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Injuries And Footwear (Part 2): Minimalist Running Shoes

Knapik JJ, Orr R, Pope R, Grier T 16(1). 89 - 96 (Journal Article)

This article defines minimalist running shoes and examines physiological, biomechanical, and injury rate differences when running in conventional versus minimalist running shoes. A minimalist shoe is one that provides "minimal interference with the natural movement of the foot, because of its high flexibility, low heel to toe drop, weight and stack height, and the absence of motion control and stability devices." Most studies indicate that running in minimalist shoes results in a lower physiological energy cost than running in conventional shoes, likely because of the lower weight of the minimalist shoe. Most individuals running in conventional shoes impact the ground heel first (rearfoot strike pattern), whereas most people running in minimalist shoes tend to strike with the front of the foot (forefoot strike pattern). The rate at which force is developed on ground impact (i.e., the loading rate) is generally higher when running in conventional versus minimalist shoes. Findings from studies that have looked at associations between injuries and foot strike patterns or injuries and loading rates are conflicting, so it is not clear if these factors influence injury rates; more research is needed. Better-designed prospective studies indicate that bone stress injuries and the overall injury incidence are higher in minimalist shoes during the early weeks (10-12 weeks) of transition to this type of footwear. Longer-term studies are needed to define injury rates once runners are fully transitioned to minimalist shoes. At least one longer-term minimalist-shoe investigation is ongoing and, hopefully, will be published soon.

A Threat-based, Statewide EMS Protocol To Address Lifesaving Interventions In Potentially Volatile Environments

Levy MJ, Straight KM, Marino MJ, Alcorta RL 16(1). 98 - 102 (Journal Article)

Red Rash

Banting J, Meriano T 16(1). 76 - 80 (Journal Article)

The series objective is to review various clinical conditions/ presentations, including the latest evidence on management, and to dispel common myths. In the process, core knowledge and management principles are enhanced. A clinical case will be presented. Cases will be drawn from real life but phrased in a context that is applicable to the Special Operations Forces (SOF) or tactical emergency medical support (TEMS) environment. Details will be presented in such a way that the reader can follow along and identify how they would manage the case clinically depending on their experience and environment situation. Commentary will be provided by currently serving military medical technicians. The medics and author will draw on their SOF experience to communicate relevant clinical concepts pertinent to different operational environments including SOF and TEMS. Commentary and input from active special operations medical technicians will be part of the feature.

Sleep As A Strategy For Optimizing Performance

Yarnell AM, Deuster PA 16(1). 81 - 85 (Journal Article)

Recovery is an essential component of maintaining, sustaining, and optimizing cognitive and physical performance during and after demanding training and strenuous missions. Getting sufficient amounts of rest and sleep is key to recovery. This article focuses on sleep and discusses (1) why getting sufficient sleep is important, (2) how to optimize sleep, and (3) tools available to help maximize sleep-related performance. Insufficient sleep negatively impacts safety and readiness through reduced cognitive function, more accidents, and increased military friendly-fire incidents. Sufficient sleep is linked to better cognitive performance outcomes, increased vigor, and better physical and athletic performance as well as improved emotional and social functioning. Because Special Operations missions do not always allow for optimal rest or sleep, the impact of reduced rest and sleep on readiness and mission success should be minimized through appropriate preparation and planning. Preparation includes periods of "banking" or extending sleep opportunities before periods of loss, monitoring sleep by using tools like actigraphy to measure sleep and activity, assessing mental effectiveness, exploiting strategic sleep opportunities, and consuming caffeine at recommended doses to reduce fatigue during periods of loss. Together, these efforts may decrease the impact of sleep loss on mission and performance.

Accuracy and Reliability of Triage at the Point of Injury During Operation Enduring Freedom

Plackett TP, Nielsen JS, Hahn CD, Rames JM 16(1). 51 - 56 (Journal Article)

Background: Accurate point-of-injury reports and casualty evacuation requests allow for optimal resource utilization. However, the accuracy of these reports has not been previously studied. Methods: All trauma patients treated at one of three forward surgical elements (FSE) in Western Afghanistan during May-August 2012 were prospectively included. North American Treaty Organization (NATO) 9-line medical evacuation request and mechanism, injuries, signs, and treatments (MIST) reports were compared to the initial findings on arrival to the FSE. Results: There were 179 casualty evacuation reports and 298 patients. NATO 9-line and/or MIST reports were available for 70% of these. Triage was accurate for 77%, but there was 17% overtriage and 6% undertriage (k = .619). The number of patients was accurate in 95% of reports, the mechanism of injury was accurate for 98%, and the body region involved was accurate for 92% (k = .850, .943, and .870, respectively). There was no difference between the mean vital signs at the point of injury or on arrival at the FSE. When analyzed individually, however, there was no correlation between each casualty's pulse, mean arterial pressure, or respiratory rate between the two time points. Discussion: There was a high degree of correlation between the triage category of casualty evacuation reports and the patient's actual medical needs. There was also a highly significant association with the number of patients, mechanism of injury, and bodily injuries. However, there was discordance between the vital signs at an individual level, which may represent regression toward the resuscitation threshold.

