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Advanced Ranger First Responder Handbook
Advanced Ranger First Responder Handbook (978-1-7332239-8-0)
The Advanced Ranger First Responders are entrusted with an advanced skillset of procedures, medications, and training. They are trained on specific first responder medical skills to provide a higher level of trauma response during Ranger operations. The ARFR is expected to provide limited scope trauma and emergency care in a tactical or austere setting; they may work independently or in support of a medical provider. They are proficient at advanced medical procedures and basic medication administration. The skills in this handbook enhance the basics of Tactical Combat Casualty Care (TCCC)
ATP-P Handbook 10th Edition (978-0-9966297-6-8)

The Advanced Tactical Protocols-Paramedic (ATP-P) Handbook is an essential reference tool for the tactical and combat medics, SWAT team members, and medical professionals operating in austere environments.

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Customers living in Europe can purchase the ATP-P 10th Edition through Medical Sales Consultants and save a significant amount of money on shipping and processing.

Details and contact:

Before you buy, you will receive an offer with your total price, including shipping and VAT.

Kunden, die in Europa leben, können die ATP-P 10th Edition über Medical Sales Consultants kaufen und eine erhebliche Menge Geld für Versand und Bearbeitung sparen.

Details und Kontakt:

Vor dem Kauf erhalten Sie ein Angebot mit Ihrem Gesamtpreis, einschließlich Versand und Mehrwertsteuer.

Ranger Medic Handbook 2020 Updates (978-1-7332239-6-6)
The Ranger Medic Handbook is the medical instruction handbook provided to Ranger Medics by the 75th Ranger Regiment. It is the premier resource for all Ranger Medics and is now available exclusively for purchase by Breakaway Media and by digital subscription on the Journal of Special Operations Medicine website. This handbook is offered on Water/Tear Proof Paper. The 2020 Updates is the official and current edition of the Ranger Medic Handbook.

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Print: 978-1-7332239-6-6
20th Anniversary Collector's Edition

The 20th Anniversary Collector's Edition features all 4 editions of the 2020 Journal of Special Operations Medicine. Each edition features a retrospective look at the evolution of SOF Medicine and TCCC protocols.

The Spring edition focuses on the use of whole blood, Summer deals with Hemorrhage Control, Fall looks at Prolonged Field Care, and Winter dives into the changes to TCCC.

Regular price for all 4 journals is $160 - buy the set for $128 - a 20% savings!

Winter 2020 Journal (Vol 20 Ed 4)

Vol 20 Ed 4
Winter 2020 Journal of Special Operations Medicine
ISSN: 1553-9768

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Available for preorder. Estimated ship date is December 31st 2020

Spring 2021 Journal (Vol 21 Ed 1)

Vol 21 Ed 1
Spring 2021 Journal of Special Operations Medicine
ISSN: 1553-9768

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Available for preorder. Estimated ship date is March 31st 2021

Independent Duty Medical Technician (IDMT) Protocols Handbook (978-1-7332239-0-4)

US Air Force Independent Duty Medical Technician (IDMT), Medical and Dental Treatment Protocols, Ed 2.1 Handbook is a resource for Air Force IDMT medical personnel with advanced skills and knowledge. These protocols are the product of a concerted effort by representatives from all major command surgeons offices with the express goal to standardize  the  care  IDMTs  are  permitted  to  provide regardless of location and command affiliation. These protocols clearly define the scope of care parameters that the IDMT is expected and trained to work within. These treatment protocols are designed as a guide to accepted step-by-step treatments for medical disorders that may be encountered by IDMTs in the field

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Standard Medical Operations Guide (SMOG) CY 2020 (978-1-7332239-2-8)

This current set of medical guidelines were developed through a collaboration of Emergency Medicine professionals, experienced Flight Medics, Aeromedical Physician Assistants, Critical Care Nurses, and Flight Surgeons. There has been close coordination in the development of these guidelines by the Joint Trauma System, Committee of En Route Combat Casualty Care and the Committee of Tactical Combat Casualty Care. The shared goal is to ensure excellent en route care that is standard across all evacuation and emergency medical pre-hospital units. All these enhancements and improvements will advance en route care across the services and the Department of Defense.

