsibility of diplomatic operations in foreign countries. The US military often supports these missions and, when needed, may be called upon to provide security in the event of changes in the host nation's government stability. The US military was requested to help evacuate the consulate in Benghazi after the attack on September 11, 2012. The medical requirements to support such a mission remain unclear, and data are lacking. We sought to describe the medical care required during this evacuation mission. Methods: This is a secondary analysis of a previously described dataset from the United States Transportation Command (TRANSCOM) Regulating Command & Control and Evacuation System (TRAC2ES) from 2008 to 2018, with a focus on cases involving the evacuation after the Libyan consulate attack in September 2012. Within our dataset, we isolated all cases of evacuation from the attack on US government facilities in Benghazi. We describe the available data within TRAC2ES, including the free text information placed by the initiating medical personnel. Results: We identified three cases of evacuations within TRAC2ES associated with the Benghazi consulate attack. All cases were evacuated from host nation hospitals to Landstuhl Regional Medical Center (LRMC) by military aircraft under urgent status. Case 1 was an adult male injured by an undocumented mechanism. He was found to be in severe shock, received four units of blood prior to transport, and was intubated. Case 2 was an adult male injured by an undocumented mechanism. He had documented smoke inhalation injury and was found to be coughing up black sputum. Case 3 was an adult male injured by an undocumented mechanism. He had a compound radial fracture with an external fixator in place and subsequently developed compartment syndrome. He was intubated prior to transport. Conclusions: Our case series focuses on the unique aspects of military support of diplomatic missions in countries lacking a stable government-specifically, what transpired in Benghazi. Such events showcase areas of potential collaboration between the Department of State and the Department of Defense in coordinating medical evacuations for casualties sustained during diplomatic missions.

Stuart SM, Bohan ML, Mclean JB, Walchak AC, Friedrich EE 22(4). 87 - 92 (Journal Article)

Background: Exsanguination is the leading cause of preventable posttraumatic death, especially in the prehospital arena. Traditional hemorrhage control methods involve packing the wound with hemostatic agents, providing manual pressure, and then applying a pressure dressing to stabilize the treatment. This is a lengthy process that frequently destabilizes upon patient transport. Conversely, the iTClamp, a compact wound closure device, is designed to rapidly seal wound edges mechanically, expediting clot formation at the site of injury. Objectives: To determine the efficacy of the iTClamp with and without wound packing in the control of a lethal junction hemorrhage. Methods: Given the limited available information regarding the efficacy of the iTClamp in conjunction with traditional hemostatic agents, this study used a swine model of severe junctional hemorrhage. The goal was to compare a multiagent strategy using the iTClamp in conjunction with XSTAT to the traditional method of Combat Gauze packing with pressure dressing application. Readouts include application time, blood loss, and rebleed occurrence. Results: Mean application times of the iTClamp treatment alone or in conjunction with other hemostatic agents were at least 75% faster than the application time of Combat Gauze with pressure dressing. Percent blood loss was not significantly different between groups but trended the highest for Combat Gauze treated swine, followed by iTClamp plus XSTAT, iTClamp alone and finally iTClamp plus Combat Gauze. Conclusion: The results from this study demonstrate that the iTClamp can be effectively utilized in conjunction with hemostatic packing to control junctional hemorrhages.

Ward H, Downing N, Goller S, Stremick J 22(4). 93 - 96 (Case Reports)

The Role 2 environment presents several challenges in diagnosing and treating complex medical and life-threatening conditions. They are primarily designed to perform damage control resuscitation and surgery in the setting of trauma with less emphasis on complex medical care and limited ability to hold patients for more than 72 hours. Providing care to Soldiers and civilians in the deployed setting is made more difficult by the limited number of personnel, lack of advanced diagnostic equipment such as CT scanners, harsh working conditions, and austere resources. Despite these challenges, deployed physicians have continued to provide high levels of care to injured Soldiers and civilians by using clinical judgment, validated clinical decision-making tools, and adjunct diagnostic tools, such as ultrasound. In this case series we will present three complex medical cases involving pulmonary embolism (PE), ventricular tachycardia (VT), and aortic dissection that were seen in a deployed Role 2 setting. This article will highlight and discuss the challenges faced by deployed providers and ways to mitigate these challenges.

