Articles

Kechijian D, Rush SC 12(3). 43 - 49 (Journal Article)

Progressive injury prevention and physical preparation programs are needed in military special operations to optimize mission success and Operator quality of life and longevity. While physical risk is inherent in Special Operations, non-traumatic injuries resulting from overuse, poor biomechanics, and arbitrary exercise selection can be alleviated with proper medical care and patient education. An integrated approach to physical readiness that recognizes the continuity between rehabilitation and performance training is advocated to ensure that physiological adaptations do not come at the expense of orthopedic health or movement proficiency. Movement quality should be regularly evaluated and enforced throughout the training process to minimize preventable injuries and avoid undermining previous rehabilitative care. While fitness and proper movement are not substitutes for Operator specific tasks, they are foundational to many tactically-relevant skills. In light of how much is at stake, sports medicine care in the military, especially special operations, should parallel that which is practiced in professional and collegiate athletics.

Gay DG, Paul J 12(3). 50 - 51 (Journal Article)

Hing M, Cabrera J, Barstow C, Forsten RD 12(3). 23 - 35 (Journal Article)

To determine the rates of Post-traumatic Stress Disorder (PTSD) positive symptom scores in Special Operations Forces (SOF) personnel, an anonymous survey of SOF was employed, incorporating the PTSD Checklist (PCLM) with both demographic and deployment data. Results indicate that all SOF units studied scored above the accepted cut-offs for PTSD positive screening.1 When total symptom severity score exceeded established cutoff points and were combined with criteria for Diagnostic and Statistical Manual of Mental Disorders, Edition 4 (DSM-IV) diagnosis of PTSD,2 approximately 16-20% of respondents met scoring threshold for positive screening, almost double those of conventional Army units. Collectively, Special Forces (SF) Soldiers and SOF combat- arms Soldiers had significantly higher PLC-M scores than their non-combat-arms SOF counterparts. SOF Soldiers with three or more deployments to Afghanistan had significantly higher PCL-M scores. Considering the evidence suggesting that SOF Soldiers are hyper-resilient to stress, these results should drive further research schemata and challenge clinical assumptions of PTSD within Special Operations.

Grambusch DM, Hoedebecke KL 12(3). 36 - 42 (Journal Article)

Leptospirosis is a bacterial zoonosis with worldwide distribution and is potentially lethal to those infected if left untreated. Due to the global posture of the U.S. Special Operations community, there is a seemingly perfect overlap of the regions in which they deploy and areas with concurrent endemic leptospirosis infection. Furthermore, Special Operations Forces (SOF) personel are known for working by, with, and through the host nation defense force, who tend to be commonly affected and often serve as a reservoir for this infection. Other risk factors including the usage of infected military working dogs, contaminated training sites, and certain recreational activities associated with water increase the danger of exposure for this cohort. Due to this increased risk of leptospirosis by U.S. Special Operations service members, medical providers within this community must understand and utilize proper preventive medicine, prophylaxis, early detection, diagnosis, and treatment for this potentially lethal infection.

Faudree LK 12(3). 14 - 18 (Journal Article)

On 3 October 2001, the first chalk of Night Stalkers left Campbell Army Airfield enroute to Uzbekistan in support of what would become our nation's longest war. The vast majority of Soldiers were untested in war and would quickly have the opportunity to meet with the enemies of our nation in close combat. The two Special Operations Task Forces (TF), TF Dagger to the north in Uzbekistan and TF Sword in the south (aboard the USS Kitty Hawk) were our nation's first strike options against Al Qaeda and Taliban forces in Afghanistan. Due to the inherent nature of forced entry operations (restrictive terrain, lack of medical infrastructure, etc.) TF Dagger and TF Sword utilized 160th Special Operations Aviation Regiment (Airborne) [SOAR (A)] rotary wing aircraft solely for the Casualty Evacuation (CASEVAC) operations during the first months of Operation ENDURING FREEDOM.