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Prehospital Needle Decompression Improves Clinical Outcomes in Helicopter Evacuation Patients With Multisystem Trauma: A Multicenter Study

Henry R, Ghafil C, Golden A, Matsushima K, Eckstein M, Foran CP, Theeuwen H, Bentley DE, Inaba K, Strumwasser A 21(1). 49 - 54 (Journal Article)

Background: The utility of prehospital thoracic needle decompression (ND) for tension physiology in the civilian setting continues to be debated. We attempted to provide objective evidence for clinical improvement when ND is performed and determine whether technical success is associated with provider factors. We also attempted to determine whether certain clinical scenarios are more predictive than others of successful improvement in symptoms when ND is performed. Methods: Prehospital ND data acquired from one air ambulance service serving 79 trauma centers consisted of 143 patients (n = 143; ND attempts = 172). Demographic and clinical outcome data were retrospectively reviewed. Patients were stratified by prehospital characteristics and indications. Objective outcomes were measured as improvement in vital signs, subjective patient assessment, and physical examination findings. Univariate analysis was performed using chi-square for variable proportions and unpaired Student's t-test for variable means; p < .05 was considered statistically significant. Results: The success rate of ND performed for hypoxia (70.5%) was notably higher than ND performed for hemodynamic instability (20.3%; p < .01) or cardiac arrest (0%; p < .01). Compared to vital sign parameters, clinical examination findings as part of the indication for ND did not reliably predict technical success (p > .52 for all indications). No difference was observed comparing registered nurse versus paramedic (p = .23), diameter of catheter (p > .13 for all), or length of catheter (p = .12). Conclusion: Prehospital ND should be considered in the appropriate clinical setting. Outcomes are less reliable in cases of cardiopulmonary arrest or hypotension with respiratory symptoms; however, this should not deter prehospital providers from attempting ND when clinically indicated. Additionally, the success rate of prehospital ND does not appear to be related to catheter type or the role of the performing provider.

Performance Characteristics of Fluid Warming Technology in Austere Environments

Blakeman T, Fowler J, Branson R, Petro M, Rodriquez D 21(1). 18 - 24 (Journal Article)

Resuscitation of the critically ill or injured is a significant and complex task in any setting, often complicated by environmental influences. Hypothermia is one of the components of the "Triad of Death" in trauma patients. Devices for warming IV fluids in the austere environment must be small and portable, able to operate on battery power, warm fluids to normal body temperature (37°C), and perform under various conditions, including at altitude. The authors evaluated four portable fluid warmers that are currently fielded or have potential for use in military environments.

Rationale and Implementation of a Novel Special Operations Medical Officer Course

Fedor PJ, Dorsch J, Kharod C, Paladino L, Rush SC 21(1). 25 - 29 (Journal Article)

Background: The Air Force Special Warfare Medical Officer Course was created to address the lack of operationally focused, job-specific clinical training for medical officers (MOs). This course addresses the gap in knowledge, skill, and application of operational medicine, as well as the behavioral health, human performance, education, and medical oversight of Operators. Methods: The course was designed around the senior author's decade of experience piecing together training for his own role as a pararescue flight surgeon and informed by 5 years of flight surgeon courses, lessons learned from case studies of ill-prepared deployed physicians, and input from prehospital medicine subject matter experts. Results: Air Force pararescue and special tactics flight surgeons, physician assistants, and an independent duty medical technician (IDMT) attended. The course consisted of 10 full weekdays of didactics and skills sessions covering theory and application of operational medicine, human performance optimization, behavioral health for Operators, adult education theory, principles of prehospital clinical oversight, and other expeditionary concepts. The course culminated with combat casualty care scenario-based exercises, in which the providers performed operational medicine in full kit with weapons and simulation rounds. Discussion: For many logistical and practical reasons, civilian medical experience, traditional military medical training, existing special operations medical courses, and "merit badge" card classes are not adequate preparation for this specialized role. Focused, job-specific training should be provided to Special Operations Forces Medical Officers (SOFMO) and, ultimately, to any MO deploying in support of medics or combatants. The goal is to maximize the success of military medical operations while reducing the morbidity and mortality of combat and training casualties. Conclusion: This operationally focused MO course can serve as a model for the future training of SOFMO and has stimulated discussion for consideration of a joint approach to prehospital medical training.

