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Battlefield Analgesia: TCCC Guidelines Are Not Being Followed

Schauer SG, Robinson JB, Mabry RL, Howard JT 15(1). 85 - 89 (Journal Article)

Background: Servicemembers injured in combat often experience moderate to severe acute pain. Early and effective pain control in the prehospital setting has been shown to reduce the sequelae of untreated pain. Current data suggest that lack of point-of-injury (POI) analgesia has significant, downstream effects on healthcare quality and associated costs. Methods: This was a process improvement project to determine the current rate of adherence to existing prehospital pain management guidelines. The records of patients who had sustained a major injury and met current Tactical Combat Casualty Care (TCCC) criteria for POI analgesia from July 2013 through March 2014 were reviewed to determine if pain medication was given in accordance with existing guidelines, including medication administration and routes. On 31 October 2013, the new TCCC guidelines were released. The "before" period was from July 2013 through October 2013. The "after" period was from November 2013 through March 2014. Results: During the project period, there were 185 records available for review, with 135 meeting TCCC criteria for POI analgesia (68 pre-, 66 postintervention). Prior to 31 October 2013, 17% of study patients received analgesia within guidelines at the POI compared with 35% in the after period. The most common medication administered preand post-release was oral transmucosal fentanyl citrate. Special Operations Forces had higher adherence rates to TCCC analgesia guidelines than conventional forces, but these still were low. Conclusion: Less than half of all eligible combat casualties receive any analgesia at the POI. Further research is needed to determine the etiology of such poor adherence to current TCCC guidelines.

Mindfulness: A Fundamental Skill for Performance Sustainment and Enhancement

Deuster PA, Schoomaker E 15(1). 93 - 99 (Journal Article)

The term "mindfulness" has become very fashionable within the military and across multiple sectors of civilian and first responder populations. Overall, the key concept of mindfulness is intentionally being acutely aware of what is going on internally as well as externally, without reacting. Mindfulness and the awareness that underlies it are inherent capabilities that can be honed through training. As such, classes in mindfulness are being offered in many venues and medical clinics are using mindfulness-based interventions for patients for a wide range of medical issues. The evidence behind the benefits of mindfulness is extensive and instructive. Importantly, evidence suggests that mindfulness can be helpful for many operational, leadership, and personal activities and is likely beneficial for enhancing resilience and overall health. Many current military leaders are using mindfulness as a tool to better prepare for a dynamic and uncertain future.

Operational Point-of-Care Ultrasound Review: Low-Cost Simulators and Resources for Advanced Prehospital Providers

Ross EM, Deaton TG, Hurst N, Siefert J 15(1). 71 - 78 (Journal Article)

Prehospital ultrasound use is a relatively new skill set. The military noted the clear advantages of this skill set in the deployed setting and moved forward with teaching their advanced combat trauma medics skills to perform specific examinations. The training curriculum for Special Operations-level clinical ultrasound was created and adapted from training guidelines set forth by the American College of Emergency Physicians with a focus on the examinations relevant to the Special Operations community. Once providers leave the training environment, skill sustainment can be difficult. We discuss the relevant ultrasound exams for the prehospital setting. We address opportunities to improve point-of-care ultrasound skills through hands-on experience while in a fixed medical facility. Options for simulation-based training are discussed with descriptions for creating lowcost simulation models. Finally, a list of online resources is provided to review specific ultrasound examinations.

A Study of Prehospital Medical Documentation by Military Medical Providers During Precombat Training

McGarry AB, Mott JC, Kotwal RS 15(1). 79 - 84 (Journal Article)

Documentation of medical care provided is paramount for improving performance and ultimately reducing morbidity and mortality. However, documentation of prehospital trauma care on the battlefield has historically been suboptimal. Modernization of prehospital documentation tools have aligned data and information to be gathered with up-to-date treatment being rendered through Tactical Combat Casualty Care (TCCC) protocols and practices. Our study was conducted to evaluate TCCC Card completion, and accuracy of card completion, by military medical providers conducting precombat training through the Tactical Combat Medical Care Course. Study results do not show a deficiency in TCCC documentation training as provided by this course which should translate to adequate ability to accurately document prehospital trauma care on the battlefield. Leadership emphasis and community acceptance is required to increase compliance with prehospital documentation.

