Articles

Johnson JE, Sims K, Hamilton DJ, Kragh JF 14(2). 21 - 25 (Journal Article)

Background: Hemorrhage from the trunk-appendage junctions is a common, preventable cause of death on the battlefield. The recently U.S. Food and Drug Administration (FDA)-cleared SAM® Junctional Tourniquet (SJT) was designed to control out-of-hospital inguinal and axillary hemorrhage. The purpose of the present study was to provide safety and effectiveness data associated with use of the SJT. Such data provided support for regulatory clearance. Methods: The SJT was tested in a perfused cadaver experiment simulating inguinal or axillary wound hemorrhage. Results: No safety problems or tissue damage occurred, and flow normalized promptly after tourniquet removal. During SJT use, an average of 107mmHg occluded the distal external iliac artery in an average of 7 seconds of inflation time; manual pressure as a control averaged 139mmHg. In SJT use, an average of 739mmHg occluded the axillary artery in an average of 5 seconds of inflation time; manual pressure as a control averaged 1237mmHg. The control was a referent that achieved results that were similar in one body area but different in the other; both findings indicate the device is as safe as, if not safer than, manual compression. Conclusion: The SJT was shown to be safe and effective in hemorrhage control in a cadaver model for both the axillary and inguinal areas. The SJT's Target Compression Devices required pressures approximately equal to or lower than manual pressure to achieve hemostasis in these junctional regions.

Croushorn J 14(2). 6 - 8 (Journal Article)

"Junctional hemorrhage" is defined as bleeding from the areas at the junction of the trunk and its appendages. This is an important cause of potentially preventable deaths on the battlefield and a difficult condition to treat in the civilian prehospital setting. Having a solution to definitively treat the condition decreases the mortality and morbidity of these injuries. The Abdominal Aortic and Junctional Tourniquet™ is (1) a Food and Drug Administration-cleared device that is currently indicated for pelvic, inguinal, and axillary bleeding; (2) the only junctional tourniquet with an indication for pelvic bleeding; (3) the only junctional tourniquet reported with a successful axillary use; and (4) effective at lower tissue pressures than other junctional tourniquets available.

Calvano CJ, Enzenauer RW, Wenkel JW, Henke JL, Rohrbough CK, Miller SL, Howerton PH, Schreffler JP 14(2). 9 - 13 (Journal Article)

Eye injuries are common in forward areas of operations. Definitive diagnosis and care may be limited not by provider skill but rather by available equipment. The ability to treat simple trauma such as corneal foreign bodies at the Role 1 level has advantages including rapid return to duty, decreased cost of treatment, and, most important, decreased risk of delayed care. We propose the device such as a hand-held portable slit lamp should be made available for appropriate Special Operations Medical Forces (SOFMED) or aviation providers.

Rivard SC, Crandall ML, Gibbs NF 14(1). 99 - 102 (Journal Article)

Servicemembers are often exposed to extreme environments with sun exposure, often laying the foundation for future skin cancer. Basal cell carcinoma (BCC) is the most common of skin cancers. We present the case of a 36-year-old male active duty Seabee who presents with a left shoulder plaque that initially started as an erythematous papule but has now increased to greater than 6cm in the past 10 years and is diagnosed as giant basal cell carcinoma (GBCC). Although only 0.5% to 1% of BCCs develop into GBCCs, there is the potential for metastasis and even death. This article addresses the concerning and potentially fatal diagnosis of GBCC, including your initial impressions and differential diagnoses, available treatment options, and ways to prevent it from ever occurring in our military population.

Klotz JK, Leo M, Andersen BL, Nkodo AA, Garcia G, Wichern AM, Chambers MJ, Gonzalez ON, Pahle MU, Wagner JA, Robinson JB, Kragh JF 14(2). 1 - 5 (Journal Article)

Junctional hemorrhage, bleeding that occurs at the junction of the trunk and its appendages, is the most common preventable cause of death from compressible hemorrhage on the battlefield. As of January 2014, four types of junctional tourniquets have been developed and cleared by the U.S. Food and Drug Administration (FDA). Successful use of the Abdominal Aortic Tourniquet (AAT™) and Combat Ready Clamp (CRoC™) has already been reported. We report here the first known prehospital use of the SAM® Junctional Tourniquet (SJT) for a battlefield casualty with inguinal junctional hemorrhage.

