Articles

Walker S, Agree O, Harris R, DesRosiers TT 23(2). 49 (Journal Article)

Introduction: Timely vascular access is critical, as hemorrhage is the number one cause of death on the battlefield. Anecdotal evidence in the Military Health System identified an operationally relevant procedural skills gap in vascular access, and data exist in civilian literature showing high rates of iatrogenic injuries when lack of robust procedural opportunity exists. Multiple pre-deployment training courses are available for surgical providers, but no comprehensive pre-deployment vascular access training exists for non-surgical providers. Methods: This mixed-method review aimed to find relevant, operationally focused, vascular access training publications. A literature review was done to identify both relevant military clinical practice guidelines (CPGs) and full text articles. Reviewers also investigated available pre-deployment trainings for both surgeons and non-surgeons in which course administrators were contacted and details regarding the courses were described. Results: We identified seven full-text articles and four CPGs. Two existing surgical training programs and Army, Navy, and Air Force pre-deployment training standards for non-surgeons were evaluated. Conclusion: A cost-effective and accessible pre-deployment curriculum utilizing reviewed literature in a "learn, do, perfect" structure is suggested, building on pre-existing structures while incorporating remotely accessible didactics, hands-on practice with portable simulation models, and live-feedback training.

Brandt M, Liccardi C, Heidle J, Woods TD, White C, Mullins JR, Blackwell J, Le L, Brantley K 23(2). 44 (Journal Article)

Background: Recent data published by the Special Operations community suggest the Lethal Triad of Trauma should be changed to the Lethal Diamond, to include coagulopathy, acidosis, hypothermia, and hypocalcemia. The purpose of this study is to determine the prevalence of trauma-induced hypocalcemia in level I and II trauma patients. Methods: This is a retrospective cohort study conducted at a level I trauma center and Special Operations Combat Medic (SOCM) training site. Adult patients were identified via trauma services registry from September 2021 to April 2022. Patients who received blood products prior to emergency department (ED) arrival were excluded from the study. Ionized calcium levels were utilized in this study. Results: Of the 408 patients screened, 370 were included in the final analysis of this cohort. Hypocalcemia was noted in 189 (51%) patients, with severe hypocalcemia identified in two (<1%) patients. Thirty-two (11.2%) patients had elevated international normalized ratio (INR), 34 (23%) patients had pH <7.36, 21 (8%) patients had elevated lactic acid, and 9 (2.5%) patients had a temperature of <35°C. Conclusion: Hypocalcemia was prevalent in half of the trauma patients in this cohort. The administration of a calcium supplement empirically in trauma patients from the prehospital environment and prior to blood transfusion is not recommended until further data prove it beneficial.

Reyes J, Kelly J, Badaki-Makun O, Anders J 23(2). 40 (Journal Article)

Introduction: Although the instances of Special Operations Forces (SOF) medical providers treating pediatric pelvic fractures are rare, such fractures are notable injuries in terror attacks and are at high risk for morbidity and mortality for the patient as well as stress for the provider. Presently, guidelines for pediatric-sized pelvic stabilization device application are limited to measured pelvic circumference. This study aims to inform more practical sizing guidelines. Methods: Subjects aged 1 year to 14 years were enrolled. Subject height, weight, pelvic circumference, and fit on the Broselow Pediatric Emergency Tape® (Armstrong Medical Industries), fit with the Pediatric PelvicBinder® (PelvicBinder), and fit with the small SAM Pelvic Sling® (SAM® Medical) were collected. The primary outcome was the proportion of subjects fitting each device. Results: Sixty-five subjects were recruited; median age was 5 years (interquartile range, 1-8 years); 40 (62%) subjects were male. Ninety-one percent of subjects fit within the scale of the Broselow Tape (height <143-cm). One hundred percent of subjects with a height <143-cm had an appropriate fit with the Pediatric PelvicBinder (95% confidence level [CI], 91.8-100%), while 91.7% of subjects with a height >143-cm fit the SAM Pelvic Sling (95%CI, 61.5-99.8%). Conclusions: Providers should attempt to fit the Pediatric PelvicBinder for children >1 year old with suspected unstable pelvic fracture who fall on the Broselow Tape (<143-cm). The small SAM Pelvic Sling should be used for those taller than 143-cm.

