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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.
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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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Dietary Supplements for Musculoskeletal Pain: Science Versus Claims

Crawford C, Saldanha L, Costello R, Deuster PA 18(2). 110 - 114 (Journal Article)

Special Operations Forces (SOF) face unique challenges that manifest themselves both mentally and physically. The extremes of training and combat can affect the readiness to perform at peak levels, especially when confronted with musculoskeletal pain. Many SOF Operators turn to dietary supplements in hopes of gaining an edge. Although some supplements are now being marketed for pain, decisions to use these products need to be driven by information that is evidence based. We describe SOF-specific evidence-based recommendations for the use of dietary ingredients for pain that emerged from a rigorous scientific evaluation. These recommendations are compared with the label claims made in the commercial market by companies selling products to combat musculoskeletal pain. This information can be used by the SOF medical community to assist Operators in making informed decisions when considering or selecting dietary supplements for maintaining and optimizing performance.

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Epidemiologic Evidence and Possible Mechanisms for the Association Between Cigarette Smoking and Injuries. Part 2: Is the Relationship Between Smoking and Injuries Causal?

Knapik JJ, Bedno SA 18(2). 117 - 122 (Journal Article)

Part 1 of this series reviewed the epidemiologic evidence for the association between cigarette smoking and injuries and possible biological and psychosocial mechanisms to account for this relationship. In the present article, nine criteria are explored to determine if smoking is a direct cause of injuries (i.e., a causal relationship). There is substantial evidence that individuals who smoked in the past have a higher subsequent risk of injury. A recent meta-analysis found that smokers in the military were 1.31 times more likely to be injured than nonsmokers and Servicemembers with low, medium, and high levels of smoking had 1.27, 1.37, and 1.71 times, respectively, the risk of injury compared with nonsmokers. The association between smoking and injuries has been reported in at least 18 US military studies and in 14 civilian studies in seven countries. The biological plausibility of the association was discussed extensively in part 1 of this series. A possible alternative explanation with sufficient data was that smokers may be risk takers and it is the risk-taking behavior that increases injury risk (not smoking per se). Once an individual no longer smokes, a decrease in injury risk has been reported for at least bone health and wound healing. The effects of smoking do not appear to be specific to one type of injury, possibly because of the numerous compounds in tobacco smoke that could affect tissues and physiological processes, with evidence provided for bones, tendons, and healing processes. The association was consistent with other knowledge, with some evidence provided from other types of medical problems and trends in smoking and injury-related mortality. In summary, the association between smoking and injuries appears to meet many of the criteria for a causal relationship.

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What's in a Rash? Viral Exanthem Versus CBRNE Exposure: Teleconsultation Support for Two Special Forces Soldiers With Diffuse Rash in an Austere Environment

Lee HD, Butterfield S, Maddry J, Powell D, Vasios WN, Yun H, Ferraro D, Pamplin JC 18(2). 133 - 135 (Journal Article)

Objective: Review clinical thought process and key principles for diagnosing weaponized chemical and biologic injuries. Clinical Context: Special Operation Forces (SOF) team deployed in an undisclosed, austere environment. Organic Expertise: Two SOF Soldiers with civilian EMT-Basic certification. Closest Medical Support: Mobile Forward Surgical Team (2 hours away); medical consults available by e-mail, phone, or video-teleconsultation. Earliest Evacuation: Earliest military evacuation from country 12-24 hours. With teleconsultation, patients departed to Germany as originally scheduled without need for Medical Evacuation.

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Intelligent Exam for Crucial Intelligence. . .

Dare C, Hampton K 18(2). 141 (Journal Article)

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Ether Anesthesia in the Austere Environment: An Exposure and Education

Morgans LB, Graham N 18(2). 142 - 146 (Journal Article)

Medical services in the austere and limited environment often require therapeutics and practices uncommon in modern times due to a lack of availability, affordability, or expertise in remote areas. In this setting, diethyl ether, or simply ether anesthesia, still serves a role today as an effective inhalation agent. An understanding of ether as an anesthetic not only illustrates the evolution in surgical anesthesia but also demonstrates ether's surviving function and durable use as a practical agent in developing nations. Although uncommon, it is not unseen, so a working knowledge should be understood if observation and advocacy for patients receiving this method of anesthesia are experienced.