The Effects of Movement on Hemorrhage When QuikClot® Combat Gauze™ Is Used in a Hypothermic Hemodiluted Porcine Model

Garcia-Blanco J, Gegel B, Burgert J, Johnson S, Johnson D 15(1). 57 - 60 (Journal Article)

Background: The purpose of this study was to compare the effectiveness of QuikClot® Combat Gauze™ (QCG) to a control wound dressing to withstand movement in a porcine model with hemodilution and hypothermia. Design: This was a prospective study with a between-subjects experimental design. Twenty-six Yorkshire swine were randomly assigned to two groups: QCG (n = 13) or a control dressing (n = 13). Methods: The subjects were exsanguinated to 30% of the blood volume; hypothermia was induced for 10 minutes. The hemostatic agent, QCG, was placed into the wound, followed by standard wound packing. If hemostasis was achieved, 5L of crystalloid solution were rapidly administered intravenously, and the wound was again observed for rebleeding. If no bleeding occurred, the extremity on the side of the injury was systematically moved through flexion, extension, abduction, and adduction sequentially 10 times or until rebleeding occurred. Results: An independent t test indicated there were significant differences in the number of movements before rebleeding between the QCG group (mean ± standard deviation [SD], 32.92 ± 14.062) and the control group (mean ± SD, 6.15 ± 15.021) (ρ < .0001). Conclusion: QCG produces a robust clot that can withstand more movement than a control dressing.

Review, Clinical Update, and Practice Guidelines for Excited Delirium Syndrome

Gerold KB, Gibbons ME, Fisette RE, Alves D 15(1). 62 - 69 (Journal Article)

Excited delirium syndrome (ExDS) is a term used to describe patients experiencing a clinical condition characterized by bizarre and aggressive behavior, often in association with the use of chronic sympathomimetic drug abuse. The agitated and disruptive behavior of persons with ExDS often results in a call to police resulting in an arrest for disorderly conduct. The suspect's inability to comply with police commands during the arrest frequently results in a struggle and the use of physical or chemical control measures, including the use of conductive energy weapons (CEWs). Deaths from this hypermetabolic syndrome are infrequent but potentially preventable with early identification, a coordinated aggressive police intervention, and prompt medical care. Preliminary experiences suggest that ExDS is a medical emergency treated most effectively using a coordinated response between police officers and emergency medical providers. Once the person suspected of experiencing ExDS is in custody, medical providers should rapidly sedate noncompliant patients with medications such as ketamine or an antipsychotic drug such as haloperidol in combination with a benzodiazepine drug such as midazolam or diazepam. Once sedated, patients should undergo a screening medical assessment and undergo initial treatment for conditions such as hyperthermia and dehydration. All patients exhibiting signs of ExDS should be transported rapidly to a medical treatment facility for further evaluation and treatment. This article reviews the epidemiology, clinical presentation, diagnosis, and treatment options for ExDS.

Laboratory Testing of Emergency Tourniquets Exposed to Prolonged Heat

Davinson JP, Kragh JF, Aden JK, DeLorenzo RA, Dubick MA 15(1). 32 - 28 (Journal Article)

Background: Environmental exposure of tourniquets has been associated with component damage rates, but the specific type of environmental exposure, such as heat, is unknown. Emergency-tourniquet damage has been associated with malfunction and loss of hemorrhage control, which may risk loss of life during first aid. The purposes of the study are to determine the damage rate of tourniquets exposed to heat and to compare the rate to that of controls. Methods: Three tourniquet models (Combat Application Tourniquet®; SOF® Tactical Tourniquet; Ratcheting Medical Tourniquet®) were tested using a manikin (HapMed Leg Tourniquet Trainer; www.chisystems .com) that simulates extremity hemorrhage. The study group of 15 tourniquets (five devices per model, three models) was exposed to heat (oven at 54.4°C [130°F] for 91 days), and 15 tourniquets similarly constituted the control group (unexposed to heat). Damage, hemorrhage control, distal pulse stoppage, time to effectiveness, pressure (mmHg), and blood loss volumes were measured. Results: Three tourniquets in both groups had damage not associated with heat exposure (ρ = 1). Heat exposure was not associated with change in effectiveness rates (ρ = .32); this lack of association applied to both hemorrhage control and pulse stoppage. When adjusted for the effects of user and model, the comparisons of time to effectiveness and total blood loss were statistically significant (ρ < .0001), but the comparison of pressure was not (ρ = .0613). Conclusion: Heat exposure was not associated with tourniquet damage, inability to gain hemorrhage control, or inability to stop the distal pulse.