Samutsakorn DK, Carius BM 23(3). 36 (Journal Article)

Introduction: Extremity bleeding and subsequent hemorrhagic shock is one of the main causes of preventable battlefield death, leading to mass-fielding of modern tourniquets, such as the Combat Application Tourniquet (CAT; Composite Resources). Numerous look-alike tourniquets, such as the Military Tactical Emergency Tourniquet (MTET; SZCTKlink), flood commercial markets, offering visually near-identical tourniquets for drastically reduced prices. We examined the performance of the MTET compared with that of the CAT. Methods: We undertook a randomized crossover trial to observe self-applied tourniquets to the lower extremity by combat medics, comparing the CAT to the MTET in application time and success rates, proven by loss of distal pulse assessed by Doppler ultrasound in <1 minute. Results: All 50 participants (100%) successfully applied the CAT versus 40 participants (80%) using the MTET (p = .0001). Median application time for the CAT (29.03 seconds; range, 18.63 to 59.50 seconds) was significantly less than those of successful MTET applications (35.27 seconds; range, 17.00 to 58.90 seconds) or failed MTET applications (72.26 seconds; range, 62.84 to 83.96 seconds) (p = .0012). Of 10 MTET failures, three (30%) were from application time >1 minute and seven (70%) from tourniquet mechanical failure. Conclusion: The MTET performed worse than the CAT did in all observed areas. Despite identical appearance, look-alike tourniquets should not be assumed to be equivalent in quality or functionality to robustly tested tourniquets.

Bedolla C, Zilevicius D, Copeland G, Guerra M, Salazar S, April MD, Long B, Naylor JF, De Lorenzo RA, Schauer SG, Hood RL 23(2). 19 (Journal Article)

Introduction: Airway obstruction is the second leading cause of death on the battlefield. The harsh conditions of the military combat setting require that devices be able to withstand extreme circumstances. Military standards (MIL-STD) testing is necessary before devices are fielded. We sought to determine the ability of supraglottic airway (SGA) devices to withstand MIL-STD testing. Methods: We tested 10 SGA models according to nine MIL-STD-810H test methods. We selected these tests by polling five military and civilian emergency-medicine subject matter experts (SMEs), who weighed the relevance of each test. We performed tests on three devices for each model, with operational and visual examinations, to assign a score (1 to 10) for each device after each test. We calculated the final score of each SGA model by averaging the score of each device and multiplying that by the weight for each test, for a possible final score of 2.6 to 26.3. Results: The scores for the SGA models were LMA Classic Airway, 25.9; AuraGain Disposable Laryngeal Mask, 25.5; i-gel Supraglottic Airway, 25.2; Solus Laryngeal Mask Airway, 24.4; LMA Fastrach Airway, 24.4; AuraStraight Disposable Laryngeal Mask, 24.1; King LTS-D Disposable Laryngeal Tube, 22.1; LMA Supreme Airway, 21.0; air-Q Disposable Intubating Laryngeal Airway, 20.1; and Baska Mask Supraglottic Airway, 18.1. The limited (one to three) samples available for testing provide adequate preliminary information but restrict the range of failures that could be discovered. Conclusions: Lower scoring SGA models may not be optimal for military field use. Models scoring sufficiently close to the top performers (LMA Classic, AuraGain, i-gel, Solus, LMA Fastrach, AuraStraight) may be viable for use in the military setting. The findings of our testing should help guide device procurement appropriate for different battlefield conditions.

Schauer SG, Damrow T, Martin SM, Hudson IL, De Lorenzo RA, Blackburn MB, Hofmann LJ, April MD 23(2). 19 (Journal Article)