McCown ME, Monterroso VH, Cardona W 14(1). 86 - 90 (Journal Article)

Objective: Emerging infectious and zoonotic diseases are made up in large proportion by vector-borne diseases (VBD). Dogs are parasitized by disease vectors such as ticks and mosquitoes, making dogs adequate reservoirs for zoonoses. Risk of exposure to VBD exists for the U.S. military personnel and Military Working Dogs (MWD) when deployed globally. The importance of canine VBD surveillance relates to veterinary and public health significance for the host nations as well as for the U.S. troops and MWDs. The objective of this work was to survey dogs from the cities of Medellin, Barranquilla, and Cartagena in Colombia to determine the prevalence of heartworm disease (Dirofilaria immitis), ehrlichiosis (Ehrlichia canis), Lyme disease (Borrelia burgdorferi), and anaplasmosis (Anaplasma phagocytophilum). Methods: Canine (n = 498) blood samples (1-3mL) were collected during July 2011 from Medellin (n = 175), Barranquilla (n = 223), and Cartagena (n = 100) and were tested on-site using IDEXX SNAP® 4Dx® Test Kits. Results: The overall combined sample prevalence of E. canis, A. phagocytophilum, D. immitis, and B. burgdorferi was 62%, 33%, 1.6%, and 0%, respectively. In Medellin, 26% of the samples were positive for E. canis, 12% for A. phagocytophilum, and 0% for D. immitis. In Barranquilla, sample prevalence for E. canis, A. phagocytophilum, and D. immitis was 83%, 40%, and 2%, respectively. In Cartagena, E. canis, A. phagocytophilum, and D. immitis prevalence was 80%, 51%, and 3%, respectively. Conclusion: E. canis and A. phagocytophilum are present in all three surveyed cities. There is a higher sample prevalence for E. canis and A. phagocytophilum than for D. immitis. In addition, the prevalence for these organisms is higher in Barranquilla and Cartagena than in Medellin. Overall, this study emphasizes the value of surveillance for VBDs in order to determine disease prevalence, develop risk assessments, and implement control measures.

Levy MJ, Gerold KB 14(1). 93 - 95 (Journal Article)

Burnett MW 14(1). 96 - 98 (Journal Article)

It is estimated that more than 20 million cases of Salmonella enterica serotype Typhi and 6 million cases of paratyphoid disease occur worldwide annually, with typhoid disease alone causing more than 200,000 deaths. The clinical manifestations, diagnosis, treatment, and vaccination guidelines are discussed.

O'Hara R, Henry A, Serres J, Russell D, Locke R 14(1). 67 - 78 (Journal Article)

Objective: Military training in elite warfighters (e.g., U.S. Army Rangers, Navy SEALs, and U.S. Air Force Battlefield Airmen) is challenging and requires mental and physical capabilities that are akin to that of professional athletes. However, unlike professional athletes, the competitive arena is the battlefield, with winning and losing replaced by either life or death. The rigors of both physical training and prolonged deployments without adequate rest and food intake can compromise physical performance. Therefore, the primary purpose of this effort was to identify occupational stressors on the physical performance of Special Operators during training and while on missions. The secondary purpose was to suggest specific countermeasures to reduce or prevent significant decrements in physical performance and reduce musculoskeletal injuries. Methods: A search of the literature for 2000-2012 was performed using the Air Force Institute of Technology search engines (i.e., PubMed and ProQuest). There were 29 articles located and selected that specifically addressed the primary and secondary purposes of this literature review. The remaining 32 of 61 referenced articles were reviewed after initial review of the primary literature. Conclusions: This review indicates that operational stress (e.g., negative energy balance, high-energy expenditure, sleep deprivation, environmental extremes, heavy load carriage, etc.) associated with rigorous training and sustained operations negatively affects hormonal levels, lean muscle mass, and physical performance of Special Operators. The number of musculoskeletal injuries also increases as a result of these stressors. Commanders may use simple field tests to assess physical decrements before and during deployment to effectively plan for missions. Specific countermeasures for these known decrements are lacking in the scientific literature. Therefore, future researchers should focus on studying specific physical training programs, equipment, and other methods to minimize the effects of operational stress and reduce recovery time. These countermeasures could prevent mission mishaps and may save the lives of Special Operators during severe operational stress.

Johnson D, Dial J, Ard J, Yourk T, Burke E, Paine C, Gegel B, Burgert J 14(1). 79 - 85 (Journal Article)

Introduction: The military recommends that a 500mL bolus of Hextend® be administered via an intravenous (IV) 18-gauge needle or via an intraosseous (IO) needle for patients in hypovolemic shock. Purposes: The purposes of this study were to compare the time of administration of Hextend and the hemodynamics of IV and IO routes in a Class II hemorrhage swine model. Methods: This was an experimental study using 27 swine. After 30% of their blood volume was exsanguinated, 500mL of Hextend was administered IV or IO, but not to the control group. Hemodynamic data were collected every 2 minutes until administration was complete. Results: Time for administration was not significant (p = .78). No significant differences existed between the IO and IV groups relative to hemodynamics (p > .05), but both were significantly different than the control group (p < .05). Conclusions: The IO route is an effective method of administering Hextend.