Conversion of the Abdominal Aortic and Junctional Tourniquet (AAJT) to Infrarenal Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) Is Practical in a Swine Hemorrhage Model

Stigall K, Blough PE, Rall JM, Kauvar DS 21(1). 30 - 36 (Journal Article)

Background: Two methods of controlling pelvic and inguinal hemorrhage are the Abdominal Aortic and Junctional Tourniquet (AAJT; Compression Works) and resuscitative endovascular balloon occlusion of the aorta (REBOA). The AAJT can be applied quickly, but prolonged use may damage the bowel, inhibit ventilation, and obstruct surgical access. REBOA requires technical proficiency but avoids many of the complications associated with the AAJT. Conversion of the AAJT to REBOA would allow for field hemorrhage control with mitigation of the morbidity associated with prolonged AAJT use. Methods: Yorkshire male swine (n = 17; 70-90kg) underwent controlled 40% hemorrhage. Subsequently, AAJT was placed on the abdomen, midline, 2cm superior to the ilium, and inflated. After 1 hour, the animals were allocated to an additional 30 minutes of AAJT inflation (continuous AAJT occlusion [CAO]), REBOA placement with the AAJT inflated (overlapping aortic occlusion [OAO]), or REBOA placement following AAJT removal (sequential aortic occlusion [SAO]). Following removal, animals were observed for 3.5 hours. Results: No statistically significant differences in survival, blood pressure, or laboratory values were found following intervention. Conversion to REBOA was successful in all animals but one in the OAO group. REBOA placement time was 4.3 ± 2.9 minutes for OAO and 4.1 ± 1.8 minutes for SAO (p = .909). No animal had observable intestinal injury. Conclusions: Conversion of the AAJT to infrarenal REBOA is practical and effective, but access may be difficult while the AAJT is applied.

Use of a Pressure Cooker to Achieve Sterilization for an Expeditionary Environment

Cook RK, McDaniel J, Pelaez M, Beltran T, Webb O 21(1). 37 - 39 (Journal Article)

Background: Sterilization of healthcare instruments in an expeditionary environment presents a myriad of challenges including portability, cost, and sufficient electrical power. Using pressure cookers to sterilize instruments presents a low-cost option for sterilization in prehospital settings. This project's objective was to determine if sterility can be achieved using a commercially available pressure cooker. Methods: Presto® 4-quart stainless steel pressure cookers were heated using Cuisinart® CB-30 cast-iron single burners. One 3M™ Attest™ 1292 Rapid Readout Biological Indicator and one 3M™ Comply™ SteriGage™ integrator strip were sealed in a Henry Schein® Sterilization Pouch and placed in a pressure cooker and brought to a pressure of 103.4kPa. Sterility was verified after 20 minutes at pressure. The Attest vials were incubated in a 3M Attest 290 Auto-Reader for 3 hours with a control vial. Results: Sterility using the pressure cooker was achieved in all tested bags, integrator strips, and Attest vials (n = 128). The mean time to achieve the necessary 103.4kPa was 379 seconds (standard deviation (SD) = 77). Neither the ambient temperature nor humidity were found to affect the pressure cooker's time to achieve adequate pressure, nor the achieved depth on the integrator strip (all p > .05). Conclusion: This study provides evidence that sterilization is possible with offthe- shelf pressure cookers. Though lacking US Food and Drug Administration (FDA) approval, the use of this commercially available pressure cooker may provide a method of sterilization requiring minimal resources from providers working in expeditionary environments.

Combat Casualty Care Training: Implementation of a Simulation-Based Program in a Cross-Cultural Setting: Experience of the French Military Health Service in West Africa

Cotte J, Montcriol A, Benner P, Belliard V, Roumanet P, Puidupin A, Puidupin M 21(1). 41 - 43 (Journal Article)

Introduction: In the French army, combat casualty care (CCC) training involves the use of simulation. The application of this pedagogic method in a cross-cultural environment has not previously been described. In this report, we explore the challenges highlighted by multiple training sessions for foreign medical providers in West Africa. Methods: We collected the data from six 2-week courses held in Libreville, Gabon. Our main objective was to describe the course; our secondary objective was to assess our trainees' progress in their knowledge of CCC. Results: The first week involved lectures, technical workshops, and single-patient simulations. The second part emphasized multiple-victim simulations and interactions with combatants and was held in the Gabonese rainforest. Sixty- two trainees undertook the six sessions. Their knowledge improved during the course, from a median score of 4 (of a maximum of 40) before to 9.5 after (p < .05). Discussion: Our study is the first to describe medical-level CCC training in a cross-cultural environment. Challenges are numerous, notably differences in the expected roles of instructors and trainees. Mitigating those difficulties is possible through cultural awareness and self-awareness. Our results are limited by the absence of evaluation of improvement in the actual management of patients. Conclusion: CCC training using medical simulation is feasible in a cross-cultural environment.