SOLCUS: Update On Point-of-Care Ultrasound In Special Operations Medicine

Hampton K, Vasios WN, Loos PE 16(1). 58 - 61 (Journal Article)

Point-of-care ultrasonography has been recognized as a relevant and versatile tool in Special Operations Forces (SOF) medicine. The Special Operator Level Clinical Ultrasound (SOLCUS) program has been developed specifically for SOF Medics. A number of challenges, including skill sustainment, high-volume training, and quality assurance, have been identified. Potential solutions, including changes to content delivery methods and application of tele-ultrasound, are described in this article. Given the shift in operational context toward extended care in austere environments, a curriculum adjustment for the SOLCUS program is also proposed.

Testing of Junctional Tourniquets by Medics of the Israeli Defense Force in Control of Simulated Groin Hemorrhage

Chen J, Benov A, Nadler R, Landau G, Sorkin A, Aden JK, Kragh JF, Glassberg E 16(1). 36 - 42 (Journal Article)

Background: Junctional hemorrhage is a common cause of battlefield death but little is known about testing of junctional tourniquet models by medics. The purpose of the testing described herein is to assess military experience in junctional tourniquet use in simulated prehospital care. Methods: Fourteen medics were to use the following four junctional tourniquets: Combat Ready Clamp (CRoC), Abdominal Aortic Junctional Tourniquet (AAJT), Junctional Emergency Treatment Tool (JETT), and SAM Junctional Tourniquet (SJT). The five assessment categories were safety, effectiveness, time to effectiveness, and two categories of user preference: (1) by all models assessed, and (2) by only the model most preferred. Users ranked preference by answering, "If you had to go to war today and you could only choose one, which tourniquet would you choose to bring?" Results: All tourniquet uses were safe. By the time the first five testers were done, all three AAJT models had been broken. CRoC and AAJT had the highest percentage effectiveness as their difference was not statistically significant. SJT and JETT had fastest mean times to effectiveness as their difference was not significant. For preference, using each user's ranking of all models assessed, SJT and AAJT were most preferred as their difference was not significant. For each user's most preferred model, SJT, AAJT, and JETT were most preferred as their difference was not significant. Conclusion: In the five assessment categories, multiple tourniquet models performed similarly well; SJT and AAJT performed best in four categories, JETT was best in three, and CRoC was best in two. Differences between the top-ranked models in each category were not statistically significant.

Evaluation and Testing of Junctional Tourniquets by Special Operation Forces Personnel: A Comparison of the Combat Ready Clamp and the Junctional Emergency Treatment Tool

Theodoridis CA, Kafka KE, Perez AM, Curlee JB, Yperman PC, Oppermann N, Holmstroem E, Niegsch DD, Mannino A, Ramundo N 16(1). 44 - 50 (Journal Article)

Background: Previous research has shown that external hemorrhage from proximal leg amputations and junctional sites represents 19.2% of potentially survivable lethal hemorrhage. A recent effort to address this problem has resulted in the development of various junctional tourniquets. This study assessed and compared two Tactical Combat Casualty Care Committee-approved junctional tourniquets, the Combat Ready Clamp (CRoC) and the Junctional Emergency Treatment Tool (JETT), to contribute to their future development and to better inform on the decisions for device selection by military units. Aims of the study also were to provide concrete feedback and suggestions on how to effectively apply the devices. Methods: Via a specific questionnaire, 75 international attendees of the International Special Training Centre Medical Branch Special Operations Forces Advanced Medical First Responder course evaluated the CRoC and the JETT on different parameters. Both devices were tested objectively through timed applications aimed at stopping unilateral lower-extremity distal pulse on 33 of these 75 students, verified by palpation by Medical Branch instructors. Subjective and objective data were examined for mutual correlation. Results: Users ranked the JETT higher than the CRoC on all parameters, including effectiveness on the battlefield (ρ < .001), ease of use (ρ < .039), speed of application (ρ < .001), and not slipping in use (ρ < .001), although the difference on other parameters such as effectiveness in hemorrhage control was not statistically significant. Considering all parameters together, the JETT was evaluated as a better device than the CRoC (ρ < .001). The application time measurement suggested that the JETT was applied faster (by approximately 15 seconds on average; p < .001). The fastest CRoC and JETT applications were 37 and 29 seconds, respectively. The JETT was not easier to use or more effective than the CRoC; there was a 9% failure rate of the JETT occluding a unilateral common femoral artery. The JETT's efficacy in occluding a unilateral common femoral artery can be compromised if the device's pelvic binder is not sufficiently tightened prior to threading the T-handled pad. The CRoC's application time can be drastically reduced if the device is kept assembled and firm pressure is immediately asserted upon placement on the intended location through the vertical arm, then threading the device. Both devices were applied safely; no adverse effects were reported during or after application. Conclusion: Even though the JETT might be preferred by military medical providers, the CRoC still has merits. As both devices proved to occlude the arterial flow in no less than 54 seconds on average, they could be used to supplement direct pressure and wound packing, the latter two still being considered the immediate actions for inguinal bleeding control. Considering that the CRoC and the JETT can be applied in as little as 37 and 29 seconds, respectively, users should be effectively trained and entirely proficient on either device to justify their election as the primary countermeasure to hemorrhage not amenable to regular tourniquets.