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Old Tricks for New Dogs? John Caddy and the Victorian Origins of TCCC

Reynolds PS 18(2). 58 - 62 (Journal Article)

The success of Tactical Combat Casualty Care (TCCC) in reducing potentially preventable combat deaths may rely on both specific interventions (such as tourniquets) and the systematized application of immediate care. Essential elements of a combat care system include clear specification of immediate care priorities, standardized methodology, and inclusion and training of all nonmedical personnel in early response. Although TCCC is fairly recent, the construct is similar to that first suggested during the mid-nineteenth century by John Turner Caddy (1822-1902), a British Royal Navy staff surgeon. Although naval warfare engagements at the time were relatively infrequent, casualties could be numerous and severe and often overwhelmed the small medical staff on board. Caddy recognized that nonmedical personnel properly trained in the fundamentals of combat injury management would result in lives saved and greatly improved morale. The novelty was in his attempt to make procedures simple enough to be performed by nonmedical personnel under stress. However, Caddy's guidelines were completely overlooked for nearly two centuries. The principles of best practice for managing combat trauma injuries learned in previous wars have often been lost between conflicts. Understanding the historical roots of combat first responder care may enable us to better understand and overcome barriers to recognition and retention of essential knowledge.

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Surgery at Sea: The Effect of Simulated High Sea States on Surgical Performance

Pierce E, Rapada R, Herder PA, LaPorta AJ, Hoang TN, Pena M, Blankenship J, Kiser J, Catlin SA 18(2). 64 - 70 (Journal Article)

Background: The US Navy initiated design concepts for a Medical Mission Module Support Container (M3SC), a mobile operating room capable of rapid installation aboard maneuverable ships within proximity of active combat units. The M3SC provides an alternative echelon of care in the current trauma system by decreasing the time between point of injury, arrival, and surgical intervention. The mobile ships used as M3SC platforms, however, are more susceptible to oceanic conditions that can induce detrimental physiologic motion sickness in medical personnel and patients aboard the vessels. This study investigated the effects of different sea-state motion conditions on the performance of surgical teams. Methods: Six four-person surgical teams performed 144 procedures in an M3SC aboard a Stewart motion table that simulated motion profiles of sea states 0, 3, and 4. A modified human-worn partial- task surgical simulator was used as a surgical surrogate to simulate the four most common, wartime, improvised explosive device injuries in the past 10 years. Electroencephalographs and heart rate variability (HRV) data were collected from surgeons and surgical technologists during each procedure to assess real-time physiologic responses to motion. Two postprocedure surveys, a Surgical Task Load Index and a Motion Sickness Assessment Questionnaire, were given to assess subjective responses of workload stress and motion-induced kinetosis. Surgical subject matter experts quantified surgical performance after each procedure by measuring blood loss and orthopedic pin placement to evaluate each intervention. Results: Motion did not significantly influence overall performance (ρ = .002). Surgical procedure was the strongest predictor of performance. HRV was used to measure stress and was increased in surgical technologists; however, HRV was decreased for surgeons and technologists in motion. There was a significant interaction between role and motion (ρ = .002): Surgeons had higher workloads than did surgical technologists and neither demonstrated differences between motion and no motion. Surgeons demonstrated significantly decreased workloads under motion conditions (ρ = 0.002); however, surgeons perceived their workload to be higher. We attribute this to their increased critical thinking and physical execution of procedures. Surgeons and surgical technologists showed a trend toward HRV suppression within the motion conditions. This may indicate a coping response to the increased stress of the motion setting. Procedure and team dynamic were the strongest predictors of overall performance, suggesting a learning curve exists and that added focus on training should be enforced. Conclusion: Based on data collected in this study, similar surgical procedures should be implemented aboard these classes of ships. By doing so, injured military personnel would have more timely access to care. Surgical team members were aware of craft motion, used compensatory measures, and exhibited some physiological response.