Commercial and Improvised Pelvic Compression Devices: Applied Force and Implications for Hemorrhage Control

Bailey RA, Simon EM, Kreiner A, Powers D, Baker L, Giles C, Sweet R, Rush SC 21(1). 44 - 48 (Journal Article)

Uncontrolled hemorrhage secondary to unstable pelvic fractures is a preventable cause of prehospital death in the military and civilian sectors. Because the mortality rate associated with unstable pelvic ring injuries exceeds 50%, the use of external compression devices for associated hemorrhage control is paramount. During mass casualty incidents and in austere settings, the need for multiple external compression devices may arise. In assessing the efficacy of these devices, the magnitude of applied force has been offered as a surrogate measure of pubic symphysis diastasis reduction and subsequent hemostasis. This study offers a sensor-circuit assessment of applied force for a convenience sample of pelvic compression devices. The SAM® (structural aluminum malleable) Pelvic Sling II (SAM Medical) and improvised compression devices, including a SAM Splint tightened by a Combat Application Tourniquet® (C-A-T; North American Rescue) and a SAM® Splint tightened by a cravat, as well as two joined cravats and a standard-issue military belt, were assessed in male and female subjects. As hypothesized, compressive forces applied to the pelvis did not vary significantly based on device operator, subject sex, and subject body fat percentage. The use of the military belt as an improvised method to obtain pelvic stabilization is not advised.

Secondary Traumatic Stress in Emergency Services Systems (STRESS) Project: Quantifying Personal Trauma Profiles for Secondary Stress Syndromes in Emergency Medical Services Personnel With Prior Military Service

Renkiewicz GK, Hubble MW 21(1). 55 - 64 (Journal Article)

Background: EMS personnel are often exposed to traumatic material during their duties. It is unknown how prior military experience affects the presence of stress in EMS personnel. Methods: This was a prospective cross-sectional study. Nine EMS agencies provided data on call mix, while individuals were recruited during training evolutions. The survey evaluated sociodemographic factors and the relationship between childhood trauma and previous military service using the Adverse Childhood Experiences questionnaire, Life Events Checklist DSM-5, and Military History Questionnaire. Descriptive statistics calculated personal trauma profiles, comparing civilian EMS personnel to those with prior service. Hierarchical linear regression assessed the predictive utility of military history to scores on the Impact of Events Scale-Revised. Results: A total of 765 EMS personnel participated in the study; 52.8% were male, 11.4% were minorities, and 11.6% had prior military service. A total of 64.4% of civilian EMS providers had any stress syndrome, while that number was 71.8% in those with prior military service. Hierarchical linear regression identified that years of service and the performance of combat patrols or other dangerous duty accounted for a unique criterion variance in the regression model. Conclusions: Prior military service or combat deployments alone do not contribute to the presence of stress syndromes. However, performance of combat patrols or other dangerous duties while deployed was a contributing factor. These results must be interpreted holistically, as other factors contribute to the presence of vicarious trauma (VT) in EMS personnel who are also veterans.

Red-Green Tactical Lighting Is Preferred for Suturing Wounds in a Simulated Night Environment

Noyes BP, Mclean JB, Walchak AC, Zarow GJ, Gaspary MJ, Knoop KJ, Roszko PJ 21(1). 65 - 69 (Journal Article)

Background: Delivering medical care in nighttime conditions is challenging, as 25% of Special Operations medical Operators have reported that problems with lighting contributed to poor casualty outcomes. Red light is often used in nighttime operations but makes blood detection difficult and diminishes depth perception and visual acuity. Red-green combination lighting may be superior for differentiating blood from tissue and other fluids but had not been tested versus red-only or green-only lighting for combat-related medical procedures, such as wound suturing. Methods: Dark-adapted medical resident physicians (N = 24) sutured 6cm long, 3cm deep, full-thickness lacerations in deceased swine under red-only, green-only, and red-green lighting provided by a tactical flashlight using a randomized within-subjects design. Time to suture completion, suture quality, user ratings, and user preference data were contrasted at p < .05. This study was approved by Naval Medical Center Portsmouth IRB. Results: Suture completion time and suture quality were similar across all lighting conditions. Participants rated red-green lighting as significantly easier for identifying blood, identifying instruments, and performing suturing (p < .01). Red-green lighting was preferred by 83% of participants compared to 8% each for red-only and green-only (p < .001). Conclusions: Pending further study under tactical conditions, red-green lighting is tentatively recommended for treating battlefield wounds in low-light environments.