Management of External Hemorrhage in Tactical Combat Casualty Care: The Adjunctive Use of XStat™ Compressed Hemostatic Sponges: TCCC Guidelines Change 15-03

Sims K, Montgomery HR, Dituro P, Kheirabadi BS, Butler FK 16(1). 19 - 28 (Journal Article)

Exsanguination from wounds in the so-called junctional regions of the body (i.e., the neck, the axilla, and the groin) was responsible for 19% of the combat fatalities who died from potentially survivable wounds sustained in Afghanistan or Iraq during 2001 to 2011. The development of improved techniques and technology to manage junctional hemorrhage has been identified in the past as a high-priority item by the Committee on Tactical Combat Casualty Care (CoTCCC) and the Army Surgeon General's Dismounted Complex Blast Injury (DCBI) Task Force. Additionally, prehospital care providers have had limited options with which to manage hemorrhage resulting from deep, narrow-track, penetrating trauma. XStat™ is a new product recently approved by the US Food and Drug Administration as a hemostatic adjunct to aid in the control of bleeding from junctional wounds in the groin or axilla. XStat has now been recommended by the CoTCCC as another tool for the combat medical provider to use in the management of junctional hemorrhage. The evidence that supports adding XStat to the TCCC Guidelines for the treatment of external hemorrhage is summarized in this paper.

Preliminary Comparison of New and Established Tactical Tourniquets in a Manikin Hemorrhage Model

Gibson R, Housler GJ, Rush SC, Aden JK, Kragh JF, Dubick MA 16(1). 29 - 35 (Journal Article)

Background: Emergency tourniquet use has been associated with hemorrhage control and improved survival during the wars since 2001. The purpose of the present study is to compare the differential performance of two new tactical tourniquets with the standard-issue tourniquet to provide preliminary evidence to guide decisions on device development. Methods: A laboratory experiment was designed to test the effectiveness of tourniquets on a manikin thigh. Three models of tourniquets were assessed. The Rapid Application Tourniquet System (RATS) and the Tactical Mechanical Tourniquet (TMT) were compared with the standard-issue Combat Application Tourniquet® (C-A-T). Two users conducted 30 tests each. Results: Percentages for effectiveness (hemorrhage control, yes/no) and distal pulse cessation did not differ significantly by model. When compared with the RATS, the C-A-T performed better (ρ < .001) for time to hemorrhage control and fluid loss. The C-A-T and TMT had comparable responses for most measures, but the C-A-T applied more pressure (ρ = .04) than did the TMT for hemorrhage control. Conclusion: All three tactical tourniquets showed substantial capacity for hemorrhage control. However, the two new tourniquet models (RATS and TMT) did not offer any improvement over the C-A-T, which is currently issued to military services. Indeed, one of the new models, the RATS, was inferior to the C-A-T in terms of speed of application and simulated loss of blood. Opportunities were detected for refinements in design of the two new tourniquets that may offer future improvements in their performance.