Hightower S, Chin EJ, Heiner JD 12(3). 19 - 22 (Journal Article)

Increases in intracranial pressure (ICP) may damage the brain by compression of its structures or restriction of its blood flow, and medical providers my encounter elevated ICP in conventional and non-conventional medical settings. Early identification of elevated ICP is critical to ensuring timely and appropriate management. However, few diagnostic methods are available for detecting increased ICP in an acutely ill patient, which can be performed quickly and noninvasively at the bedside. The optic nerve sheath is a continuation of the dura mater of the central nervous system and can be viewed by ocular ultrasound. Pressure changes within the intracranial cavity affect the diameter of the optic nerve sheath. Data acquired from multiple clinical settings suggest that millimetric increases in the optic nerve sheath diameter detected via ocular ultrasound correlate with increasing levels of ICP. In this review, we discuss the use of ocular ultrasound to evaluate for the presence of elevated ICP via assessment of optic nerve sheath diameter, and describe critical aspects of this valuable diagnostic procedure. Ultrasound is increasingly becoming a medical fixture in the modern battlefield where other diagnostic modalities can be unavailable or impractical to employ. As Special Forces and other austere medical providers become increasingly familiar with ultrasound, ocular ultrasound for the assessment of increased intracranial pressure may help optimize their ability to provide the most effective medical management for their patients.

Barringer N, Conkright W 12(3). 5 - 7 (Journal Article)

Given the hazardous nature of combat operations and training exercises (e.g. airborne operations) conducted by the United States military, servicemembers are at high risk for sustaining a traumatic brain injury (TBI). Since the beginning of the Iraq and Afghanistan wars, almost a quarter of a million servicemembers have sustained a TBI.1 A large number of TBIs are a result of the concussive forces generated by improvised explosive devices (IED). A smaller number are a result of penetrating head wounds. Others may be caused by activities resulting in powerful acceleration, deceleration, or rotational forces. Therapies for treating TBI thus far have been limited. Much of the research conducted to date has focused on post-injury pharmacological interventions.2 Additionally, better protective equipment could help in preventing TBIs; however, these issues are outside the scope of this paper. A relatively new area of research is investigating prophylactic measures taken to lessen the effects of TBI. One such measure involves nutritional interventions and their effects on TBI severity. Therefore, the purpose of this paper is to elucidate the potential benefits of omega-3 fatty acid intake as it relates to TBI severity.

Campbell BH, Alderman SM 12(3). 8 - 13 (Journal Article)

Background: Selection criteria for Special Operations Forces (SOF) physicians are often unclear to potential candidates without prior SOF experience. To date, no published career resource exists to guide the careers of physicians interested in becoming a SOF surgeon. Using a survey tool, desirable characteristics and personal attributes were identified that can be used to inform candidate career decisions and better prepare them for a future position in Special Operations. Methods: A descriptive, cross-sectional survey instrument was developed and distributed to current Army SOF Command Surgeons for further distribution to subordinate surgeons. Results were analyzed as a cohort and by subordinate command. Results: Respondents consisted of current SOF Surgeons. Uniformly, the individual characteristics most strongly desired are professionalism, being a team player, and leadership. Possessing or obtaining Airborne and Flight Surgeon qualifications prior to consideration for a surgeon position was highly desired. Residency training within Family Medicine or Emergency Medicine constituted the vast majority of specialty preference. Conclusions: Understanding which characteristics and attributes are desirable to current surgeons and commanders can aid physicians interested in SOF surgeon positions. Using this study and future studies can guide career planning and foster the selection of ideally trained physicians who will operate at the tip of the spear. The views expressed are those of the author(s) and do not reflect the official policy of the Department of the Army, the Department of Defense or the U.S. Government.

Rush SC, Bremer J, Foresto C, Rubin AM, Anderson PI 12(2). 77 - 82 (Journal Article)

Introduction: Intraosseous (IO) devices have gained popularity because of TCCC. The ability to gain access to the vascular system when intra venous access is not possible, and techniques such as central lines or cut-downs are beyond the scope of battlefield providers and tactically not feasible, has lead to the increased use of IO access. Since tibias are often not available sites in blast injury patients, the sternum was often used. Recently the humeral head has gained popularity because of ease of access and placement. The optimal needle length has not been defined or studied. Methods and Materials: Fifty consecutive shoulder MRIs among 18-40 year old patients were reviewed. Distances from the skin surface to the cortex from anterior and lateral trajectories were simulated and measured. Two different lateral trajectories were studied described as lateral minimum and lateral maximum trajectories, correlating with seemingly less and greater soft tissue. The cortical thickness was also recorded. Mean values and ranges for the measurements were determined. Results: The anterior trajectory represented the shortest distance. Mean anterior, mean lateral minimum and mean lateral maximum distances were 2.3, 3.0 and 4.7cm with corresponding ranges of 1.1-4.1, 1.6-5.7 and 2.8-7.4cm respectively. The cortical thickness was 4mm in all cases. Conclusions: Although this information was gathered amongst civilians, and many military members may have more soft tissue, these results indicate that needle length generally in the 40-50mm range should be used via the anterior approach. Use of a standard 25mm needle often used in the tibia would be inadequate in over half the cases, and may result in undue tissue compression or distortion.

