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ATP-P 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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Pararescue Medical Operations (PJ MED) handbook 7th Ed (978-0-9966297-8-2)
The Pararescue Medical Operations Handbook is designed to form the basis of medical practice during both Rescue Operations and training mishaps for USAF Pararescuemen (PJs). This revised handbook includes an outline of the Principles of PJ medicine and the patient assessment checklist. This approach to patients is slightly modified from traditional primary and secondary surveys to reflect both a more efficient and a comprehensive approach to combat trauma based on PJ experience and data from Overseas Contingency Operations. Portions of the Tactical Combat Casualty Care (TCCC) guidelines and the ATP Tactical Medical Emergency Protocols (TMEPS) that pertain to the Pararescue are included and have been modified to suit the PJ mission. The goal remains to have all PJs work to a single standard. The section on prolonged care has been modified and expanded based on PJ experiences.
Spring 2019 Journal (Vol 19 Ed 1)

Vol 19 Ed 1
Spring 2019 Journal of Special Operations Medicine
ISSN: 1553-9768

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Available for preorder. Estimated ship date is 30 Sep 18

Summer 2019 Journal (Vol 19 Ed 2)

Vol 19 Ed 2
Summer 2019 Journal of Special Operations Medicine
ISSN: 1553-9768

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Available for preorder. Estimated ship date is June 30th 2019

Case Presentation: Creation and Utilization of a Novel Field Improvised Autologous Transfusion System in a Combat Casualty

Scarborough T, Turconi M, Callaway DW 19(2). 134 - 137 (Journal Article)

This case report describes the technical aspects in first use of a novel field improvised autologous transfusion (FIAT) system. It highlights a potential solution for specific trauma patients during advanced resuscitative care (ARC) and prolonged field care (PFC) scenarios where other blood products are not available.

Improvised Inguinal Junctional Tourniquets: Recommendations From the Special Operations Combat Medical Skills Sustainment Course

Kerr W, Hubbard B, Anderson B, Montgomery HR, Glassberg E, King DR, Hardin RD, Knight RM, Cunningham CW 19(2). 128 - 133 (Journal Article)

Effectively and rapidly controlling significant junctional hemorrhage is an important effort of Tactical Combat Casualty Care (TCCC) and can potentially contribute to greater survival on the battlefield. Although the US Food and Drug Administration (FDA) has approved labeling of four devices for use as junctional tourniquets, many Special Operations Forces (SOF) medics do not carry commercially marketed junctional tourniquets. As part of ongoing educational improvement during Special Operations Combat Medical Skills Sustainment Courses (SOCMSSC), the authors surveyed medics to determine why they do not carry commercial tourniquets and present principles and methods of improvised junctional tourniquet (IJT) application. The authors describe the construction and application of IJTs, including the use of available pressure delivery devices and emphasizing that successful application requires sufficient and repetitive training.

Without Jumping to Conclusions

Hampton K 19(2). 127 (Journal Article)

Fever of Unknown Origin in US Soldier: Telemedical Consultation Limitations in a Deployment to West Africa

Auchincloss PJ, Nam JJ, Blyth D, Childs G, Kraft K, Robben PM, Pamplin JC 19(2). 123 - 126 (Journal Article)

Objective: Review the application of telemedicine support for managing a patient with possible sepsis, suspected malaria, and unusual musculoskeletal symptoms. Clinical Context: Regionally Aligned Forces (RAF) supporting US Army Africa/Southern European Task Force (USARAF/ SETAF) in the Africa Command area of responsibility. Care provided by a small Role I facility on the compound. Organic Medical Expertise: Five 68W combat medics (one is the patient); one SOCM trained 68W combat medic. No US provider present in country. Closest Medical Support: Organic battalion physician assistant (PA) located in the USA; USARAF PA located in Italy; French Role II located in bordering West African country; medical consultation sought via telephone, WhatsApp® (communication with French physician) or over unclassified, encrypted e-mail. Earliest Evacuation: Estimated at 12 to 24 hours with appropriate country clearances and approval to fly from three countries including French forces support approval.