Gerhardt RT, Berry J, Mabry RL, Flournoy L, Arnold RG, Hults C, Robinson JB, Thaxton RA, Cestero R, Heiner JD, Koller AR, Cox KM, Patterson JN, Dalton WR, McKeague AL, Gilbert G, Manemeit C, Adams BD 14(1). 50 - 57 (Journal Article)

Objective: We sought to determine whether Contingency Telemedical Support (CTS) improves the success rate and efficiency of primary care providers performing critical actions during simulated combat trauma resuscitation. Critical actions included advanced airway, chest decompression, extremity hemorrhage control, hypothermia prevention, antibiotics and analgesics, and hypotensive resuscitation, among others. Background: Recent studies report improved survival associated with skilled triage and treatment in the out-of-hospital/preoperative phase of combat casualty care. Historically, ground combat units are assigned primary care physicians and physician assistants as medical staff, due to resource limitations. Although they are recognized as optimal resuscitators, demand for military trauma surgeons and emergency physicians exceeds supply and is unlikely to improve in the near term. Methods: A prospective trial of telemedical mentoring during a casualty resuscitation encounter was studied using a high-fidelity patient simulator (HFPS). Subjects were randomized and formed into experimental (CTS) or control teams. CTS team leaders were equipped with a headset/microphone interface and telementored by a combat-experienced emergency physician or trauma surgeon. A standardized, scripted clinical scenario and HFPS were used with 14 critical actions. At completion, subjects were surveyed. Statistical approach included contingency table analysis, two-tailed t-test, and correlation coefficient. This study was reviewed and approved by our institutional review board (IRB). Results: Eighteen CTS teams and 16 control teams were studied. By intention-to-treat ITT analysis, 89% of CTS teams versus 56% of controls completed all life-threatening inventions (LSIs) (p < .01); 78% versus 19% completed all critical actions (p < .01); and 89% versus 56% established advanced airways within 8 minutes (p < .06). Average time to completion in minutes (95% confidence interval [CI] 95) was 12 minutes (10-14) for CTS versus 18 (16-20) for controls, with 75% of control teams not completing all critical actions. Conclusion: In this model, real-time telementoring of simulated trauma resuscitation was feasible and improved accuracy and efficiency of non-emergency-trained resuscitators. Clinical validation and replicated study of these findings for guiding remote damage control resuscitation are warranted.

Wentz LM, Eldred JD, Henry MD, Berry-Caban CS 14(1). 58 - 66 (Journal Article)

Vitamin D deficiency initiates a loss of combat effectiveness by impairing physical and cognitive functioning of combat Operators. Synthesized in response to sunlight and consumed in the diet, vitamin D functions as a hormone and regulates gene expression for nearly 300 genes throughout the human body. These target genes are involved processes essential to combat operations, such as immune function, response to stress, inflammation, and regulation of calcium movement. Since widespread vitamin D deficiency is observed across the U.S. population, poor vitamin D status is expected in Servicemembers. Physical conditions linked to vitamin D deficiency include increased risk for muscle or bone injury, muscle weakness, and reduced neuromuscular function. Hormonally, vitamin D levels have been positively correlated with testosterone levels. Vitamin D deficiency is also associated with cognitive decline, depression, and may prolong recovery following mild traumatic brain injury (mTBI). Since vitamin D deficiency elevates systemic inflammation, poor vitamin D status at the time of brain injury may prolong the inflammatory response and exacerbate postconcussive symptoms. Furthermore, veterans with mTBI experience chronic endocrine dysfunction. While vitamin D status has not been assessed post-mTBI, it is plausible that vitamin D levels are altered along with testosterone and growth hormone, raising the question of whether vitamin D deficiency results from trauma-related hormonal abnormalities or whether vitamin D deficiency increases the risk for endocrine dysfunction. Through its association with testosterone production, vitamin D deficiency may increase the risk for posttraumatic stress disorder (PTSD) since testosterone levels are altered in veterans with PTSD. Therefore, vitamin D status has a significant impact on Operator health and performance. Supplementing vitamin D to deficient Operators provides a noninvasive and low-cost intervention to maintain combat force.