Background: Airway obstruction is the second leading cause of potentially preventable death on the battlefield. The treatment for airway obstruction is intubation or advanced airway adjunct, which has a known risk of aspiration. We sought to describe the variables associated with aspiration pneumonia after prehospital airway intervention. Methods: This is a sub-analysis of previously described data from the Department of Defense Trauma Registry (DoDTR) from 2007 to 2020. We included casualties that had at least one prehospital airway intervention with documentation of subsequent aspiration pneumonia or pneumonia within three days of the intervention. We used a generalized linear model with Firth bias estimates to test for associations. Results: There were 1,509 casualties that underwent prehospital airway device placement. Of these, 41 (2.7%) met inclusion criteria into the aspiration pneumonia cohort. The demographics had no statistical difference between the groups. The non-aspiration cohort had fewer median ventilator days (2 versus 6, p < 0.001), intensive care unit days (2 versus 7, p < 0.001, and hospital days [3 versus 8, p < 0.001]). Survival was lower in the non-aspiration cohort (74.2% versus 90.2%, p = 0.017). The administration of succinylcholine was higher in the non-aspiration cohort (28.0% versus 12.2%, p = 0.031). In our multivariable model, only the administration of succinylcholine was significant and was associated with lower probability of aspiration pneumonia (odds ratio 0.56). Conclusion: Overall, the incidence of aspiration pneumonia was low in our cohort. The administration of succinylcholine was associated with a lower odds of developing aspiration pneumonia.

Thompson P, Ciarglia A, Handspiker E, Bjerkvig C, Bynum JA, Glassberg E, Gurney J, Hudson AJ, Jenkins DH, Nicholson S, Strandenes G, Braverman MA 23(2). 9 (Journal Article)

Introduction: Tension pneumothorax (TPX) is the third most common cause of preventable death in trauma. Needle decompression at the fifth intercostal space at anterior axillary line (5th ICS AAL) is recommended by Tactical Combat Casualty Care (TCCC) with an 83-mm needle catheter unit (NCU). We sought to determine the risk of cardiac injury at this site. Methods: Institutional data sets from two trauma centers were queried for 200 patients with CT chest. Inclusion criteria include body mass index of ≤30 and age 18-40 years. Measurements were taken at 2nd ICS mid clavicular line (MCL), 5th ICS AAL and distance from the skin to pericardium at 5th ICS AAL. Groups were compared using Mann-Whitney U and chi-squared tests. Results: The median age was 27 years with median BMI of 23.8 kg/m2. The cohort was 69.5% male. Mean chest wall thickness at 2nd ICS MCL was 38-mm (interquartile range (IQR) 32-45). At 5th ICS AAL, the median chest wall thickness was 30-mm (IQR 21-40) and the distance from skin to pericardium was 66-mm (IQR 54-79). Conclusion: The distance from skin to pericardium for 75% of patients falls within the length of the recommended needle catheter unit (83-mm). The current TCCC recommendation to "hub" the 83mm needle catheter unit has potential risk of cardiac injury.

Snyder R, Brillhart DB 99(5). 0 (Journal Article)

Rib fractures are common injuries that cause significant discomfort and can lead to severe pulmonary complications. Rib injury most often results from high-velocity traumatic mechanisms, while rarely representing underlying metastatic disease or secondary injury due to pulmonary illness. Because most rib fractures are caused by obvious trauma, algorithms are focused on treatment rather than investigating the exact mechanism of rib fractures. Chest radiographs are often the initial imaging performed but have proven to be unreliable in identification of rib fracture. Computed tomography (CT) is a diagnostic option as it is more sensitive and specific than simple radiographs. However, both modalities are generally unavailable to Special Operations Forces (SOF) medical personnel working in austere locations. These medical providers could potentially diagnose and treat rib fractures in any environment using a standardized approach that includes clarity of mechanism, pain relief, and point-of-care ultrasound (POCUS). This case demonstrates an approach to the diagnosis and treatment of a rib fracture in a 47-year-old male who presented to a military treatment facility with unlocalized flank and back pain, but the methods employed have applicability to the austere provider working far from the resources of a medical center.

Melanson V, Hershfield J, Deegan MK, Cho H, Perinon D, Bateman SL, Barnhill JC 99(5). 0 (Journal Article)

Massive hemorrhaging remains the most common cause of preventable battlefield deaths. Blood used for trauma care requires a robust donation network, capacity for long-term storage, and extensive and accurate testing. Bioengineering technologies could offer a remedy to these constraints in the form of blood substitutes-fluids that could be transfused into patients to provide oxygen, carry away waste, and aid in coagulation-that would be used in prolonged casualty care and in far-forward settings, overcoming the obstacles of distance and time. The different molecular properties of red blood cells (RBCs), blood substitutes, and platelet replacements contribute to their respective utilities, and each type is currently represented in ongoing clinical trials. Hemoglobin oxygen carriers (HBOCs) are the most advanced RBC replacements, many of which are currently being evaluated in clinical trials in the United States and other countries. Despite recent advancements, challenges remaining in the development of blood alternatives include stability, oxygen capacity, and compatibility. The continued research and investment in new technologies has the potential to significantly benefit the treatment of life-threatening emergency injuries, both on the battlefield and in the civilian sector. In this review, we discuss military blood-management practices and military-specific uses of individual blood components, as well as describe and analyze several artificial blood products that could be options for future battlefield use.

