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Crimean-Congo Hemorrhagic Fever

Burnett MW 15(4). 96 - 98 (Journal Article)

In mid-September 2009, a 22-year-old critically ill Soldier was medically evacuated from a treatment facility in southern Afghanistan to Landstuhl Regional Medical Center in Germany. Despite the efforts of the team at Landstuhl, this patient died and became the US military's first known victim of Crimean-Congo hemorrhagic fever (CCHF). CCHF is caused by a virus, which bears the same name. Because a vaccine is lacking, as well as an effective antiviral treatment, prevention is key.

Middle East Respiratory Syndrome

Shishido AA, Letizia A 15(4). 99 - 101 (Journal Article)

Middle East respiratory syndrome (MERS) emerged in the Arabian Peninsula in 2012, and subsequently spread to other countries in Europe and Asia, and to the United States. As of August 2015, the disease has infected 1,400 patients, of whom 500 have died, yielding a 36% mortality rate. The exact mode of transmission is unknown and there are no proven treatments. While the overall case rate for MERS has been low, its presence in countries that house US troops, unknown mode of transmission, and high mortality rate make it a significant health concern among US military personnel.

Fever and Thrombocytopenia in a Returning Soldier

Downs JW, Biggane PJ 15(4). 75 - 78 (Journal Article)

A case of fever and thrombocytopenia in a 33-year-old Special Forces Soldier with recent deployment to the Philippines is discussed, as are differential diagnosis and initial medical management at an overseas, fixed US military medical treatment facility. The authors discuss lessons learned that are applicable for Special Operations Forces (SOF) medical providers and recommend a renewed and continued emphasis on tropical medicine and infectious disease training for SOF medical providers.

Taser and Conducted Energy Weapons

LeClair TG, Meriano T 15(4). 83 - 88 (Journal Article)

Garrison Clinical Setting Inadequate for Maintenance of Procedural Skills for Emergency Medicine Physicians: A Cross-Sectional Study

Schauer SG, Varney SM, Cox KL 15(4). 67 - 70 (Journal Article)

Background: Emergency medicine physicians (EPs) are often placed in far-forward, isolated areas in theater. Maintenance of their emergency intervention skills is vital to keep the medical forces deployment ready. The US Army suggests that working at a Military Treatment Facility (MTF) is sufficient to keep emergency procedural skills at a deployment-ready level. We sought to compare the volume of emergency procedures that providers reported necessary to maintain their skills with the number available in the MTF setting. Methods: EPs were surveyed to quantify the number of procedures they reported they would need to perform yearly to stay deployment-ready. We obtained procedure data for their duty stations and compared the procedure volume with the survey responses to determine if working at an MTF is sufficient to keep providers' skills deployment ready. Results: The reported necessary average numbers per year were as follows: tube thoracostomy (5.9), intubation (11.4), cricothyrotomy (4.2), lumbar puncture (5.2), central line (10.0), focused assessment with sonography for trauma (FAST) (21.3), reductions (10.6), splints (10.5), and sedations (11.7). None of the procedure volumes at MTFs met provider requirements with the exception of FAST examinations at the only trauma center. Conclusions: This suggests the garrison clinical environment is inadequate for maintaining procedure skills. Further research is needed to determine modalities that will provide adequate training volume.

Remote Telementored Ultrasound-Directed Compression to Potentially Accelerate Hemostasis in Exsanguinating Junctional Vascular Injuries

Kirkpatrick AW, McKee JL, McKee I, Panebianco NL, Ball CG 15(4). 71 - 74 (Journal Article)

Bleeding to death has been identified as the leading cause of potentially preventable injury-related death worldwide. Temporary hemorrhage control could allow the patient to be transported to a site capable of damage- control surgery. A novel device that may offer a fast and effective means of controlling nontruncal bleeding (junctional and extremity) is the iTClamp (Innovative Trauma Care; This case study demonstrated that a motivated and intelligent, but untrained, first responder could successfully localize the actual anatomic site of an exsanguinating bleed and then could relatively easily compress this site to control the bleeding site by using ultrasound-guided manual-compression techniques.