Rittenhouse M, Deuster PA 22(4). 97 - 101 (Journal Article)

Full-spectrum human performance optimization (HPO) is essential for Special Operations Forces (SOF). Nutrition is one part of HPO and is important for all aspects of performance. One area of increased interest in this regard is omega-3 polyunsaturated fatty acids (omega-3). Research has indicated that Servicemembers (SM), including SOF, do not eat the recommended 2 to 3 servings per week of fatty fish and have low omega-3 levels. Therefore, alternative approaches are warranted. The purpose of this article is to highlight the potential mental and physical health and performance benefits of omega-3. Consuming omega-3 on a regular basis would not only be beneficial for the health of SOF but also for their training and overall performance.

Knapik JJ, Caldwell JA, Ritland BM 22(4). 102 - 110 (Journal Article)

Sleep professionals suggest adults should sleep at least seven hours per night and define good sleep quality as 1) sleep onset ≤15 minutes, 2) one or fewer awakenings per night, 3) awake after sleep onset ≤20 minutes, and 4) sleep efficiency (ratio of sleep time to time in bed) ≥85%. This paper focuses on associations between injuries and sleep quality/duration among military personnel and strategies to optimize sleep and mitigate effects of sleep loss. Investigations among military personnel generally used convenience samples who self-reported their injury and sleep quality/quantity. Despite these limitations, data suggest that lower sleep quality or duration is associated with higher risk of musculoskeletal injury (MSI). Possible mechanisms whereby poor sleep quality/duration may influence MSI include hormonal changes increasing muscle catabolism, increases in inflammatory processes affecting post-exercise muscle damage, and effects on new bone formation. Sleep can be optimized by a slightly cool sleeping environment, bedding that maintains a stable thermal microclimate around the body, not using media devices near bedtime or in the sleeping environment, minimizing noise, and having regular bed and awaking times. Sleep loss mitigation strategies include napping (<30 to 90 minutes), sleep banking (extended time in bed), and judicious use of caffeine or modafinil.

Nam JJ, McCravy MS, Haines KL, Thomas SB, Aden JK, Johnston LR, Mason PE, Gurney J, Sams VG 22(4). 111 - 116 (Journal Article)

Background: The purpose of our study was to assess risks/ outcomes of acute respiratory distress syndrome (ARDS) in US combat casualties. We hypothesized that combat trauma patients with ARDS would have worse outcomes based on mechanism of injury (MOI) and labs/vital signs aberrancies. Materials and Methods: We reviewed data on military Servicemembers serving in Iraq and Afghanistan from 1 January 2003 to 31 December 2015 diagnosed with ARDS by ICD-9 code. We extracted patient demographics, injury specifics, and mortality from the Department of Defense Trauma Registry (DoDTR). Results: The most common MOI was an explosion, accounting for 67.6% of all injuries. Nonsurvivors were more likely to have explosion-related injuries, have higher injury severity score (ISS), higher international normalized ratio (INR), lower platelet count, greater base deficit, lower temperature, lower Glasgow Coma Scale (GCS) score, and lower pH. There was no significant difference in deaths across time. Conclusion: By identifying characteristics of patients with higher mortality in trauma ARDS, we can develop treatment guidelines to improve outcomes. Given the high mortality associated with trauma ARDS and relative paucity of clinical data available, we need to improve battlefield data capture to better guide practice and ultimately improve care. The management of ARDS will be increasingly relevant in prolonged casualty care (PCC; formerly prolonged field care) on the modern battlefield.

Parkes M, Gill G 22(4). 117 - 121 (Journal Article)

Research into British perspectives of the medical history of Far East prisoners of war (FEPOWs) has been conducted by the Liverpool School of Tropical Medicine (United Kingdom), resulting from decades of treating FEPOW veterans that began after their repatriation in late 1945. This paper examines some of the ingenious ways that British medical officers, medical orderlies, and volunteers fought to save the lives of thousands of FEPOWs during captivity in the Second World War. It highlights some of the key medical challenges, together with the resourcefulness of a "citizen's army" of conscripts and volunteers who used their civilian knowledge, skills, and ingenuity in many ways to support Allied medical staff. Using the most basic of materials, they were able to produce a vast array of medical support equipment and even drugs, undoubtedly saving many lives.