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Survey of Casualty Evacuation Missions Conducted by the 160th Special Operations Aviation Regiment During the Afghanistan Conflict

Redman TT, Mayberry KE, Mora AG, Benedict BA, Ross EM, Mapp JG, Kotwal RS 18(2). 79 - 85 (Journal Article)

Background: Historically, documentation of prehospital combat casualty care has been relatively nonexistent. Without documentation, performance improvement of prehospital care and evacuation through data collection, consolidation, and scientific analyses cannot be adequately accomplished. During recent conflicts, prehospital documentation has received increased attention for point-of-injury care as well as for care provided en route on medical evacuation platforms. However, documentation on casualty evacuation (CASEVAC) platforms is still lacking. Thus, a CASEVAC dataset was developed and maintained by the 160th Special Operations Aviation Regiment (SOAR), a nonmedical, rotary-wing aviation unit, to evaluate and review CASEVAC missions conducted by their organization. Methods: A retrospective review and descriptive analysis were performed on data from all documented CASEVAC missions conducted in Afghanistan by the 160th SOAR from January 2008 to May 2015. Documentation of care was originally performed in a narrative after-action review (AAR) format. Unclassified, nonpersonally identifiable data were extracted and transferred from these AARs into a database for detailed analysis. Data points included demographics, flight time, provider number and type, injury and outcome details, and medical interventions provided by ground forces and CASEVAC personnel. Results: There were 227 patients transported during 129 CASEVAC missions conducted by the 160th SOAR. Three patients had unavailable data, four had unknown injuries or illnesses, and eight were military working dogs. Remaining were 207 trauma casualties (96%) and five medical patients (2%). The mean and median times of flight from the injury scene to hospital arrival were less than 20 minutes. Of trauma casualties, most were male US and coalition forces (n = 178; 86%). From this population, injuries to the extremities (n = 139; 67%) were seen most commonly. The primary mechanisms of injury were gunshot wound (n = 89; 43%) and blast injury (n = 82; 40%). The survival rate was 85% (n = 176) for those who incurred trauma. Of those who did not survive, most died before reaching surgical care (26 of 31; 84%). Conclusion: Performance improvement efforts directed toward prehospital combat casualty care can ameliorate survival on the battlefield. Because documentation of care is essential for conducting performance improvement, medical and nonmedical units must dedicate time and efforts accordingly. Capturing and analyzing data from combat missions can help refine tactics, techniques, and procedures and more accurately define wartime personnel, training, and equipment requirements. This study is an example of how performance improvement can be initiated by a nonmedical unit conducting CASEVAC missions.

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Picture This: Management of Canine Pyotraumatic Dermatitis (a.k.a., Hot Spot)

Palmer LE 18(2). 105 - 109 (Journal Article)

Pyotraumatic dermatitis (a.k.a., hot spot) is a rapidly developing, superficial, moist, exudative dermatitis commonly induced by self-inflicted trauma. Although not acutely life threatening, these lesions are extremely pruritic and distracting and significantly interfere with the canine's operational effectiveness and ability to stay on task. The review discusses a case, including clinical presentation, diagnosis, treatment, and prognosis.

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Ascaris

Burnett MW 18(2). 115 - 116 (Journal Article)

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Arthropod Borne and Zoonotic Infections Among Military Personnel in Georgia

Chitadze N, Gureshidze N, Rostiaschvili N, Danelia N, Dalakishvili K, Durglishvili L, Kuchukhidze R, Imnadze P, Chlikadze R, Betashvili M, Kuchuloria T, Akhvlediani N, Rivard R, Nikolich M, Bautista CT, Washington MA, Akhvlediani N 18(2). 136 - 140 (Journal Article)

Military personnel are at an increased risk for exposure to arthropod- borne and zoonotic pathogens. The prevalence of these pathogens has not been adequately described in the country of Georgia. As the Georgian military moves toward an increased level of capability and the adoption of European Union and North Atlantic Treaty Organization standards, international field exercises will become more frequent and will likely involve an increasing number of international partners. This study was undertaken with the goal of defining the arthropod-borne and zoonotic pathogen threat in Georgia so force health protection planning can proceed in a rational and data-driven manner. To estimate disease burden, blood was taken from 1,000 Georgian military recruits between October 2014 and February 2016 and screened for previous exposure to a set of bacterial and viral pathogens using a antibody-based, serologic procedure. The highest rate of exposure was to Salmonella enterica serovar Typhi, and the lowest rate of exposure was to Coxiella burnettii (the causative agent of Q fever). These data provide insight into the prevalence of arthropod-borne infections in Georgia, fill a critical knowledge gap, will help guide future surveillance efforts, and will inform force health protection planning.