Evaluating Alternatives to Traditional Cotton Laparotomy Sponges for Blood Absorption in the Austere and Mobile Surgical Environment

Sirkin MR, Cook P, Davis KG 15(4). 54 - 58 (Journal Article)

Background: The operative control of noncompressible hemorrhage is the single largest impact that could be addressed in reducing the mortality on the battlefield. Laprotomy pads, traditionally used for hemorrhage evacuation, are made of woven cotton, and, while effective, their use requires a substantial amount of space and adds weight. This poses no concern in traditional operating rooms but is a hindrance for mobile providers and providers in austere environments. We sought to compare different absorptive compunds to ascertain their utility as alternatives for traditional laparotomy pads. Methods: Samples of cotton laparotomy pads, pure rayon sheets, rayon-polypropylene composite sheets, and non-polyester composite "microfiber" sheets were weighed and submerged in heparinized whole bovine blood. After saturation, the favrics were weighed, wrung dry, reweighed, and resubmerged. This process was performed for a total of three sequential submersions. The saturated weights and dry weights of each fabric were used to calculate how much blood each fabric could absorb initially and after multiple repeated uses. The initial densities of the four fabrics was calculated and compared. Results: The initial submersions demonstrated that 1g each of cotton, rayon, rayon-polypropylene, and nylon-polyester were able to absorb 7.58g, 12.98g, 10.16g, and 9.73g of blood respectively. The second and third sequential trials, which were statistically similar, demonstrated that 1g of cotton, rayon, rayon-polypropolyene, and nylon-polyester were able to absorb 1.73g, 2.83g, 2.3g, and 2.3g of blood, respectively. The calculated densities of cotton, rayon, rayon-polypropylene, and nylon-polyester were 0.087g/cm³, .012g/cm³, 0.098g/cm³, and 0.093g/cm³, respectively. Conclusion: Per gram, rayon absorbed approximately 1.7 times more blood thancotton and three-quarters the amount of the storage space. Rayon also retained its superior absorption abilites on repeated uses, demonstrating the potential for re-use in remote and austere environments. Thus, rayon could serve as a viable alternative to traditional cotton laparotomy pads in the austere environments.

OK, Doc . . . What Do I Really Have? Posttraumatic Stress Disorder Versus Traumatic Brain Injury

Figueroa XA, Wright JK 15(4). 59 - 66 (Journal Article)

The authors review the diagnostic overlap that exists between posttraumatic stress disorder (PTSD) and traumatic brain injury (TBI). Achieving the correct diagnosis is much more difficult and the potential to inappropriately treat patients is greater than most physicians realize. The need to properly diagnose and select appropriate treatment strategies is essential, especially with TBI cases. A number of new and experimental therapies are being used to treat PTSD effectively and reverse the neurological sequelae of TBI, potentially returning to active duty Servicemembers who are undergoing a medical review board.

Different Width and Tightening System: Emergency Tourniquets on Distal Limb Segments

Wall PL, Sahr SM, Buising CM 15(4). 28 - 38 (Journal Article)

Background: Tourniquets are used on distal limb segments. We examined calf and forearm use of four thigh-effective, commercial tourniquets with different widths and tightening systems: 3.8cm windlass Combat Application Tourniquet® (CAT, and Special Operations Forces® Tactical Tourniquet-Wide (SOFTTW,, 3.8cm ratchet Ratcheting Medical Tourniquet - Pediatric (RMT-P, www.ratchetingbuckles. com), and 10.4cm elastic Stretch-Wrap-And-Tuck Tourniquet® (SWATT, Methods: From Doppler-indicated occlusion, windlass completion was the next securing opportunity; ratchet completion was one additional tooth advance; elastic completion was end tucked under a wrap. Results: All applications on the 16 recipients achieved occlusion. Circumferences were calf 38.1 ± 2.5cm and forearm 25.1 ± 3.0cm (p < .0001, t-test, mean ± SD). Pressures at Occlusion, Completion, and 120-seconds after Completion differed within each design (p < .05, one-way ANOVA; calf: CAT 382 ± 100, 510 ± 108, 424 ± 92mmHg; SOFTT-W 381 ± 81, 457 ± 103, 407 ± 88mmHg; RMT-P 295 ± 35, 350 ± 38, 301 ± 30mmHg; SWATT 212 ± 46, 294 ± 59, 287 ± 57mmHg; forearm: CAT 301 ± 100, 352 ± 112, 310 ± 98mmHg; SOFTT-W 321 ± 70, 397 ± 102, 346 ± 91mmHg; RMT-P 237 ± 48, 284 ± 60, 256 ± 51mmHg; SWATT 181 ± 34, 308 ± 70, 302 ± 70mmHg). Comparing designs, pressures at each event differed (p < .05, one-way ANOVA), and the elastic design had the least pressure decrease over time (p < .05, one-way ANOVA). Occlusion losses differed among designs on the calf (p < .05, χ²; calf: CAT 1, SOFTT-W 5, RMT-P 1, SWATT 0; forearm: CAT 0, SOFTT-W 1, RMT-P 2, SWATT 0). Conclusions: All four designs can be effective on distal limb segments, the SWATT doing so with the lowest pressures and least pressure losses over time. The pressure change from Occlusion to Completion varies by tourniquet tightening system and can involve a pressure decrease with the windlass tightening systems. Pressure losses occur in as little as 120 seconds following Completion and so can loss of Occlusion. This is especially true for nonelastic strap tourniquet designs.