Cwikla J, Edwards TH, Giles JT, Kennedy S, Smith B, de Porras DG, Scott LL 22(4). 122 - 129 (Journal Article)

Background: Prevention of deployment-related injury is critical for readiness of US military working dogs (MWDs). This study evaluated deployment-related injuries to determine if they were potentially preventable and identify possible abatement strategies. Methods: Data were collected on 195 MWD injury events that occurred between 11 September 2001 and 31 December 2018. Injuries were reviewed by a panel of veterinarians and categorized into groups based on panel consensus. The panel also established which interventions could have been effective for mitigating injuries. Multipurpose canine (MPC) and conventional MWD injury event characteristics were compared to identify meaningful differences. Results: Of the 195 injuries, 101 (52%) were classified as preventable or potentially preventable. Most (72%) of the potentially preventable injuries occurred in conventional MWDs, with penetrating injuries (64%) being the most common type of trauma. For the preventable/potentially preventable injuries, the most common preventative intervention identified was handler training (53%) followed by protective equipment (46%). There were differences between MPCs and conventional MWDs for injury prevention category, type of trauma, mechanism of injury, and preventative intervention (all p < .001). Conclusion: The application of a preventable review process to MWD populations may be beneficial in identifying potentially preventable injuries and preventative intervention strategies.

Saxon L, Faulk RT, Barrett T, McLelland S, Boberg J 22(4). 78 - 82 (Journal Article)

The role of US Special Operations Forces (SOF) globally has expanded greatly in the past 20 years, leaving SOF serving multiple deployments with little time or ability to recover in between. Currently, assessments of the health and human performance capabilities of these individuals are episodic, precluding an accurate assessment of physical and mental load over time, and leading to high rates of acute and chronic injury to the mind and body. The collection of personal health-related continuous datasets has recently been made feasible with the advancement of digital technologies. These comprehensive data allow for improved assessment, and consequently better results, partly due to the warfighters' real-time access to their data. Such information allows Soldiers to engage in their own health optimization. This article describes a research platform that allows for collection of data via a custom-made secure mobile application that extends the type, scope, and frequency of data collection beyond what is feasible during an in-person encounter. By digitizing existing assessments and by incorporating additional physical, neurocognitive, psychological, and lifestyle assessments, the platform provides individuals with the ability to better understand their mental and physical load, as well as reserve. The results of this interactive exchange may help to preserve the health of users as well as the stability and readiness of units.

Stevens R, Pierce B, Tilley L 22(4). 72 - 76 (Journal Article)

Military medicine has made significant advancements in decreasing mortality by addressing the lethal triad - metabolic acidosis, coagulopathy, and hypothermia. However, casualties are still succumbing to injury. Recent conflict zones have led to the development of remarkable life-saving innovations, including the management of compressible hemorrhage and whole blood transfusions. Nevertheless, hypothermia prevention and treatment techniques remain relatively unchanged. Hypothermia prevention is anticipated to become more critical in future operations due to a predicted increase in evacuation times and reliance on Prolonged Casualty Care (PCC). This is likely secondary to increasingly distanced battlespaces and the mobility challenges of operating in semi-/non-permissive environments. Innovation is essential to combat this threat via active airway rewarming in the vulnerable patient. Thus, we propose the development, fabrication, and efficacy testing of a device in which we estimate being able to control temperature and humidity at physiologic levels in the PCC setting and beyond.

O'Hara R, Sussman LR, Sheehan R, Keizer B, Tiede JM 22(4). 65 - 69 (Journal Article)

The flotation-restriction environmental stimulation technique (FR) may have utility as a recovery tool for improving performance in elite competitive athletes and Special Operations Forces Operators (SOs). Studies suggest that FR may ameliorate various neurophysiological disorders and improve performance in recreational and elite athletic populations. We sought to understand whether there is evidence to support the use of FR to enhance physiological and psychological performance parameters in the SO population and to provide postulations as to the mechanisms of action of FR therapy. We performed an online literary search of publications dating from 1982 to 2021 and identified 34 sources addressing the aims, depending on population and condition or conditions, being treated. The reported physiological and psychological benefits of FR range from immediate to lasting 4 months. Overall, eight to twelve FR treatment sessions of from 40 to 90 minutes each may provide variable long-term benefits. The associated synergistic benefits of FR may be attributed to its thermal, chemical, and mechanical effects but deserve further exploration. Based on the current evidence, FR may serve as an effective performance-recovery therapy for improving pain, sleep, and performance measures (e.g., marksmanship and physical performance) in trained, untrained, and healthy adults. Future research focusing on FR as a unimodal recovery intervention is warranted in a specialized group of SOs.