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Nursing Interventions in Prolonged Field Care

Ostberg D, Loos PE, Mann-Salinas EA, Creson C, Powell D, Riesberg JC, Keenan S, Shackelford S 18(2). 123 - 132 (Journal Article)

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Junctional Tourniquet Use During Combat Operations in Afghanistan: The Prehospital Trauma Registry Experience

Schauer SG, April MD, Fisher AD, Cunningham CW, Gurney J 18(2). 71 - 74 (Journal Article)

Background: Hemorrhage is the leading cause of potentially preventable death on the battlefield. Although the resurgence of limb tourniquets revolutionized hemorrhage control in combat casualties in the recent conflicts, the mortality rate for patients with junctional hemorrhage is still high. Junctional tourniquets (JTQs) offer a mechanism to address the high mortality rate. The success of these devices in the combat setting is unclear given a dearth of existing data. Methods: From the Prehospital Trauma Registry (PHTR) and the Department of Defense Trauma Registry, we extracted cases of JTQ use in Afghanistan. Results: We identified 13 uses of a JTQ. We excluded one case in which an improvised pelvic binder was used. Of the remaining 12 cases of JTQ use, seven had documented success of hemorrhage control, three failed to control hemorrhage, and two were missing documentation regarding success or failure. Conclusion: We report 12 cases of prehospital use of JTQ in Afghanistan. The findings from this case series suggest these devices may have some utility in achieving hemorrhage control strictly at junctional sites (e.g., inguinal creases). However, they also highlight device limitations. This analysis demonstrates the need for continued improvements in technologies for junctional hemorrhage control, prehospital documentation, data fidelity and collection, as well as training and sustainment of the training for utilization of prehospital hemorrhage control techniques.

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The Role of Magnetic Resonance Imaging in Optimizing Injury Management in Air Force Pararescuemen, Combat Rescue Officers, and Survival Specialists

Rush SC, Foresto C, Hewitt CW, Grossman MG, Petersen CD, Gallo I, Staak BP, Rush JT 18(2). 86 - 89 (Journal Article)

Operators perform physically demanding jobs associated with a variety of overuse and acute musculoskeletal injuries. The current management of musculoskeletal complaints in the Air Force includes plane radiographs and 6 weeks of physical therapy (PT) before consideration of orthopedic consultation and magnetic resonance imaging (MRI); however, MRI shows a clear advantage compared with plane radiographs. We conducted a performance improvement project and conclude that (1) MRI allowed for definitive diagnosis as well as definitive triage for care in a timely manner, (2) guidelines for ordering lumbosacral MRIs should be followed and not ordered for pain that is not progressive and severe or not associated with a neurological finding, and (3) because of the risk of X-ray exposure in patients in their 20 and 30s, X-rays should be avoided in this setting unless definitely indicated.

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Are the King LTS Laryngeal Tube and the Ambu AuraOnce Laryngeal Mask Useful Airway Adjuncts for Military Medics?

Regner D, Frykholm P 18(2). 90 - 96 (Journal Article)

Background: Airway management is a critical skill that may be essential in the battlefield. The aim of this study was to determine if combat life savers and medics with no or limited clinical experience could provide airway control using the disposable laryngeal suction tube (LTS-D) and the Ambu® AuraOnce ™ disposable laryngeal mask (LMA). Methods: Eight military medics with limited clinical experience and no airway management experience secured the airway on 19 intrahospital anesthetized patients using the LTS-D and the LMA. Each patient was treated with both airway adjuncts in a randomized order. Each medic was studied on at least two and not more than three patients. Success of insertion, number of attempts, and time to correct placement with verified ventilation were recorded. Results: When using the LTS-D, the first-attempt success rate for the medics with the first patient was 50% (four of eight) and 75% (six of eight) on the second attempt. With the second patient, the first-attempt success rate was 87.5% (seven of eight), and on the third patient, it was 100% (three of three). For all patients, the accumulated first-attempt success rate was 73.7% (14 of 19) and 84.2% (16 or 19) for second attempts with the LTS-D. The success rate on first attempt with the LMA was 100% (19 of 19) on the first patient. On the second intervention with the LMA, there was a significant decrease in mean time to verified ventilation, from 56.4 seconds to 27.7 seconds (ρ = .043), and time to verified ventilation with no leakage, from 61.3 seconds to 32.3 seconds (ρ = .029). Insertion attempts for three LTS-Ds and one LMA failed. Conclusion: This study suggests that for the safe use of the laryngeal tube suction by inexperienced airway providers, a clinical training program is required. The LMA proved superior to the LTS-D with a 100% success rate at the first attempt, which suggests that minimal training is needed before clinical use. We therefore recommend the LMA as the primary airway adjunct for military medics, despite a hypothetically inferior protection from aspiration.