Gates K, Baer L, Holcomb JB 14(1). 40 - 44 (Journal Article)

Objective: Junctional bleeding from the groin is a leading cause of potentially preventable death on the battlefield. To address this problem, a novel device called the Junctional Emergency Treatment Tool (JETT™) was developed. The JETT was designed to stabilize pelvic ring fractures while controlling lower extremity bleeding sustained during high-energy traumatic events on the battlefield and in the civilian environment. Our purpose was to assess the effectiveness of the JETT in the control of simulated life threatening hemorrhage from proximal injuries in the groin of a perfused cadaver. Methods: The JETT was compared with the standard issue combat tourniquet and a Food and Drug Administration (FDA)-cleared junctional hemorrhage control clamp (CRoC™) in a perfused human cadaver model. The JETT's ability to stop pulsatile flow at the common femoral artery was assessed through proximal aorta and distal measurements of arterial flow rates and pressures. Results: In three cadavers, when the JETT or the CRoC was applied in the groin, there was an immediate cessation of fluid flow from the common femoral artery while the inlet flow aortic pulsatile pressure was maintained. However, the time to bilateral application of the JETT was faster (10 seconds vs. 68 seconds) than bilateral sequential application of two CRoC devices. Conclusions: The JETT is a single device capable of effectively and quickly controlling bilateral lower extremity junctional hemorrhage at normal physiological blood pressures.

Levitan RM 14(1). 45 - 49 (Journal Article)

The author describes a cricothyrotomy system that consists of two devices that, packaged together, are labeled the Control-Cric™ system. The Cric-Key™ was invented to verify tracheal location during surgical airway procedures- without the need for visualization, aspiration of air, or reliance on clinicians' fine motor skills. The Cric-Knife™ combines a scalpel with an overlying sliding hook to facilitate a smooth transition from membrane incision to hook insertion and tracheal control. In a recent test versus a traditional open technique, this system had a higher success rate and was faster to implement.

Kragh JF, Wallum TE, Aden JK, Dubick MA, Baer DG 14(1). 26 - 29 (Journal Article)

Objective: The purpose of the present study is to determine the performance of tourniquet use by the placement of the tourniquet's windlass on the extremity in four positions-medial, lateral, anterior, and posterior-to inform tourniquet instructors and develop best tourniquet practices. Methods: A HapMed™ Leg Tourniquet Trainer was used as a manikin to test the effectiveness of an emergency tourniquet, the Special Operations Forces Tactical Tourniquet. Two users made 10 tests, each in four positions. Results: Effectiveness rates of tourniquet use were 100% in all four positions. The two tourniquet users were both right-hand dominant and used their right hand to turn the windlass. One user turned the windlass clockwise, and the other turned it counterclockwise. The association between time to stop bleeding and tourniquet position was statistically significant but associations between time to stop bleeding and the user, user-by-position, and windlass turn number were not statistically significant. The association between tourniquet position and pressure under the tourniquet was statistically significant, and the association between user and pressure under the tourniquet was statistically significant, but the user-by-position and windlass turn number were not statistically significant. The associations between tourniquet position and blood loss volume, user and blood loss volume, and user-by-position and blood loss volume were statistically significant. Conclusions: The present study found that tourniquet effectiveness rates were uniformly 100% irrespective of whether the windlass position was medial, lateral, anterior, or posterior. These excellent clinical and statistical results indicate that users may continue to place the tourniquets as they prefer upon the proximal thigh.

Mills AF, Argon NT, Ziya S, Hiestand B, Winslow J 14(1). 30 - 39 (Journal Article)

Objective: Current guidelines for mass-casualty triage do not explicitly use information about resource availability. Even though this limitation has been widely recognized, how it should be addressed remains largely unexplored. The authors present a novel framework developed using operations research methods to account for resource limitations when determining priorities for transportation of critically injured patients. To illustrate how this framework can be used, they also develop two specific example methods, named ReSTART and Simple- ReSTART, both of which extend the widely adopted triage protocol Simple Triage and Rapid Treatment (START) by using a simple calculation to determine priorities based on the relative scarcity of transportation resources. Methods: The framework is supported by three techniques from operations research: mathematical analysis, optimization, and discrete-event simulation. The authors' algorithms were developed using mathematical analysis and optimization and then extensively tested using 9,000 discrete-event simulations on three distributions of patient severity (representing low, random, and high acuity). For each incident, the expected number of survivors was calculated under START, ReSTART, and Simple-ReSTART. A web-based decision support tool was constructed to help providers make prioritization decisions in the aftermath of mass-casualty incidents based on ReSTART. Results: In simulations, ReSTART resulted in significantly lower mortality than START regardless of which severity distribution was used (paired t test, ρ < .01). Mean decrease in critical mortality, the percentage of immediate and delayed patients who die, was 8.5% for low-acuity distribution (range -2.2% to 21.1%), 9.3% for random distribution (range -0.2% to 21.2%), and 9.1% for high-acuity distribution (range -0.7% to 21.1%). Although the critical mortality improvement due to ReSTART was different for each of the three severity distributions, the variation was less than 1 percentage point, indicating that the ReSTART policy is relatively robust to different severity distributions. Conclusions: Taking resource limitations into account in mass-casualty situations, triage has the potential to increase the expected number of survivors. Further validation is required before field implementation; however, the framework proposed in here can serve as the foundation for future work in this area.