Compensatory Reserve for Early and Accurate Prediction of Hemodynamic Compromise: Case Studies for Clinical Utility in Acute Care and Physical Performance

Stewart CL, Nawn CD, Mulligan J, Grudic G, Moulton SL, Convertino VA 16(1). 6 - 13 (Journal Article)

Background: Humans are able to compensate for significant loss of their circulating blood volume, allowing vital signs to remain relatively stable until compensatory mechanisms are overwhelmed. The authors present several clinical and performance case studies in an effort to demonstrate real-time measurements of an individual's reserve to compensate for acute changes in circulating blood volume. This measurement is referred to as the Compensatory Reserve Index (CRI). Methods: We identified seven clinical and two physical performance conditions relevant to military casualty and operational medicine as models of intravascular volume compromise. Retrospective analysis of photoplethysmogram (PPG) waveform features was used to calculate CRI, where 1 represents supine normovolemia and 0 represents hemodynamic decompensation. Results: All cases had CRI values suggestive of volume compromise (<0.6) not otherwise evident by heart rate and systolic blood pressure. CRI decreased with reduced central blood volume and increased with restored volume (e.g., fluid resuscitation). Conclusion: The results from these case studies demonstrate that machine-learning techniques can be used to (1) identify a clinical or physiologic status of individuals through real-time measures of changes in PPG waveform features that result from compromise to circulating blood volume and (2) signal progression toward hemodynamic instability, with opportunity for early and effective intervention, well in advance of changes in traditional vital signs.

Short Report Comparing Generation 6 Versus Prototype Generation 7 Combat Application Tourniquet® in a Manikin Hemorrhage Model

Kragh JF, Moore VK, Aden JK, Parsons DL, Dubick MA 16(1). 14 - 17 (Journal Article)

Background: The Combat Application Tourniquet® (C-A-T) is the standard-issue military tourniquet used in first aid in 2015, and the current model is called Generation 6. Soldiers in the field, however, have been asking for design changes in a possible Generation 7 to improve ease of use. This study compared the differential performance in use of the C-A-T in two designs: Generation 6 (C-A-T 6) versus a prototype Generation 7 (C-A-T 7). Methods: A laboratory experiment was designed to test the performance of two tourniquet designs in hemorrhage control, ease of use, and user preference. Ten users of the two C-A-T models placed them on a manikin thigh to stop simulated bleeding. Users included trauma researchers and instructors of US Army student medics. Ten users conducted 20 tests (10 each of both designs). Results: Most results were not statistically significant in their difference by C-A-T design. The mean difference in blood loss was statistically significant (ρ = .03) in that the C-A-T 7 performed better than the C-A-T 6, but only in the mixed statistical model analysis of variance, which accounted for user effects. The difference in ease-of-use score was statistically significant (ρ = .002); the C-A-T 7 was easier. All users preferred the C-A-T 7. Conclusion: In each measure, the C-A-T Generation 7 prototype performed similar or better than Generation 6, was easier to use, and was preferred.

Integrated Education of All Responders

McSwain NE 15(4). 160 - 162 (Journal Article)

Physical Therapy Treatment Of Chronic Neck Pain A Discussion And Case Study: Using Dry Needling And Battlefield Acupuncture

Guthrie RM, Chorba R 16(1). 1 - 5 (Case Reports)

Purpose: Chronic mechanical neck pain can have a complex clinical presentation and is often difficult to treat. This case study illustrates a successful physical therapy treatment approach using dry needling and auricular acupuncture techniques. Case Report: A 51-year-old active-duty, male US Marine was treated by a physical therapist in a direct-access military clinic for chronic neck pain poorly responsive to previous physical therapy, pharmacologic, and surgical interventions. Needling techniques were combined with standard physical therapy interventions to address the comprehensive needs of the patient. Within five treatments, the patient reported reduced pain levels from 8-9/10 to 0-2/10, improved sleep quality, and increased function with daily activities. Over several months, the patient reduced multiple medication use by greater than 85%. The effects of treatment were lasting, and the patient accomplished a successful transition to an independent maintenance program. Conclusion: Needling techniques have the potential to expedite favorable physical therapy outcomes for active-duty service members suffering from chronic mechanical and degenerative neck pain. The dramatic improvements observed in this case warrant additional exploration of treatment efficacy and delineation of best practices in the delivery of these techniques.

Hemorrhage Control Devices: Tourniquets and Hemostatic Dressings

Holcomb JB, Butler FK, Rhee P 15(4). 153 - 156 (Journal Article)

Deconstructing the Definition of Prolonged Field Care

Keenan S 15(4). 125 (Journal Article)

The Continuing Threat of Intentional Mass Casualty Events in the U.S.

Fabbri WP 15(4). 142 - 145 (Journal Article)

Recovery of Bacteria and Fungi From a Leg Wound

Washington MA, Barnhill JC, Duff MA, Griffin J 15(4). 113 - 116 (Journal Article)

Acute and chronic wound infections can both be encountered in the deployed setting. These wounds are often contaminated by bacteria and fungi derived from the external environment. In this article, we present the case of a wound infection simultaneously colonized by Enterobacter cloacae (a bacterial pathogen) and Trichosporon asahii (an unusual fungal pathogen). We describe the examination and treatment of the patient and review the distinguishing characteristics of each organism

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