Comprehensive Performance Nutrition for Special Operations Forces

Daigle KA, Logan CM, Kotwal RS 15(4). 40 - 53 (Journal Article)

Special Operations Forces (SOF) training, combat, and contingency operations are unique and demanding. Performance nutrition within the Department of Defense has emphasized that nutrition is relative to factors related to the desired outcome, which includes successful performance of mentally and physically demanding operations and missions of tactical and strategic importance, as well as nonoperational assignments. Discussed are operational, nonoperational, and patient categories that require different nutrition strategies to facilitate category-specific performance outcomes. Also presented are 10 major guidelines for a SOF comprehensive performance nutrition program, practical nutrition recommendations for Special Operators and medical providers, as well as resources for dietary supplement evaluation. Foundational health concepts, medical treatment, and task-specific performance factors should be considered when developing and systematically implementing a comprehensive SOF performance nutrition program. When tailored to organizational requirements, SOF unit- and culture-specific nutrition education and services can optimize individual Special Operator performance, overall unit readiness, and ultimately, mission success.

Hypolipidemia in a Special Operations Candidate: Case Report and Review of the Literature

Strain JE, Vigilante JA, DiGeorge NW 15(4). 1 - 5 (Journal Article)

Background: A 19-year-old male military recruit who presented for a screening physical for US Naval Special Warfare Duty was found to have hypolipidemia. Medical history revealed mildly increased frequency of bowel movements, but was otherwise unremarkable. His presentation was most consistent with heterozygous familial hypobetalipoproteinemia (FHBL), and the patient was cleared for Special Operations duty. Methods: A literature search was conducted using PubMed/MEDLINE. Keywords included familial hypobetalipoproteinemia, heterozygous familial hypobetalipoproteinemia, abetalipoproteinemia, hypolipidemia, diving, special operations, and military. Results that included cases of familial hypobetalipoproteinemia were included. Results: Review of the literature reveals that FHBL is a genetic disorder frequently, but not always, due to a mutation in the apolipoprotein B (apoB) gene. Those with the condition should be screened for ophthalmologic, neurologic, and gastrointestinal complications. Analysis of the disease, as well as the absence of reported cases of FHBL in diving and Special Operations, suggest there is minimal increased risk in diving and Special Operations for patients who are likely heterozygous, are asymptomatic, and have a negative workup for potential complications from the disease. Conclusion: Individuals with presumed or proven heterozygous FHBL seeking clearance for Special Operations duty should be given precautions, undergo careful questioning for history of disease-specific complications, and should have a baseline evaluation. If negative, it seems reasonable to clear the patient for Special Operations and diving.

Testing Tourniquet Use in a Manikin Model: Two Improvised Techniques

Lyles WE, Kragh JF, Aden JK, Dubick MA 15(4). 21 - 26 (Journal Article)

Background: Improvised tourniquets may be used to treat limb wound hemorrhage, but there is little evidence for best techniques of use. The purpose of the present study is to compare use of two techniques of improvised tourniquet application and use of a common commercial tourniquet that is nonimprovised. Methods: A laboratory experiment was conducted to assess three groups of strap-and-windlass tourniquet designs on a manikin to test for differences in performance. Groups included two types of improvised tourniquets (bandage and bandana) and a third group that served as a control, the commercial Combat Application Tourniquet. Two users performed 10 tests of each group. Results: The commercial CAT had 100% effectiveness, but both improvised tourniquets had poor effectiveness (40% and 10% for the bandage and bandana groups, respectively). The commercial CAT performed fastest; the two improvised tourniquet groups were slower than the commercial group (p < .0001, both) but were not statistically different from each other. All time-of-application results in the commercial group were less than the minimums of either improvised group. The commercial CAT had the highest mean pressures, and all such pressures were within safe and effective ranges. Low pressures generated by both improvised tourniquet groups were ineffective. All results of simulated blood loss with the commercial CAT group were less than the minimums of either improvised tourniquet group. Conclusion: In the present experiment, the commercial CAT performed better than either improvised tourniquet.

This Is Africa

Verlo AR, Bailey HH, Cook MR 15(3). 114 - 119 (Journal Article)

Military deployments will always result in exposure to health hazards other than those from combat operations. The occupational and environmental health and endemic disease health risks are greater to the Special Operations Forces (SOF) deployed to the challenging conditions in Africa than elsewhere in the world. SOF are deployed to locations that lack life support infrastructures that have become standard for most military deployments; instead, they rely on local resources to sustain operations. Particularly, SOF in Africa do not generally have access to advanced diagnostic or monitoring capabilities or to medical treatment in austere locations that lack environmental or public health regulation. The keys to managing potential adverse health effects lie in identifying and documenting the health hazards and exposures, characterizing the associated risks, and communicating the risks to commanders, deployed personnel, and operational planners.