Update: Five Years of Prolonged Field Care in Special Operations Medicine

Riesberg JC, Loos PE 19(2). 122 (Journal Article)

This brief quarterly update from the SOMA Prolonged Field Care (PFC) Working Group focuses on the first of ten sequential reviews of the PFC Core Capabilities, starting with advanced airway management.

Introduction to the NATO Special Operations Combat Medic Research Ongoing Series

Sardianos D, Boland J 19(2). 118 - 121 (Journal Article)

Technology has become a necessity in modern society, providing capabilities that have never been experienced before. The integration of such capabilities arms today's Special Operations medic with abilities that can make a vast difference to the survivability rate of an ill or injured patient. Taking advantage of new technological capabilities such as advanced monitoring and diagnostics and portable ultrasound also plays a key role; together with the evolution in modern communication.

Exertional Heat Stroke: Pathophysiology, Epidemiology, Diagnosis, Treatment, and Prevention

Knapik JJ, Epstein Y 19(2). 108 - 116 (Journal Article)

Temperature increases due to climate changes and operations expected to be conducted in hot environments make heat-related injuries a major medical concern for the military. The most serious of heat-related injuries is exertional heat stroke (EHS). EHS generally occurs when health individual perform physical activity in hot environments and the balance between body heat production and heat dissipation is upset resulting in excessive body heat storage. Blood flow to the skin is increased to assist in dissipating heat while gut blood flow is considerably reduced, and this increases the permeability of the gastrointestinal mucosa. Toxic materials from gut bacteria leak through the gastrointestinal mucosa into the central circulation triggering an inflammatory response, disseminated intravascular coagulation (DIC), multiorgan failure, and vascular collapse. In addition, high heat directly damages cellular proteins resulting in cellular death. In the United States military, the overall incidence of clinically diagnosed heat stroke from 1998 to 2017 was (mean ± standard deviation) 2.7 ± 0.5 cases/10,000 Soldier-years and outpatient rates rose over this period. The cornerstone of EHS diagnosis is recognition of central nervous dysfunction (ataxia, loss of balance, convulsions, irrational behavior, unusual behavior, inappropriate comments, collapse, and loss of consciousness) and a body core temperature (obtained with a rectal thermometer) usually >40.5°C (105°F). The gold standard treatment is whole body cold water immersion. In the field where water immersion is not available it may be necessary to use ice packs or very cold, wet towels placed over as much of the body as possible before transportation of the victim to higher levels of medical care. The key to prevention of EHS and other heat-related injuries is proper heat acclimation, understanding work/rest cycles, proper hydration during activity, and assuring that physical activity is matched to the Soldiers' fitness levels. Also, certain dietary supplements (DSs) may have effects on energy expenditure, gastrointestinal function, and thermoregulation that should be considered and understood. In many cases over-motivation is a major risk factor. Commanders and trainers should be alert to any change in the Soldier's behavior. Proper attention to these factors should considerably reduce the incidence of EHS.

Optimizing Warfighter Lethality Through Human Performance Education

Deuster PA, Lunasco T, Messina LA 19(2). 100 - 104 (Journal Article)

Humans are the heart of our warfighting efforts and, as such, human performance must be optimized and sustained to maintain effective and successful SOF Operators over the long haul. How do we do this? Based on the July 2018 signing of a Joint Requirements Oversight Council Memo (JROC) making Total Force Fitness (TFF) a required framework for taking care of our military Servicemembers, we propose three solutions for further optimizing the performance of SOF. The proposed solutions are human performance optimization (HPO)/TFF capability-based blueprinting (CBB), HPO integrator profession (HPO-I), and HPO-centric education and training across the total force. These solutions would potentiate the Preservation of the Force and Family (POTFF) concept by improving the targeting of resources and support of Operator and unit operational readiness. These solutions, the knowledge, skills, abilities, and experiences in HPO from a holistic perspective and the opportunity to obtain college credits through the Uniformed Services University of the Health Sciences (USU) College of Allied Health Sciences (CAHS) are described here.