Neal DJ, Loconti P, Mengel T, Holway K, Wenner D 22(4). 60 - 64 (Journal Article)

On October 10, 2019, the Loudoun County Sheriff's Office (LCSO) and Loudoun County Fire and Rescue (LCFR) led one of the largest act of violence (AVI) exercises ever conducted in Loudoun County, Virginia. Over 300 participants and 50 role-players participated across 15 county departments and agencies within Loudoun County. The exercise identified an important recommendation: "future joint unified command trainings are needed throughout the fire and law enforcement command structures." Effective, unified command is an essential NFPA 3000 principle of responding to an AVI. "The success or failure of the response will hinge on the quality of unified command." After-action reports from AVIs across the United States emphasized the importance of unified command. A second exercise recommendation proposed "a joint AVI unified command competency scenario between LCFR and LCSO should be developed and delivered across all levels of supervision . . . this scenario should demonstrate ‘best practices' for establishing and operating unified command between LCFR and LCSO." The authors developed two active shooter command competency simulations that require LCSO and LCFR to form unified command and manage the initial response. The simulations reinforced accepted response practices, such as identification of cold/warm/hot zones, early unified command, rescue task force team deployment, and protected corridor establishment. The simulations were packaged into a unified command competency training and simulation program. Through the facilitated debriefings with participants and facilitator debriefs, three types of lessons learned were identified: 1) high threat incident response lessons, 2) lessons for conducting AVIs in the command competency lab, and 3) active threat operational considerations for command officers.

Kamimori GH, McQuiggan W, Ramos AN, LaValle CR, Misistia A, Salib J, Egnoto MJ 22(4). 56 - 59 (Journal Article)

Background: Tamping explosive charges used by breachers is an increasingly common technique. The ability to increase the directional effectiveness of the charge used, combined with the potential to reduce experienced overpressure on breachers, makes tamping a desirable tool not only from an efficacy standpoint for breachers but also from a safety standpoint for operational personnel. The long-term consequences of blast exposure are an open question and may be associated with temporary performance deficits and negative health symptomatology. Purpose: This work evaluates breaches of varying charge weight, material breached, and tamping device used to determine the value of tamping during various scenarios by measuring actual breaches conducted during military and law enforcement training for efficacy and blast overpressure on Operators. Methods: Three data collections across 18 charges of various construction were evaluated with blast overpressure sensors at various distances and locations where breachers would be located, to assess explosive forces on human personnel engaged in breaching activities. Results and Conclusions: Findings indicate that water tamping in general is a benefit on moderate and heavy charges but offers less benefit at a low charge with regard to mitigating blast overpressure on breachers. Reduced overpressure allows Operators to stage closer to explosives and lowers the potential for compromised reaction time. It also reduces the likelihood of negative consequences that can result from excessive overpressure exposure and allow Operators to "do more with less" in complex environments, where resource access may be limited by logistic or other limitations. However, tamping in all instances improved blast efficacy in creating successful breaches. Future studies are planned to investigate tamping mediums beyond water and environment changes, whether tamping can be used to mitigate acoustic insult, and other explosive types.

Getz C, Stuart SM, Barbour BM, Verga JM, Roszko PJ, Friedrich EE 22(4). 50 - 54 (Journal Article)

Background: Surgical cricothyrotomy (SC) is a difficult procedure with high failure rates in the battlefield environment. The difficulty of this procedure is compounded in a low-light tactical environment in which white light cannot be used. This study compared the use of red-green (RG) light and red (R) light in the performance of SC in a low-light environment. Materials and Methods: Tactical Combat Casualty Care-certified navy corpsmen (n = 33) were provided 15 minutes of standardized instruction followed by hands-on practice with the Tactical CricKit and the H&H bougie-assisted Emergency Cricothyrotomy Kit. Participants acclimated to a dark environment for 30 minutes before performing SC on a mannequin with both devices using both R and RG light in a randomized order. Application time, success, participant preference, and participant confidence were analyzed. Results: There were similarly high levels of successful placement (>87.5%) in all four cohorts. Light choice did not appear to affect placement time with either of the two kits. On Likert-scale surveys, participants reported that RG decreased difficulty (p < .0001) and increased confidence (p < .0001) in performing the procedure. Conclusion: RG light increased confidence and decreased perceived difficulty when performing SC, though no differences in placement time or success were observed.

Daniel Y, Derkenne C, Mahe P, Travers S, Martinaud C 22(4). 46 - 49 (Journal Article)

Warm fresh whole-blood transfusion between comrades on the battlefield, also known as "buddy transfusion," has been thrust back into the limelight for several years now. It means drawing blood on the battlefield, once a bleeding soldier needs a transfusion, from one of their uninjured companions and immediately infusing it. It is a lifesaving procedure, effective and hardy. This work aims to answer the main questions that military caregivers might have about it: interest of this procedure, donor and recipient safety, and hemostatic capacity of the blood collected this way.