Saint-jean L, Corcostegui S, Galant J, Derkenne C 99(5). 0 (Case Reports)

We report the case of a patient suffering from a chemical burn caused by white phosphorus, for whom initial management required decontamination using multimodal analgesia. This case report should be familiar to other military emergency physicians and Tactical Emergency Medical Support for two reasons: 1) A phosphorus burn occurs from a chemical agent rarely encountered, with minimal research available in the medical literature, despite the use of this weapon in the recent Ukrainian conflict, and 2) We discuss the use of multimodal analgesia, combining loco-regional anesthesia (LRA) and an intranasal pathway, which can be used in a remote and austere environment.

Biggs A, Heller T, Colvin K, Wood D, Jewell JA, Littlejohn LF 99(5). 0 (Journal Article)

Special Operations organizations have recently demonstrated their commitment to enhanced cognitive functioning and improving brain health through the development of a Cognitive Domain. However, as this new enterprise becomes supported by more resources and personnel, a critical question involves what cognitive assessments should be conducted to evaluate cognitive functions. The assessment itself forms a crux in the Cognitive Domain that could mislead cognitive practitioners if not properly applied. Here, the discussion addresses the most important criteria to satisfy in the development of a Special Operations cognitive assessment, including operational relevance, optimization, and speed. Cognitive assessments in this domain must incorporate the following: (1) a task with clear operational relevance to ensure meaningful results, (2) no ceiling effects so that performance can support cognitive enhancement initiatives, and (3) the task itself should impose a minimal time requirement to avoid creating a substantial logistical burden. A dynamic threat assessment task supported by drift diffusion modeling can meet all requisite criteria, while also providing more insight into decision parameters of Special Operations personnel than any currently used test. The discussion concludes with a detailed description of this recommended cognitive assessment task, as well as the research and development steps needed to support its application.

Colesar MT, Baker JB 99(5). 0 (Journal Article)

In the most austere combat conditions, Yugoslav guerillas of World War II (WWII) demonstrated an innovative and effective hospitalization system that saved countless lives. Yugoslav Partisans faced extreme medical and logistical challenges that spurred innovation while waging a guerrilla war against the Nazis. Partisans used concealed hospitals ranging between 25 to 215 beds throughout the country with wards that were often subterranean. Concealment and secrecy prevented discovery of many wards, which prototypically contained two bunk levels and held 30 patients in a 3.5 × 10.5-meter space that included storage and ventilation. Backup storage and treatment facilities provided critical redundancy. Intra-theater evacuation relied on pack animals and litter bearers while partisans relied on Allied fixed wing aircraft for inter-theater evacuation.

Taylor M, Barczak-Scarboro NE, Hernandez L 99(5). 0 (Journal Article)

Purpose: This report describes the development and validation of the U.S. Navy Explosive Ordnance Disposal (EOD) Combat Mindset Scale-Training (CMS-T), a population-specific measure of psychological strategy use in EOD training environments. Methods: Scale items were developed by a working group composed of active-duty technicians from EOD Training and Evaluation Unit 1, Naval Health Research Center scientists, and a psychometrician. The working group developed 30 candidate items, which were administered to EOD accessions (new recruits), advanced students, and technicians (N = 164). Factor structure was explored with principal axis factoring and Varimax rotation with Kaiser normalization. Internal consistencies were established via Cronbach alpha, and convergent validity was evaluated with correlational and ANOVA models. Results: Five internally stable subscales were derived from 19 essential items, explaining 65% of total variance. The subscales were named relaxation, attentional-emotional control (AEC), goal setting-visualization (GSV), internal dialogue (ID), and automaticity. The most frequently used strategies were GSV and ID. Expected relationships emerged between strategies, most notably AEC and mental health. The scale also differentiated between subgroups. Conclusion: The EOD CMS-T demonstrates a stable factor structure, internal reliability, and convergent validity. This study yields a valid, practical, and easily administered instrument to support EOD training and evaluation.