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Prehospital Administration of Antibiotic Prophylaxis for Open Combat Wounds in Afghanistan: 2013-2014

Schauer SG, Fisher AD, April MD, Stolper KA, Cunningham CW, Carter R, Fernandez JD, Pfaff JA 18(2). 53 - 56 (Journal Article)

Background: Military operations place injured Servicemembers at high risk for open wounds. Austere environments and initial wound contamination increase the risk for infection. Wound infections continue to cause significant morbidity among injured Servicemembers. Limited evidence suggests that early antibiotic therapy for open wounds reduces infection rates. Methods: We obtained data from the Prehospital Trauma Registry (PHTR) from January 2013 through September 2014. This database includes data from Tactical Combat Casualty Care (TCCC) cards, Department of Defense 1380 forms, and after-action reports to provide near-real-time feedback to units on prehospital medical care. We evaluated whether patients with open wounds received antibiotics in accordance with TCCC guidelines. Low adherence was defined at less than 80%. Results: In this data set, overall, prefixed facility providers administered antibiotics to 54.0% of patients with an open combat wound. Of the antibiotics given, 11.1% were within TCCC guidelines. The relatively low administration and adherence rates persisted across subgroup analyses. Conclusion: Overall, relatively few patients with open combat wounds receive antibiotic administration as recommended by TCCC guidelines. In the group that received antibiotics, few received the specific antibiotics recommended by TCCC guidelines. The development of strategies to improve adherence to these TCCC recommendations is a research priority.

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Methods for Early Control of Abdominal Hemorrhage: An Assessment of Potential Benefit

Cantle PM, Hurley MJ, Swartz MD, Holcomb JB 18(2). 98 - 104 (Journal Article)

Background: Noncompressible truncal hemorrhage (NCTH) after injury is associated with a mortality increase that is unchanged during the past 20 years. Current treatment consists of rapid transport and emergent intervention. Three early hemorrhage control interventions that may improve survival are placement of a resuscitative endovascular balloon occlusion of the aorta (REBOA), injection of intracavitary self-expanding foam, and application of the Abdominal Aortic Junctional Tourniquet (AAJT™). The goal of this work was to ascertain whether patients with uncontrolled abdominal or pelvic hemorrhage might benefit by the early or prehospital use of one of these interventions. Methods: This was a single-center retrospective study of patients who received a trauma laparotomy from 2013 to 2015. Operative reports were reviewed. The probable benefit of each hemorrhage control method was evaluated for each patient based on the location(s) of injury and the severity of their physiologic derangement. The potential scope of applicability of each control method was then directly compared. Results: During the study period, 9,608 patients were admitted; 402 patients required an emergent trauma laparotomy. REBOA was potentially beneficial for hemorrhage control in 384 (96%) of patients, foam in 351 (87%), and AAJT in 35 (9%). There was no statistically significant difference in the potential scope of applicability between REBOA and foam (ρ = .022). There was a significant difference between REBOA and AAJT (ρ < .001) and foam and AAJT™ (ρ < .001). The external surface location of signs of injury did not correlate with the internal injury location identified during laparotomy. Conclusion: Early use of REBOA and foam potentially benefits the largest number of patients with abdominal or pelvic bleeding and may have widespread applicability for patients in the preoperative, and potentially the prehospital, setting. AAJT may be useful with specific types of injury. The site of bleeding must be considered before the use of any of these tools.

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