Dannenbaum J, Krueger CA, Johnson AE 12(2). 83 - 92 (Journal Article)

This review article aims to describe the techniques, success rates, advantages and disadvantages of commonly used anterior shoulder reduction maneuvers. Methods: A review of literature was performed and each article was reviewed for the reported success rates, advantages, disadvantages and technical notes for each anterior shoulder reduction technique. Results: There are a wide variety of very successful shoulder reduction maneuvers, each with their own specific set of advantages and disadvantages. Conclusion: While there are some situations that may favor one of these anterior shoulder reduction techniques over another; it is largely left up to the healthcare provider to determine which maneuver is best on a patient-to-patient basis.

Calvano CJ, Enzenauer RW 12(2). 58 - 64 (Journal Article)

Identification and management of injuries to the eyes and ocular adnexa is commonly encountered by frontline medical personnel. This brief review is intended for the Special Forces Medic of all branches and describes the clinical presentation of common ophthalmic and periocular trauma with appropriate management strategies. Prompt recognition of these wounds facilitates early treatment and optimized visual outcomes for affected Soldiers and civilians alike.

Rodriquez D, Gomaa D, Blakeman T, Petroa M, Dorlac WC, Johannigman J, Branson R 12(2). 65 - 70 (Journal Article)

Mechanical ventilation in an austere environment is difficult owing to logistics, training, and environmental conditions. We evaluated the ability of professional caregivers to provide ventilatory support to a simulated patient using the Simplified Automated Ventilator (SAVe) with a mask hand attended ventilation, mask with single strap unattended ventilation, and supraglottic airway (King LT) ventilation. All three methods were performed using a SAVe with a set tidal volume of 600ml and respiratory rate of 10 breaths per minute. The simulator consisted of a head and upper torso with anatomically correct upper airway structures, trachea, esophagus, and lung which, also measured the delivered tidal volume, respiratory rate, inspiratory flow, and airway pressures. Volunteers used each airway control method to provide ventilation for 10 minutes in random order. Success of each technique was judged as a mean delivered tidal volume of > 500ml. The major finding of this study was that medical professionals using SAVe resuscitator and the manufacturer supplied face mask with single head strap failed to ventilate the airway model in every case.

Mueller G, Moloff A, Wedmore I, Schoeff J, LaPorta AJ 12(2). 71 - 76 (Journal Article)

A delicate balance exists between a beneficial stress response that enhances memory and recall performance and a detrimental high stress response that impairs memory and learning. Repetitive training in stressful situations enables people to lower their stress levels from the detrimental range to a more beneficial one.1 This is particularly true for physicians in training as they seek to achieve advanced skills and knowledge in the fields of triage, emergency medicine, and surgery prior to graduation. This need is significant for medical students entering military service after graduation. We theorize that military medical students can advance their proficiencies through an Intensive Skills Week (ISW) prior to entering their third and forth year rotations. To test this theory, Rocky Vista University will hold a week long high-intensity first-responder, emergency medicine and surgical training course, facilitated by military medical physicians, to further students' skills and maximize training using the Human Worn Partial Surgical Task Simulator (Cut Suit). We also see the possible benefit to physician and non-physician military personnel, especially Special Operations Forces (SOF) medical personnel, from developing and implementing similar training programs when live tissue or cadaver models are unavailable or not feasible.

Kirkbride JF 12(2). 42 - 47 (Journal Article)

The Global War on Terrorism became the longest standing conflict in United States military history on June 7, 2010. It is estimated that 1.64 million U.S. troops have been deployed in support of Operation Enduring Freedom and Operation Iraqi Freedom (ρ xix).1 Both conflicts have produced high numbers of casualties as the result of ground combat. The amount of casualties though has been relatively low compared to other conflicts. Some of this can be attributed to the advances in body armor and emergency medicine that allow many servicemembers to survive conditions that previously led to death. Conversely, surviving these situations leaves those same members with memories that are psychologically difficult to live with and cause chronic difficulties. Unlike an amputee, or the victim of severe burns where the signs and symptoms of their injuries are obvious, patients with psychological disorders can have a range of signs and symptoms common in many other mental disorders, making it difficult to diagnose and treat Soldiers suffering from Post-traumatic Stress Disorder (PTSD).