White N, Asato C, Wenthe A, Wang X, Ringgold K, St. John A, Han CY, Bennett JC, Stern SA 99(5). 0 (Journal Article)

Background: Our objective was to optimize a novel damage control resuscitation (DCR) cocktail composed of hydroxyethyl starch, vasopressin, and fibrinogen concentrate for the polytraumatized casualty. We hypothesized that slow intravenous infusion of the DCR cocktail in a pig polytrauma model would decrease internal hemorrhage and improve survival compared with bolus administration. Methods: We induced polytrauma, including traumatic brain injury (TBI), femoral fracture, hemorrhagic shock, and free bleeding from aortic tear injury, in 18 farm pigs. The DCR cocktail consisted of 6% hydroxyethyl starch in Ringer's lactate solution (14mL/kg), vasopressin (0.8U/kg), and fibrinogen concentrate (100mg/kg) in a total fluid volume of 20mL/kg that was either divided in half and given as two boluses separated by 30 minutes as control or given as a continuous slow infusion over 60 minutes. Nine animals were studied per group and monitored for up to 3 hours. Outcomes included internal blood loss, survival, hemodynamics, lactate concentration, and organ blood flow obtained by colored microsphere injection. Results: Mean internal blood loss was significantly decreased by 11.1mL/kg with infusion compared with the bolus group (p = .038). Survival to 3 hours was 80% with infusion and 40% with bolus, which was not statistically different (Kaplan Meier log-rank test, p = .17). Overall blood pressure was increased (p < .001), and blood lactate concentration was decreased (p < .001) with infusion compared with bolus. There were no differences in organ blood flow (p > .09). Conclusion: Controlled infusion of a novel DCR cocktail decreased hemorrhage and improved resuscitation in this polytrauma model compared with bolus. The rate of infusion of intravenous fluids should be considered as an important aspect of DCR.

Jeschke EA, Baker JB, Wyma-Bradley J, Dorsch J, Huffman SL 99(5). 0 (Journal Article)

This will be the second in a series of nine articles in which we discuss findings from our ethnographic study entitled "The Impact of Catastrophic Injury Exposure on Resilience in Special Operations Surgical Teams." Our goal in this article is to establish the practical importance of redefining resilience within a strategic framework. Our bottom-up approach to strategy development explores unconventional resilience as an integrated transformational process that promotes change-agency through the force of movement. Synthesis of empirical data derived from participant interviews and focus groups highlights conceptual attributes that make up the essential components of this framework. To achieve our goal, the authors (1) briefly remind readers how we have problematized conventional resilience; (2) explain how we analyzed qualitative quotes to extrapolate our definition of unconventional resilience; and (3) describe in detail our strategic framework. We conclude by gesturing to why this strategic framework is applicable to practical performance of all Special Operation Forces (SOF) medics.

Montagnon R, Cungi P, Aoun O, Morand G, Desmottes J, Pasquier P, Travers S, Aigle L, Dubecq C 99(5). 0 (Journal Article)

Background: Pain management is essential in military medicine, particularly in Tactical Combat Casualty Care (TCCC) during deployments in remote and austere settings. The few previously published studies on intranasal analgesia (INA) focused only on the efficacy and onset of action of the medications used (ketamine, sufentanil, and fentanyl). Side-effects were rarely reported. The aim of our study was to evaluate the use of intranasal analgesia by French military physicians. Methods: We carried out a multicentric survey between 15 January and 14 April 2020. The survey population included all French military physicians in primary-care centers (n = 727) or emergency departments (n = 55) regardless of being stationed in mainland France or French overseas departments and territories. Results: We collected 259 responses (33% responsiveness rate), of which 201 (77.6%) physicians reported being familiar with INA. However, regarding its use, of the 256 physicians with completed surveys, only 47 (18.3%) had already administered it. Emergency medicine physicians supporting highly operational units (e.g., Special Forces) were more familiar with this route of administration and used it more frequently. Ketamine was the most common medication used (n = 32; 57.1%). Finally, 234 (90%) respondents expressed an interest in further education on INA. Conclusion: Although a majority of French military physicians who replied to the survey were familiar with INA, few used it in practice. This route of administration seems to be a promising medication for remote and austere environments. Specific training should, therefore, be recommended to spread and standardize its use.

