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Burnett MW 17(3). 114 - 115 (Journal Article)

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Tools to Assess and Reduce Injury Risk (Part 1)

Knapik JJ 17(3). 116 - 119 (Journal Article)

Many injuries are preventable. Useful tools are available that can aid in assessing injury risks and developing methods to reduce these risks. This is part 1 of a two-part article that will discuss these tools, which include the Haddon Matrix, the 10 Countermeasure Strategies, the Injury Control Process, and the Army Risk-Management Process. The Haddon Matrix is 3 ® 3 table that, across the top (columns), provides an approach to conceptualizing injury prevention and control through modifications of the human, equipment, and environment; and, across rows, thinking about injury prevention and control before, during, and after the injury-producing event. The basic premise of the 10 Countermeasure Strategies is that injuries are largely due to energy exchanges between a person and the external environment in such a way that body cannot properly avoid or absorb the energy and anatomic structures are damaged. The Countermeasure Strategies are (1) eliminating the hazard altogether, (2) reducing the amount of the hazard, (3) preventing release of the hazard, (4) modifying the rate or spatial distribution of the hazard, (5) separating in space or time the hazard and the individual, (6) separating the individual from the hazard using a barrier, (7) modifying the basic qualities of the hazard, (8) strengthening the individual to make them more resistant to damage, (9) countering the damage done, and (10) stabilizing, healing, and rehabilitating the individual. Part 2 of this series will discuss the injury control process and the Army risk management process.

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Carfentanil: A New and Often Unrecognized Threat

Cowles CE, Mitchell J, Stepp JE, Bewley VZ 17(3). 120 - 122 (Journal Article)

Law enforcement officers, whether working the streets or on narcotic detail, and even those who operate in strike teams, face a new danger from an old drug: carfentanil. Drug dealers seeking to increase profits cut this cheap synthetic drug into expensive heroin, providing an extreme high. As a potent synthetic opioid narcotic, it is finding its way to the streets of the United States and can pose a threat to life for law enforcement, first responders, and medical examiners.

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An Outbreak Investigation Report and Lessons Learned by Multinational Coalition Forces: October 2016, Baghdad, Iraq

Gorzelnik SA, Kephart LN, Miklos WE 17(3). 123 - 129 (Journal Article)

Background: Public health personnel from the 28th Combat Support Hospital in Baghdad, Iraq, conducted an outbreak investigation in response to many local cases of gastrointestinal (GI) illness presenting to U.S. medical facilities. The investigation was conducted to identify the source of the illness, assess the extent of cases, and make recommendations to prevent similar outbreaks. Methods and Materials: For this retrospective cohort study, medical records and patient outbreak questionnaires were reviewed. A patient case, relative to the outbreak, was defined as any person who had developed a GI illness and presented for medical evaluation to either sick call or an emergency service at a diplomatic or military medical facility in Baghdad from 30 September to 12 October 2016. Results: A total of 123 people met the case definition. The most common presenting symptom was diarrhea (91% to 96% of cases). Other symptoms included abdominal cramps, fatigue, and headache. Most cases were military personnel (n =100). Salad was significantly associated with GI illness (70% of respondents). Five salad ingredients had significantly elevated levels of Escherichia coli. Conclusion: Mitigation strategies to reduce the probability of similar outbreaks include purchasing food solely from approved vendors or thoroughly cooking all foods, including fruits and vegetables.

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Traumatic Brain Injury Management in Prolonged Field Care

van Wyck D, Loos PE, Friedline N, Stephens D, Smedick BC, McCafferty R, Rush SC, Keenan S, Powell D, Shackelford S 17(3). 130 - 140 (Journal Article)

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Teleconsultation in Prolonged Field Care Position Paper

Vasios WN, Pamplin JC, Powell D, Loos PE, Riesberg J, Keenan S 17(3). 141 - 144 (Journal Article)

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To Cut or Not to Cut: That Is an Ultrasound Question!

Poston WH, Hampton K 17(3). 145 (Journal Article)

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Remote Dental Surgery as a Medical Civilian Assistance Program (MEDCAP): Helping Iraqi, Kurdish, and U.S. Forces Win Hearts and Minds in the Fight Against Daesh

Ferreira B 17(3). 148 - 150 (Journal Article)

Dr Ferreira discusses the work of the Humanitarian Aid and Security Forces (HASF) in providing volunteer dental services to a local Christian militia in Mosul, Iraq.