In Vitro Compatibility of Canine and Human Blood: A Pilot Study

Edwards TH, Wienandt NA, Baxter RL, Mays EL, Gay SD, Cap AP 19(2). 95 - 99 (Journal Article)

Military working dogs (MWDs) are force multipliers that are exposed to the same risks as their human counterparts on the battlefield. Hemostatic resuscitation using blood products is a cornerstone of damage control resuscitation protocols for both humans and dogs. Canine-specific blood products are in short supply in mature theaters due to logistic and regulatory concerns and are almost nonexistent in austere environments, whereas human blood products are readily available at most surgical facilities. The objective of this study was to evaluate the in vitro compatibility of human and canine blood by using standard crossmatching techniques with the canine blood acting as the recipient and the human blood acting as the donor. Blood samples were collected from 20 government-owned canines (GOCs) and 7 healthy human volunteers in addition to washed red blood cells (RBCs) from a commercial blood typing kit. Major and minor crossmatches were conducted as well as a protein denatured crossmatch. All samples in this study showed strong cross-reactivity, with the majority demonstrating profound hemolysis and a minority showing substantial agglutination. Based on the results of this study, transfusion of human blood to an MWD cannot be recommended at this time.

Survival of Casualties Undergoing Prehospital Supraglottic Airway Placement Versus Cricothyrotomy

Schauer SG, Naylor JF, Chow AL, Maddry J, Cunningham CW, Blackburn MB, Nawn CD, April MD 19(2). 91 - 94 (Journal Article)

Background: Airway compromise is the second leading cause of preventable death on the battlefield. Unlike a cricothyrotomy, supraglottic airway (SGA) placement does not require an incision and is less technically challenging. We compare the survival of causalities undergoing cricothyrotomy versus SGA placement. Methods: We used a series of emergency department (ED) procedure codes to search within the Department of Defense Trauma Registry (DODTR) from January 2007 to August 2016. This is a subanalysis of that data set. Results: During the study period, 194 casualties had a documented cricothyrotomy and 22 had a documented SGA as the sole airway intervention. The two groups had similar proportions of explosive injuries (57.7% versus 63.6%, p = .328), similar composite injury severity scores (25 versus 27.5, p = .168), and similar AIS for the head, face, extremities, and external body regions. The cricothyrotomy group had lower AIS for the thorax (0 versus 3, p = .019), a trend toward lower AIS for the abdomen (0 versus 0, p = .077), more serious injuries to the head (67.5% versus 45.5%, p = .039), and similar rates of serious injuries to the face (4.6% versus 4.6%, p = .984). Glasgow Coma Scale (GCS) scores were similar on arrival to the ED (3 versus 3, p = .467) as were the proportion of patients surviving to discharge (45.4% versus 40.9%, p = .691). On repeated multivariable analyses, the odds ratios for survival were not significantly different between the two groups. Conclusions: We found no difference in short-term outcomes between combat casualties who received an SGA vs those who received a cricothyrotomy. Military prehospital personnel rarely used either advanced airway intervention during the recent conflicts in Afghanistan and Iraq.

A Comparison of Prehospital Versus Emergency Department Intubations in Iraq and Afghanistan

Schauer SG, April MD, Tannenbaum LI, Maddry J, Cunningham CW, Blackburn MB, Arana AA, Shackelford S 19(2). 87 - 90 (Journal Article)

Background: Airway obstruction is the second most common cause of potentially preventable death on the battlefield. We compared survival in the combat setting among patients undergoing prehospital versus emergency department (ED) intubation. Methods: Patients were identified from the Department of Defense Trauma Registry (DODTR) from January 2007 to August 2016. We defined the prehospital cohort as subjects undergoing intubation prior to arrival to a forward surgical team (FST) or combat support hospital (CSH), and the ED cohort as subjects undergoing intubation at an FST or CSH. We compared study variables between these cohorts; survival was our primary outcome. Results: There were 4341 intubations documented in the DODTR during the study period: 1117 (25.7%) patients were intubated prehospital and 3224 (74.3%) were intubated in the ED. Patients intubated prehospital had a lower median age (24 versus 25 years, p < .001), composed a higher proportion of host nation forces (36.1% versus 29.1%, p < .001), had a lower proportion of injuries from explosives (57.6% versus 61.0%, p = .030), and had higher median injury severity scores (20 versus 18, p = .045). A lower proportion of the prehospital cohort survived to hospital discharge (76.4% versus 84.3%, p < .001). The prehospital cohort had lower odds of survival to hospital discharge in both univariable (odds ratio [OR] 0.60, 95% confidence interval [CI] 0.51-0.71) and multivariable analyses controlling for confounders (OR 0.70, 95% CI 0.58-0.85). In a subgroup analysis of patients with a head injury, the lower odds of survival persisted in the multivariable analysis (OR 0.49, 95% CI 0.49-0.82). Conclusions: Patients intubated in the prehospital setting had a lower survival than those intubated in the ED. This finding persisted after controlling for measurable confounders.