Anglim AM, Boyd DW 12(2). 48 - 57 (Journal Article)

Objective: For travel to high altitudes, most experts advise a gradual ascent regimen to prevent acute mountain sickness (AMS). Such standard recommendations are applied to the general public. It is generally thought, however, that those whose work requires frequent rapid ascents, such as military personnel, porters and guides, often make these ascents without adequate preventive measures and then, experience significant morbidity and potential mortality due to AMS. The aim of this study were to demonstrate that the risk of rapid ascents can be mitigated if performed with adherence to a structured nutrition and hydration plan, carrying controlled loads, and taking specific prescribed rest periods during the ascent. Methods: This study used a randomized controlled trial of a group of Nepali porters, guides, and a Westerner with similar characteristics, all participating in their first ascent of the early Himalayan season. Data collected each day included oxygen saturation (SpO(2)), heart rate (HR), weight, and blood pressure (BP). Data was collected every 300 meters(m) (1,000 feet [ft]) and at the same time and altitude at each days end. Ascent profiles, age, gender, ethnic origin, altitude of residence and experience at altitude were also obtained. In four days, a control group of Nepali porters and a Sherpa guide and an equal number of Nepali porters and a Sherpa guide in an intervention group, (led by a Westerner) went from Kathmandu (1,300m), to the summit of Kala Pattar (5,640m), and Everest Base Camp (5,380m), averaging approximately 1,000m (3,500ft) gain a day in altitude, with no acclimatization rest days. During the rapid ascent from 4,300ft to 18,500ft, a regimented program was followed by the intervention group, while the control group ascended using their traditional methods as Nepali porters and Sherpa guides. Values are given as mean ± SE. T-test, ANOVA, and Mann-Whitney tests were used to compare variables. Results: Based on mean SpO(2) measurements on the summit of Kala Pattar at 5,640m (18,500ft), the intervention group had a SpO(2) of 79.5% ± 3.209 and the control group's mean SpO(2) was 74.5% ± 3.109 (ρ = .076). Importantly, two participants dropped out of the control group at 4,900m with SpO(2) scores of 77 and 71. The ANOVA results between the groups SpO(2) at 5,640m was significant at p ≥ .04. Mann Whitney U test results demonstrate a significant (U = 21.5, p = .04) difference in median SpO(2) levels between the intervention and the control groups. This indicates that employing a regimented program is vital to the objective of sustaining adequate SpO(2) levels and yielding a successful climb. The intervention group that followed the regimented nutrition, hydration, and rest period program performed physiologically superior to the control group, especially on the longest (10 hours), highest (5,640m), and greatest altitude gain (1,090m) day-despite resting for five minutes every 25 minutes of hiking. This was achieved with no acclimatization days, and each participant residing at low altitude. Conclusions: Participants who followed a structured nutrition, hydration plan, and adhered to prescribed rest periods, performed physiologically superior to the control group who did not. Two control group participants dropped out with poor physiological measurements. This aggressive ascent profile mirrors encountered work demands on military personnel, professional porters, and guides. The beneficial effect was significant and could provide superior methods to those whose duties require aggressive ascent profiles. The implications of frequent rest periods (10 minutes an hour), a high-carbohydrate diet, and at least 3,000ml of fluid a day appear to factually present a physiologically superior method to trekking at high to very-high altitudes. The health implications for trekkers to the Himalaya (or to any place at high altitude) by using a similar regimented program are that it may allow for an AMS-free, more enjoyable experience at altitude.

Alderman SM, Arvidsson CJ, Boedecker BH, Durck CH, Ferguson JL, Harreld CE, House JH, Irizarry DJ, Oshiki MS, Sanchack KE, Torres JE 12(2). 27 - 32 (Journal Article)

Military partnering operations and military engagements with host nation civil infrastructure are fundamental missions for NATO Special Operations Forces (SOF) conducting military assistance operations. Unit medical advisors are frequently called upon to support partnering operations and execute medical engagements with host nation health systems. As a primary point of NATO SOF medical capability development and coordination, the NATO Special Operations Headquarters (NSHQ) sought to create a practical training opportunity in which medical advisors are taught how to prepare for, plan, and execute these complex military assistance operations. An international committee of SOF medical advisors, planners and teachers was assembled to research and develop the curriculum for the first NSHQ SOF Medical Engagement and Partnering (SOFMEP) course. The committee found no other venues offering the necessary training. Furthermore, a lack of a common operating language and inadequate outcome metrics were identified as sources of knowledge deficits that create confusion and inhibit process improvement. These findings provided the foundation of this committee's curricular recommendations. The committee constructed operational definitions to improve understanding and promote dialogue between medical advisors and commanders. Active learning principles were used to construct a curriculum that engages learners and enhances retention of new material. This article presents the initial curriculum recommendations for the SOFMEP course, which is currently scheduled for October 2012.