Initial Tourniquet Pressure Does Not Affect Tourniquet Arterial Occlusion Pressure

Slaven SE, Wall PL, Rinker JH, Halub ME, Hopkins JW, Sahr SM, Buising CM 15(1). 39 - 49 (Journal Article)

Background: Effective nonelastic strap-based tourniquets are typically pulled tight and friction or hook-and-loop secured before engaging a mechanical advantage system to reach arterial occlusion pressure. This study examined the effects of skin surface initial secured pressure (Friction Pressure) on the skin surface pressure applied at arterial occlusion (Occlusion Pressure) and on the use of the mechanical advantage system. Methods: Combat Application Tourniquets® (CATs; and Tactical Ratcheting Medical Tourniquets (RMTs; www were applied to 12 recipient thighs with starting Friction Pressures of 25 (RMT only), 50, 75, 100, 125, 150, 175 (CAT only), and 200mmHg (CAT only). The CAT strap was single threaded. Pressure was measured with an air-filled, size #1, neonatal blood pressure cuff under the Base (CAT), Ladder (RMT), and Strap (CAT and RMT) of each 3.8cm-wide tourniquet. Results: Base or Ladder pressure and Strap pressure were related but increasingly different at increasing pressures, with Strap pressures being lower (Friction Pressure, r > 0.91; Occlusion Pressure, r > 0.60). Friction Pressure did not affect Occlusion Pressure for either design. Across the 12 thighs, the correlation coefficient for Strap Friction Pressure versus CAT windlass turns was r = -0.91 ± 0.04, and versus RMT ladder distance traveled was r = -0.94 ± 0.06. Friction Pressures of 150mmHg or greater were required to achieve CAT Occlusion with two or fewer windlass turns. CAT and RMT Strap Occlusion Pressures were similar on each recipient (median, minimum - maximum; CAT: 318mmHg, 260-536mmHg; RMT: 328mmHg, 160-472mmHg). Conclusions: Achieving high initial strap tension is desirable to minimize windlass turns or ratcheting buckle travel distance required to reach arterial occlusion, but does not affect tourniquet surface-applied pressure needed for arterial occlusion. For same-width, nonelastic strap-based tourniquets, differences in the mechanical advantage system may be unimportant to final tourniquet-applied pressure needed for arterial occlusion.

Blood Flow Restriction Rehabilitation for Extremity Weakness: A Case Series

Hylden C, Burns T, Stinner DJ, Owens J 15(1). 50 - 56 (Journal Article)

Background: Blood flow restricted (BFR) training, the brief and partial restriction of venous outflow of an extremity during low load resistance exercises, is a safe and effective method of improving strength in healthy, active individuals. A relatively unexplored potential of this adjunctive modality lies in treating patients with severe musculoskeletal trauma, persistent chronic quadriceps and hamstring weakness despite traditional therapy, and low improvement during early postoperative strengthening. Methods: This case series describes patients with chronic quadriceps and hamstring weakness who received an intervention of BFR at low loads, 20% of 1 repetition max (1RM), to restore strength. A case series was conducted of seven patients, all located at one hospital and all with traumatic lower extremity injuries. The seven patients were treated at the same medical center and with the same BFR protocol. All seven patients had isokinetic dynamometer testing that showed persistent thigh muscle weakness despite previous rehabilitation with traditional therapy and 35% to 75% peak torque deficit in either knee extension or flexion compared with the contralateral lower extremity. Patients underwent 2 weeks of BFR training therapy using a pneumatic tourniquet set at 110mmHg while performing leg extensions, leg presses, and reverse leg presses. All affected extremities were retested after 2 weeks (six treatment sessions). Dynamometer measurements were done with flexion and extension at two speeds: 90° and 300°/sec. The data recorded included peak torque normalized for body weight, average power, and total work. Results: All seven patients demonstrated improvements in peak torque, average power, and total work for both knee flexion and extension, with power being the most improved overall. Peak torque improved an average of 13% to 37%, depending on contraction direction and speed. Average power improved an average of 42% to 81%, and total work improved an average of 35% to 55%. Conclusion: BFR therapy at low loads can affect improvement in muscle strength in patients who are unable to perform high-resistance exercise or patients who have persistent extremity weakness despite traditional therapy.