Sulfur Mustard Exposure: Review of Acute, Subacute, and Long-Term Effects and Their Management

Wolfe GA, Petteys SM, Phelps JF, Wasmund JB, Plackett TP 19(2). 81 - 86 (Journal Article)

Sulfur mustard has been used in conflicts for more than a century. Despite international recognized bans on the use of chemical weapons, there continue to be reports of their use. The authors provide a contemporary overview of sulfur mustard injury and its management in the acute, subacute, and chronic periods.

Impact of Continuous Ketamine Infusion Versus Alternative Regimens on Mortality Among Burn Intensive Care Unit Patients: Implications for Prolonged Field Care

Schauer SG, April MD, Aden JK, Rowan M, Chung KK 19(2). 77 - 80 (Journal Article)

Background: The military is rapidly moving into a battlespace in which prolonged holding times in the field are probable. Ketamine provides hemodynamic support and has analgesic properties, but the safety of prolonged infusions is unclear. We compare in-hospital mortality between intubated burn intensive care unit (ICU) patients receiving prolonged ketamine infusion lasting ≥7 days or until death versus controls. Methods: We conducted a before/after cohort study of patients undergoing admission to a burn ICU with intubation within the first 24 hours as part of treatment for thermal burns. In January 2012, this ICU implemented a novel continuous ketamine infusions protocol. We performed a preintervention and postintervention cohort analysis. Results: We identified 2394 patients meeting our inclusion criteria-475 in the ketamine group and 1919 in the control group. Regarding burn total body surface area (TBSA) involvement, there were 1533 in the <10% group, 586 in the 11-30% group, and 281 in the >31% group. The median number of ventilator-free days within the first 30 days did not vary significantly between the ketamine group and the control group: 8.5 days (interquartile range [IQR] 1-16 days) versus 8 days (IQR 3-13 days, p = .442). Subjects receiving ketamine had higher mortality rates: 59.4% (n = 117) versus 40.6% (n = 80, p < .001), with an odds ratio for in-hospital mortality of 7.51 (95% CI 5.53-10.20, p < .001). When controlling for TBSA category, ventilator days and vasopressor administration, there was no association between ketamine and in-hospital mortality (0.66, 0.41-1.05, p = .08). Conclusions: When controlling for confounders, we found no difference in in-hospital mortality between the prolonged ketamine infusion recipients versus non-recipients.

Development of a Field-Expedient Vascular Trauma Simulator

Martin CJ, Plackett TP, Rush RM 19(2). 73 - 76 (Journal Article)

The past few years have noted significant declines in combat casualty exposure over the course of a deployment. As a result, overall confidence and comfort in performing potentially life-saving therapies may wane during a deployment. Development of training simulators provides a method for bridging this gap. Herein, a field-expedient vascular trauma trainer for noncompressible torso hemorrhage is described. A low-fidelity simulator was created using a Penrose drain, intravenous tubing, suture, and a cardboard box. A higher-fidelity simulator was created using an aortobifemoral bypass graft, double-lumen endotracheal tube, suture, and an upper torso mannequin. The two trainers were successfully used to train for peripheral shunt placement and definitive vascular repair. The trainer makes use of supplies readily found at most Role 2 and 3 facilities and that are obtainable for Role 1 facilities providing damage control surgery. It provides a just-in-time way to develop and sustain confidence in the damage control principles applicable to vascular injuries.

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