Public Access Hemorrhage Control and the Stop the Bleeding Coalition

Levy MJ 15(3). 126 - 128 (Journal Article)

Rabies: 2015 Update

Burnett MW 15(3). 105 - 107 (Journal Article)

Rabies is an almost universally fatal viral disease transmitted to humans primarily by bites and scratches from infected animals, and less commonly through other routes, including transplantation of infected organs, exposure to infected neural tissue, and possibly through airborne and aerosolized routes. This disease is endemic to all continents worldwide except Antarctica, and only a few islands elsewhere can be considered "rabies free." Special Operations Forces medical providers should be aware of this disease. Prevention and recognition of risk are key due to its extreme lethality.

Extreme Conditioning Programs: Potential Benefits and Potential Risks

Knapik JJ 15(3). 108 - 113 (Journal Article)

CrossFit, Insanity, Gym Jones, and P90X are examples of extreme conditioning programs (ECPs). ECPs typically involve high-volume and high-intensity physical activities with short rest periods between movements and use of multiple joint exercises. Data on changes in fitness with ECPs are limited to CrossFit investigations that demonstrated improvements in muscle strength, muscular endurance, aerobic fitness, and body composition. However, no study has directly compared Cross-Fit or other ECPs to other more traditional forms of aerobic and resistance training within the same investigation. These direct comparisons are needed to more adequately evaluate the effectiveness of ECPs. Until these studies emerge, the comparisons with available literature suggest that improvements in CrossFit, in terms of muscular endurance (push-ups, sit-ups), strength, and aerobic capacity, appear to be similar to those seen in more traditional training programs. Investigations of injuries in ECPs are limited to two observational studies that suggest that the overall injury rate is similar to that seen in other exercise programs. Several cases of rhabdomyolysis and cervical carotid artery dissections have been reported during CrossFit training. The symptoms, diagnosis, and treatment of these are reviewed here. Until more data on ECPs emerge, physical training should be aligned with US Army doctrine. If ECPs are included in exercise programs, trainers should (1) have appropriate training certifications, (2) inspect exercise equipment regularly to assure safety, (3) introduce ECPs to new participants, (4) ensure medical clearance of Soldiers with special health problems before participation in ECPs, (4) tailor ECPs to the individual Soldier, (5) adjust rest periods to optimize recovery and reduce fatigue, (6) monitor Soldiers for signs of overtraining, rhabdomyolysis, and other problems, and (7) coordinate exercise programs with other unit training activities to eliminate redundant activities and minimize the risk of overuse injuries.

Journal Club: Ketamine in the Emergency Department

Banting J, Beriano T 15(3). 94 - 97 (Journal Article)

In this column of Clinical Corner, we are going to switch things up a little. We are going to review a journal article that is applicable to the Special Operations Forces (SOF) Medic. We plan on continuing to present clinically relevant cases, but every so often an article is published that we simply must take a deeper look at.

Androgens and Androgen Derivatives: Science, Myths, and Theories. Explored From a Special Operations Perspective

Givens ML, Deuster PA 15(3). 98 - 104 (Journal Article)

Androgen use outside of legitimate medical therapy is a perceived concern that is drawing attention across military and specifically Special Operations Forces (SOF) communities. For leadership and the medical community to properly address the issue and relate to those individuals who are using or considering use, it will be crucial to understand the scope of the problem. Limited data suggest that the prevalence of androgen use may be increasing, and inferences made from the scientific literature suggest that SOF may be a population of concern. While risks of androgen use are well known, there are little data specific to military performance that can be applied to a rigorous risk:benefit analysis, allowing myths and poorly supported theories to perpetuate within the community. Further efforts to define the potential benefits balanced against the short- and longterm risks should be undertaken. Providers within the SOF community should arm themselves with information to engage androgen users and leadership in meaningful discussion regarding androgen use.

Tourniquet Conversion: A Recommended Approach in the Prolonged Field Care Setting

Drew B, Bird D, Matteucci M, Keenan S 15(3). 81 - 85 (Journal Article)

Life-saving interventions take precedence over diagnostic maneuvers in the Care Under Fire stage of Tactical Combat Casualty Care. The immediate threat to life with an actively hemorrhaging extremity injury is addressed with the liberal and proper use of tourniquets. The emphasis on hemorrhage control has and will continue to result in the application of tourniquets that may not be needed past the Care Under Fire stage. As soon as tactically allowable, all tourniquets must be reassessed for conversion. Reassessment of all tourniquets should occur as soon as the tactical situation permits, but no more than 2 hours after initial placement. This article describes a procedure for qualified and trained medical personnel to safely convert extremity tourniquets to local wound dressings, using a systematic process in the field setting.

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