Decompression Sickness Following Altitude-Chamber Training

Studer NM, Hughes JR, Puskar J 15(1). 11 - 15 (Journal Article)

Decompression sickness (DCS) is one of several dysbarisms (medical conditions resulting from a change in atmospheric pressure) that can be encountered by the Special Operations Forces (SOF) medical provider. DCS can present with several different manifestations. The authors present the case of a 23-year-old Airman who presented with vague neurologic symptoms following altitude-chamber training. They discuss the care of casualties with DCS and its implications for SOF.

Optimizing the Use of Limb Tourniquets in Tactical Combat Casualty Care: TCCC Guidelines Change 14-02

Shackelford S, Butler FK, Kragh JF, Stevens RA, Seery JM, Parsons DL, Montgomery HR, Kotwal RS, Mabry RL, Bailey JA 15(1). 17 - 31 (Journal Article)

Return to Duty After Severe Bilateral Lower Extremity Trauma

Sheean AJ, Owens J, Suttles ST, Crossland BW, Stinner DJ 15(1). 1 - 6 (Case Reports)

Despite the preponderance of evidence demonstrating poor outcomes as a result of combat-related orthopaedic trauma, teams of medical professionals have remained undaunted in their pursuit of innovative techniques to maximize the functional capacity of Servicemembers with devastating extremity injuries. We present the case of an Active Duty Special Forces (SF) qualified senior noncommissioned officer (NCO) with severely injured extremities successfully salvaged with a multidisciplinary program involving cutting-edge prosthetic technology and a novel approach to physical rehabilitation.

Special Operations Soldier With Cardiac Family History: Use of CCTA and Protein Biomarker Testing to Detect Risk of Heart Attack From Noncalcified Plaque

Singh M, Kroman A, Singh J, Tariq H, Amin S, Morales-Pablon CA, Cahill KV, Harrison EE 15(1). 7 - 10 (Journal Article)

Objective: We sought to characterize the risk of a heart attack in a 48-year-old asymptomatic US Special Operations Command (SOCOM) Soldier without known coronary artery disease (CAD). Background: CAD continues to be a leading cause of morbidity and mortality among most age groups in the United States. Much research is dedicated to establishing new techniques to predict myocardial infarction (MI). Methods: Coronary computed tomography (CT) angiography, also known as CCTA, along with 7-protein serum biomarker risk assessment was performed for risk evaluation. Results: A 48-year-old SOCOM Soldier with a family history of heart disease had skeletal chest pain from war injuries and a 5-fold higher risk of heart attack over the next 5 years on the basis of protein markers. A nonobstructive left anterior descending coronary artery (LAD) plaque with a lipid-rich core and a thin fibrous cap (i.e., vulnerable plaque) was detected by CCTA. The patient was warned about his risk and prescribed four cardiac medications and scheduled for angioplasty even though he fell outside the guidelines by not having a severe obstructive blockage. Four days later, unfortunately, he had a heart attack before starting his medications and before angioplasty. Conclusion: CCTA with biomarker testing may have an important role in predicating acute coronary syndrome (ACS) in Special Operations Forces (SOF) Soldiers with at least one risk factor. Conventional stress testing and nuclear scanning would not detect non-flow-limiting vulnerable plaques in vulnerable patients. In order to collect more data, the PROTECT Registry has been started to evaluate asymptomatic Soldiers with at least one risk factor referred to the clinic by military physicians.

Injuries and Injury Prevention During Foot Marching

Knapik JJ 14(4). 131 - 135 (Journal Article)

Since the beginning of recorded history, Soldiers have carried arms and equipment on their bodies. More recently, loads have substantially increased, driven by improvements in weapons technology and personal protection. As Soldier loads increase, there are increases in energy cost, altered gait mechanics, increased stress on the musculoskeletal system, and more rapid fatigue, factors that may increase the risk of injury. Common injuries and symptoms experienced by Soldiers on load-carriage missions include foot blisters, metatarsalgia, knee problems, and back problems. This article discusses these problems, providing diagnoses, injury mechanisms, and preventive measures. In general, lighter loads, improving load distribution, using appropriate physical training, selecting proper equipment, and using specific prevention techniques will facilitate load carriage and provide Special Operations Forces with a higher probability of mission success.