Flanagan SC, Kotwal RS, Forsten RD 12(2). 33 - 41 (Journal Article)

Protracted use of stressors during military training courses does not necessarily enhance a Soldier's ability to regulate stress on the battlefield. Extensive stress during training can be a contributing factor to suboptimal neurologic and overall long-term health. Prolonged high-stress military training programs, as well as extended duration combat deployments, should be comprehensively scrutinized for opportunities to preserve health and increase combat effectiveness. Contemporary research in neuroscience and psychology can provide insight into training techniques that can be used to control stress and optimize performance in combat. Physical fitness training programs can elevate the stress threshold. Extensive situational training can also inoculate Soldiers to specific combat stressors. Training methods such as these will enable Soldiers to achieve higher levels of performance while under enemy fire and are encouraged for units deploying to combat.

Baker JL, Hollier PJ, Miller L, Lacy WA 12(2). 8 - 15 (Journal Article)

Heat injury is a significant concern of the Special Operations Forces Multipurpose Canine (SOF MPC). The unique athletic abilities and working environment of the SOF MPC differ from that of companion dogs or even conventional military working dogs. This should be considered in the prevention, diagnosis, and treatment of heat injury of the SOF MPC. A critical review of the literature on canine heat injury as it pertains to working dogs demonstrates limited scientific evidence on best practices for immediate clinical management of heat injury in SOF MPCs. A majority of management guidelines for heat injury in veterinary reference books and journals are based on review articles or professional opinion of the author vs. evidence from original research. In addition, guidelines are written primarily for companion animal populations vs. SOF MPCs and focus on measures to be undertaken in a clinical setting vs. point of injury. The phenomenon of "circular referencing" is also prevalent in the heat injury literature. Current guidelines supported by review articles and textbooks often provide no citation or cite other review articles for clinical standards such as normal temperature ranges, treatment methods, and recurrence of heat injury. This "circular referencing" phenomenon misrepresents anecdotal evidence and professional opinion as scientifically validated, reinforcing concepts and recommendations that are not truly supported by the evidence. Further study is needed to fully understand heat injury in SOF MPCs and how this applies to prevention, diagnosis and treatment guidelines. In order to provide SOF canine programs with best clinical advice and care, SOF Veterinarians must make clinical judgments based on evaluation of the most accurate and valid information possible. Clinical guidelines are fluid and should be reviewed regularly for relevance to the defined population in question. Clinical Guidelines should also be utilized as guiding principles in conjunction with clinical judgment vs. dictate a clinical protocol. SOF veterinarians as the veterinary support asset to SOF MPC programs should be clinically competent as well as versed in evidence based medicine practices to provide the cutting edge clinical support that is required to keep SOF MPCs operating in modern warfare environments.

Floyd CT, Rothwell SW, Risdahl J, Martin R, Olson CE, Rose N 12(2). 16 - 26 (Journal Article)

We have previously shown that lyophilized salmon thrombin and fibrinogen (STF) embedded in a dissolvable dextran dressing is as efficacious as Combat Gauze™ (CG) with regard to controlling hemorrhage and survival in non-coagulopathic swine with femoral artery lacerations. A major limitation of currently available advanced field dressings is the inability to control hemorrhage in coagulopathic casualties because of the exhaustion of host coagulation proteins. We tested the hypothesis that the STF dressing would be better able to control hemorrhage and prolong survival in coagulopathic swine compared to CG. Survival rate was 50% in CG-treated animals versus 90% in STF-treated animals. Survival time was significantly greater in STF-treated animals. Clots formed over the arterial injury in 100% of STF-treated animals compared to 0% in CG-treated animals (ρ < 0.001). STF-treated animals consumed less host coagulation factors, including platelets (ρ = 0.03). Survival after limb manipulation that simulated casualty evacuation was significantly higher with the STF dressing (ρ < 0.005). Angiographic observation of distal blood flow was seen twice as often with the STF dressing as with CG. The STF dressing allows a high survival rate, significantly greater survival time, and a significantly more stable dressing than CG in coagulopathic swine. The clot formed by the STF dressing also enables restoration of distal blood flow to the limb potentially resulting in higher limb salvage.

Reshel R 12(1). 71 - 72 (Journal Article)