Cordova CB, Cap AP, Spinella PC 14(1). 9 - 12 (Case Reports)

There are many challenges to treating life-threatening injuries for a healthcare provider deployed to a remote location in a combat setting. Once conventional treatment protocols for exsanguinating hemorrhage have been exhausted and no medical evacuation platform is available, a nonconventional method of treatment to consider is a fresh whole blood (FWB) transfusion. A FWB transfusion can be a life-saving or life-prolonging intervention in the appropriate setting. The authors present the case of a combat casualty in hypovolemic shock and coagulopathy with delayed medical evacuation to a surgical team. While the ultimate outcome was death in this case report, the patient arrived to a surgical team 15 hours after his injury, alert and oriented. In this scenario, FWB transfusion gave this patient the best chance of survival.

Butler FK, Kotwal RS, Buckenmaier CC, Edgar EP, O'Connor KC, Montgomery HR, Shackelford S, Gandy JV, Wedmore I, Timby JW, Gross K, Bailey JA 14(1). 13 - 25 (Journal Article)

Although the majority of potentially preventable fatalities among U.S. combat forces serving in Afghanistan and Iraq have died from hemorrhagic shock, the majority of U.S. medics carry morphine autoinjectors for prehospital battlefield analgesia. Morphine given intramuscularly has a delayed onset of action and, like all opioids, may worsen hemorrhagic shock. Additionally, on a recent assessment of prehospital care in Afghanistan, combat medical personnel noted that Tactical Combat Casualty Care (TCCC) battlefield analgesia recommendations need to be simplified-there are too many options and not enough clear guidance on which medication to use in specific situations. They also reported that ketamine is presently being used as a battlefield analgesic by some medics in theater with good results. This report proposes that battlefield analgesia be achieved using one or more of three options: (1) the meloxicam and Tylenol in the TCCC Combat Pill Pack for casualties with relatively minor pain who are still able to function as effective combatants; (2) oral transmucosal fentanyl citrate (OTFC) for casualties who have moderate to severe pain, but who are not in hemorrhagic shock or respiratory distress and are not at significant risk for developing either condition; or (3) ketamine for casualties who have moderate to severe pain but who are in hemorrhagic shock or respiratory distress or are at significant risk for developing either condition. Ketamine may also be used to increase analgesic effect for casualties who have previously been given opioids (morphine or fentanyl.)

Gregory JF, Beute TC 13(4). 115 - 119 (Journal Article)

Erythema ab igne is a reticulated, erythematous, hyperpigmented dermatosis resulting from chronic mild to moderate heat exposure. The authors present two cases of erythema ab igne, one from a hot water bottle to treat chronic low back pain and another from a heated automobile seat. They review other reported etiologies and highlight scenarios in which military medical providers may encounter erythema ab igne.

Pozza M, Matthew P, Lunardi F 14(1). 1 - 5 (Case Reports)

Background: On the battlefield, insidious and devastating weapons like the improvised explosive device (IED) rapidly emit extreme heat (thousands of degrees), create a shock wave (overpressure) that can hurl bodies long distances (inducing secondary fall lesions), and deliver thousands of pieces of shrapnel over hundreds of meters. Materials and Methods: Very often, Soldiers injured by an IED blast are inside their vehicle. Subsequently, they are exposed to the thermal effects of the blast. Frequently, these patients have complex wounds that consist of extensive burn areas, bone fractures, and internal organ lesions. The use of silver-nylon burn wrap dressing is widely documented for its bactericidal properties. Silverlon® Burn Dressings is an elastic bandage made of nylon and plated with pure metallic silver. Results: In summer 2008, in a U.S. advanced Role 2 facility, two U.S. Soldiers with extensive second- and third-degree burn injuries were successfully treated with the use of Silverlon Burn Dressings and Silverlon® Burn Gloves. Conclusions: From this experience emerged the ease of use silver-nylon dressing in treating badly burned Soldiers on the battlefield.