Management of Open Chest Wounds in Tactical Emergency Casualty Care: Application of Vented Versus Nonvented Chest Seals

Margolis AM, Tang N, Levy MJ, Callaway DW 14(4). 136 - 138 (Journal Article)

The 2014 midyear, full meeting of the Committee for Tactical Emergency Combat Care (C-TECC) was hosted by the Johns Hopkins University Center for Law Enforcement Medicine on June 9 and 10 in Baltimore, Maryland. As the C-TECC guidelines are increasingly recognized as the best-practice recommendations for civilian, high-threat, prehospital trauma response, a focused guidelines discussion occurred to develop bestpractice recommendations for the management of open chest wounds, specifically regarding the application of vented and nonvented chest seals.

Sore Throat

Banting J, Meriano T 14(4). 124 - 128 (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.


Burnett MW 14(4). 129 - 130 (Journal Article)

Chikungunya is a rapidly emerging infectious disease caused by a virus of the genus Alphavirus, family Togaviridae. Most commonly, patients have an acute onset of fever with often debilitating symmetric joint discomfort that can relapse months after the initial infection. This infection is typically transmitted by the bite of an infected Aedes aegypti or Aedes albopictus mosquito, vectors that also transmit dengue and yellow fever. Special Operations Forces Medical Providers should be aware of this disease, which is currently being diagnosed worldwide.

Force Health Protection Support Following a Natural Disaster: The 227th Medical Detachment's Role in Response to Superstorm Sandy

Stanley SE, Faulkenberry JB 14(4). 106 - 112 (Journal Article)

On 3 November 2012, in the wake of Superstorm Sandy, the 227th Preventive Medicine Medical Detachment deployed to support relief operations in New Jersey and New York State. The unit was on the severe weather support mission (SWRF) and ordered to provide preventive medicine support to relief personnel within the affected area. In addition, teams from the 227th conducted environmental surveillance in the two-state region where Army Corps of Engineers were pumping floodwaters from affected neighborhoods. The 227th rapid deployment highlights the complexities associated with defense support to civil authorities and provides excellent teaching points that may enhance units' expeditionary posture, regardless of mission.

This Is Africa. Bites, Stings, and Rigors: Clinical Considerations in African Operations

Lynch JH, Verlo AR, Givens ML, Munoz CE 14(4). 113 - 121 (Journal Article)

The natural health threats in Africa pose daunting clinical challenges for any provider, as evidenced by the current Ebola epidemic in West Africa, but the threat is multiplied for the Special Operations provider on the continent who faces these challenges with limited resources and the tyranny of distance. The majority of operationally significant health risks can be mitigated by strict adherence to a comprehensive force health protection plan. The simplest, yet most effective, technique for preventing mosquito-borne diseases is the prevention of mosquito bites with repellent, bed nets, and appropriate clothing in addition to chemoprophylaxis. Some of the more likely or lethal infectious diseases encountered on the continent include malaria, Chikungunya, dengue, human immunodeficiency virus, and Ebola. Venomous snakes pose a particular challenge since the treatment can be as deadly as the injury. Providers supporting African operations should educate themselves on the clinical characteristics of possible envenomations in their area while promoting snake avoidance as the primary mitigation measure. To succeed in Africa, the Special Operations provider must consider how to meet these challenges in an environment where there may not be reliable evacuation, hospitalization, or logistics channels.

Erythema Nodosum

Vigilante JA, Scribner J 14(4). 122 - 123 (Journal Article)

An active duty female Sailor reports to your clinic complaining of tender nodules to her legs beginning 1.5 weeks ago. She is diagnosed with erythema nodosum (EN), a painful disorder of the subcutaneous fat that is usually self-limited but may be a clue to an additional underlying medical diagnosis. This article reviews the pathophysiology, causes, course, diagnosis, and management of EN.

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