Tourniquet Application by Urban Police Officers: The Aurora, Colorado Experience

Jerome JE, Pons PT, Haukoos JS, Manson J, Gravitz S 21(1). 71 - 76 (Journal Article)

Background: Uncontrolled external hemorrhage is a common cause of preventable death. The Hartford Consensus recommendations presented the concept of a continuum of care, in which police officers should be considered an integral component of the emergency medical response to active shooter incidents. Recent publications have reported individual cases of tourniquet application by police officers. This report analyzed all documented cases of hemorrhage control using tourniquets applied by police officers in a single large metropolitan police department. Methods: A retrospective computerized search of all public safety communications center reports and police officer documentation for cases of tourniquet application was conducted by searching for the word "tourniquet." Each case was evaluated for indication and appropriateness using Stop The Bleed criteria for tourniquet placement. In addition, police response time was compared to emergency medical services (EMS) response time in an effort to determine if there was a time difference in response to the bleeding patient that could potentially impact patient outcomes. Results: Forty- three cases were identified over the 6-year period ending in December 2019. The majority of cases involved gunshot wounds and most were civilian victims. Injured police officers accounted for two cases (gunshot wound and dog bite). Review of the officers' narratives indicated that most applications appeared justified using the Stop The Bleed criteria (two cases were questionable if a tourniquet was necessary and one may have been placed in an incorrect location). On average, police arrived 4 minutes sooner than EMS did. Conclusion: Several reports in the literature document the success of police officer application of tourniquets to control limb hemorrhage. Most of the reports involved a small number of case reports. This is the largest case series to date from a single urban police department.

Applications of Fish Oil Supplementation for Special Operators

Heileson JL, Funderburk LK, Cardaci TD 21(1). 78 - 85 (Journal Article)

Fish oil supplementation (FOS) is beneficial for human health and various disease states. FOS has recently received attention related to its anabolic and anti-catabolic effects on skeletal muscle and cognitive performance. Since Special Operations Forces (SOF) personnel endure rigorous combat and training environments that are mentally and physically demanding, FOS may have important applications for the SOF Warfighter. The purpose of this narrative review is to explore the evidence for FOS and its application to multiple physiological and psychological contexts experienced by SOF personnel. For physical performance, FOS may promote lean body mass (LBM) accretion; however, there seems to be minimal impact on strength, power, or endurance. During physiological stress, FOS may preserve strength, power, LBM (during muscle disuse, not weight loss) and enhance recovery. For cognition, FOS likely improves reaction time, mental fatigue, and may reduce the incidence and severity of mild traumatic brain injury; however, FOS has minimal impact on attentional control and mood states. No safety concerns were evident. In conclusion, there are multiple applications of FOS for SOF personnel. Due to the minimal safety concerns and potential anabolic, anti-catabolic and cognitive benefits, FOS is a viable method to promote and sustain SOF Warfighter physical and cognitive performance. Although promising, the FOS trials to date have not been conducted in the context of the multi-stressor environments experienced by SOF personnel, thus, future studies should be conducted in a SOF population.

Making Use of Your Assets: Clinical Use of EOD Radiography in the Forward-Deployed Setting

Howard CM, Veach S, Lyon RF, Shaw KA 21(1). 87 - 89 (Journal Article)

Ultrasonography is currently the primary means of imaging for forward surgical teams/forward resuscitative surgical teams (FSTs/FRSTs). As FSTs/FRSTs are pushed farther forward into more austere environments, access to other imaging modalities may be limited, potentially affecting resources. On a recent deployment, the 126th FRST was able to use radiography equipment from a co-located explosive ordnance disposal (EOD) team to assist in the diagnosis and treatment of medical and surgical patients, thereby saving time and resources. We provide three case examples in which using EOD radiography assisted in clinical decision making. Although the safety profile has not been assessed for clinical use in humans, EOD radiography can be a useful technique to aid in time-sensitive decision making in resource-constrained operational areas.

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