Cetin M, Ylidirim M 99(5). 0 (Journal Article)

Background: Today, asymmetric conflict and terrorism pose a threat to not only soldiers but also civilians, forcing the North Atlantic Treaty Organization (NATO) to confront new threats and rethink its strategy. Various studies have shown that telemedicine is one of these advancements and that it can eventually bring expert advice to the field. Telemedicine, on the other hand, is new in Turkey and has yet to be implemented in the field. The aim of this study is to evaluate the support of health personnel with telemedicine from the perspective of military physicians. Methods: This study was carried out between 20 August 2021 and 5 October 2021 with the participation of 47 military physicians working as research assistants in a training and research hospital. A questionnaire consisting of 17 questions was used to evaluate military physicians' perspectives on telemedicine and their expectations from it. Results: Forty-six of the participants stated that they wanted a healthcare provider/expert opinion to consult about the patient/injured while they were on field and that telemedicine could be used within the scope of field medicine (4.51 ± 0.62). They also stated that telemedicine centers should employ emergency medicine specialists in particular (n = 40, 85.1%). The participants agreed that these centers would be quite useful, particularly for medical evacuations (n = 42, 89.4%). Conclusion: Telemedicine's long-term viability in our country is thought to be contingent upon it covering medical conditions that are practical, require fewer technical intricacies, and appeal to emergency health services. The openness of the personnel to innovation and change is expected to improve harmony and cooperation.

Kragh JF, O'Conor DK 99(5). 0 (Journal Article)

We sought to better understand the frostbite risk during first-aid tourniquet use by reviewing information relevant to an association between tourniquet use and frostbite. However, there is little information concerning this subject, which may be of increasing importance because future conflicts against near-peer competitors may involve extreme cold weather environments. Historically, clinical frostbite cases with tourniquet use occurred in low frequency but in high severity when leading to limb amputation. The physiologic response of vasoconstriction to cold exposure leads to limb cooling and causes a reduction of limb blood flow, but cold-induced vasodilation ensues as periodic fluctuations that increase blood flow to hands and feet. In animal experiments, tourniquet use increased the development of frostbite. Evidence from human experiments also supports an association between tourniquet use and frostbite. Clinical guidance for caregiving to casualties at risk for frostbite with tourniquet use had previously been provided but slowly and progressively dropped out of documents. Conclusions: The cause of frostbite was deduced to be a sufficiently negative heat-transfer trend in local tissues, which tourniquet use may worsen because of decreasing tissue perfusion. An association between tourniquet use and frostbite exists but not as cause and effect. Tourniquet use increased the risk of the cold causing frostbite by allowing faster cooling of a limb because of reduced blood flow and lack of cold-induced vasodilation. Care providers above the level of the lay public are warned that first-aid tourniquet use in low-temperature (<0°C [<32°F]) environmental conditions risks frostbite.

Anderson JL, Kronstedt S, Bergens MA, Johannigman J 99(5). 0 (Journal Article)

Speicher MV, McGowan J, Pruett S, Shurden J, Bianchi W, Kibler A 99(5). 0 (Journal Article)

Trauma casualty care has historically been the cornerstone of special operations military medical training. A recent case of myocardial infarction at a remote base of operations in Africa highlights the importance of foundational medical knowledge and training. A 54-year-old government contractor supporting operations in the AFRICOM area of responsibility (AOR) presented to the Role 1 medic with substernal chest pain with onset during exercise. Abnormal rhythm strips concerning for ischemia were obtained from his monitors. A MEDEVAC to a Role 2 facility was arranged and executed. At the Role 2 a non-ST-elevation myocardial infarction (NSTEMI) was diagnosed. The patient was emergently evacuated on a lengthy flight to a civilian Role 4 treatment facility for definitive care. He was found to have a 99% occlusion of the left anterior descending (LAD) coronary artery, as well as a 75% occlusion of the posterior coronary artery and a chronic 100% occlusion of the circumflex artery. The LAD and posterior arteries were stented, and the patient made a favorable recovery. This case highlights the importance of preparedness for medical emergencies and care of medically critical patients in remote and austere locations.