Dilday J, Heidenreich B, Spitzer H, Abuhakmeh Y, Ahnfeldt E, Watt J, Mase VJ 22(4). 41 - 45 (Journal Article)

Background: Tube thoracostomy is the most effective treatment for pneumothorax, and on the battlefield, is lifesaving. In combat, far-forward adoption of open thoracostomy has not been successful. Therefore, the ability to safely and reliably perform chest tube insertion in the far-forward combat theatre would be of significant value. The Reactor is a hand-held device for tube thoracostomy that has been validated for tension pneumothorax compared to needle decompression. Here we investigate whether the Reactor has potential for simple pneumothorax compared to open thoracostomy. Treatment of pneumothorax before tension physiology ensues is critical. Methods: Simple pneumothoraces were created in 5 in-vivo swine models and confirmed with x-ray. Interventions were randomized to open technique (OT, n = 25) and Reactor (RT, n = 25). Post-procedure radiography was used to confirm tube placement and pneumothorax resolution. Video Assisted Thoracoscopic Surgery (VATS) was used to evaluate for iatrogenic injuries. 50 chest tubes were placed, with 25 per group. Results: There were no statistical differences between the groups for insertion time, pneumothorax resolution, or estimated blood loss (p = .91 and .83). Injury rates between groups varied, with 28% (n = 7) in the Reactor group and 8% (n = 2) the control group (p = .06). The most common injury was violation of visceral pleura (10%, n = 5, both groups) and violation of the mediastinum (8%, n = 4, both groups). Conclusion: The Reactor device was equal compared to open thoracostomy for insertion time, pneumothorax resolution, and injury rates. The device required smaller incisions compared to tube thoracostomy and may be useful adjunct in simple pneumothorax management.

Gonzalez S, Vasquez PF, Montgomery HR, Conklin CC, Conaway ZA, Pate DM, Lopata JF, Kotwal RS 22(4). 28 - 39 (Journal Article)

The 75th Ranger Regiment's success with eliminating preventable death on the battlefield is innate to the execution of a continuous operational readiness training cycle that integrates individual and unit collective medical training. This is a tactical solution to a tactical problem that is solved by the entire unit, not just by medics. When a casualty occurs, the unit must immediately respond as a team to extract, treat, and evacuate the casualty while simultaneously completing the tactical mission. All in the unit must maintain first responder medical skills and medics must be highly proficient. Leaders must be prepared to integrate casualty management into any phase of the mission. Leaders must understand that (1) the first casualty can be anyone; (2) the first responder to a casualty can be anyone; (3) medical personnel manage casualty care; and (4) leaders have ownership and responsibility for all aspects of the mission. Foundational to training is a command-directed casualty response system which serves as a forcing function to ensure proficiency and mastery of the basics. Four programs have been developed to train individual and collective tasks that sustain the Ranger casualty response system: (1) Ranger First Responder, (2) Advanced Ranger First Responder, (3) Ranger Medic Assessment and Validation, and (4) Casualty Response Training for Ranger Leaders. Unit collective medical training incorporates tactical leader actions to facilitate the principles of casualty care. Tactical leader actions are paramount to execute a casualty response battle drill efficiently and effectively. Successful execution of this battle drill relies on a command-directed casualty response system and mastery of the basics through rehearsals, repetition, and conditioning.

Dawes JJ, Tramel W, Bartley N, Bricker D, Werth-Bailey K, Brodine L, Clark C, Goldberg P, Pagel K, Federico T, Bullinger D, Canada DM 22(4). 22 - 25 (Journal Article)

Background: The purpose of this preliminary investigation was to determine the impact of a mental and visual skills training (MVST) program on a high-value target identification and marksmanship (HVTM) task among Special Operations Forces (SOF) Soldiers. Methods: Deidentified archival data for 52 male SOF Operators (age: 31.06 ± 4.10 years) were assessed to determine if differences in performance existed between MVST program users (n = 15) and nonusers (n = 37) on a HVTM task performed immediately after a Special Forces Advanced Urban Combat (SFAUC) stress shoot. Independent-samples t-tests were utilized to determine if significant mean score differences existed between groups on specific shooting elements within the HVTM task. Effect size calculations were also performed to assess the magnitude of differences between groups in each measure of performance. Results: Statistically significant differences in performance were not discovered between MVST users and nonusers on overall score (Score) or any individual elements of the HVTM task. However, small to medium effect sizes (d = 0.305-0.493) were observed between groups in Score, Positive Identification Accuracy, Shot Accuracy, and Kill Shot Score. Conclusion: While inconclusive, these findings suggest the use of a MVST program administered by a trained cognitive performance specialist may have the potential to positively influence HVTM performance. More research using larger sample sizes is required to confirm this supposition.