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Point-of-Care Coagulation Testing for Trauma Patients in a Military Setting: A Prospective Study

Cotte J, d'Aranda E, Chauvin V, Kaiser E, Meaudre E 13(4). 59 - 62 (Journal Article)

Background and Objective: Almost 50% of military trauma patients who need transfusions develop a coagulopathy. Immediately treating this coagulopathy improves the patient's prognosis. Field military hospitals often lack laboratory devices needed to diagnose a clinically significant coagulopathy and have limited blood product resources such as plasma. Point-of-care (POC) devices for the measurement of prothrombin time (PT) are available and have been tested in a variety of situations, including hemorrhagic surgery. The authors compared a POC device, the Coaguchek XS Pro (F. Hoffmann-La Roche Ltd., Basel, Switzerland), with laboratory measures for determining the PT in military trauma patients in a field hospital. Methods: This single-center prospective study was designed to compare POC coagulation monitoring with traditional laboratory testing. It was conducted at the French military hospital located at Kabul International Airport. All patients with trauma injuries resulting from war operations were included. A blood sample was drawn immediately on admission. PT was determined both in the laboratory and with use of the Coaguchek XS pro. Results: Forty patients with war trauma were enrolled during a 3-month period. The authors recorded 69 measurements. The two methods were correlated with a correlation coefficient of 0.78 (ρ < .001). The Bland- Altman plot showed a mean difference of 5.8% (95% confidence interval -14.9% to 26.6%). Using a PT cutoff of 60%, POC had a sensitivity of 77.1% and a specificity of 94.1%. Results from POC PT measurement were available within a mean of 25.8 minutes before laboratory measures. Conclusions: The Coaguchek XS Pro device can be used successfully in an austere environment without compromising its performance.

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Effects of Intraosseous and Intravenous Administration of Hextend® on Time of Administration and Hemodynamics in a Swine Model

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

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

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Seroprevalence of Dengue Fever in US Army Special Operations Forces: Initial Results and the Way Ahead

Caci JB, Blaylock JM, De La Barrera R, Thomas SJ, Lyons AG 14(3). 111 - 115 (Journal Article)

The endemicity of dengue fever (DF) and, consequently, sequelae of DF are increasing worldwide. The increases are largely a result of widespread international travel and the increased range of the mosquito vectors. US Army Special Operations Command (USASOC) personnel are at an increased risk of exposure to dengue based on their frequent deployments to and presence in dengue endemic areas worldwide. Repeated deployments to different endemic areas can increase the risk for developing the more serious sequelae of dengue: dengue hemorrhagic fever (DHF) and dengue shock syndrome (DSS). Information about the seroprevalence rate of dengue in USASOC personnel, in particular, is lacking and is critical to assessing the risk, tailoring preventive medicine countermeasures, leveraging field diagnostics, and maintaining mission capability. In the first part of a two-part project to assess baseline seroprevalence in USASOC units, a random, unit-stratified sample of 500 anonymous serum specimens from personnel assigned to the highest-risk units in USASOC were screened for dengue using a microneutralization assay. Of the 500 specimens screened, 56 (11.2%) of 500 had neutralizing titers (NT) (MN(50) ≥ 10) against at least one DENV serotype. Subsequent sample titration resulted in 48 (85.7%) of 56 of the samples with NT (MN(50) ≥ 10) against at least one dengue serotype for an overall dengue exposure rate of 9.6% (48 of 500). The second part of the ongoing project, started in 2012, was a multicenter, serosurveillance project using predeployment and postdeployment sera collected from USASOC personnel deployed to South and Central America, Africa, and Southeast Asia. Preliminary results show a 13.2% (55 of 414) seropositivity rate. The significance of these findings as they relate to personal risk and operational impact is discussed.

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Abdominal Pain

Banting J, Meriano T 15(1). 118 - 122 (Journal Article)

The series objective is to review various clinical conditions/ presentations, including the latest evidence on management, and to dispel common myths. In the process, core knowledge and management principles are enhanced. A clinical case will be presented. Cases will be drawn from real life but phrased in a context that is applicable to the Special Operations Forces (SOF) or tactical emergency medical support (TEMS) environment. Details will be presented in such a way that the reader can follow along and identify how they would manage the case clinically depending on their experience and environment situation. Commentary will be provided by currently serving military medical technicians. The medics and author will draw on their SOF experience to communicate relevant clinical concepts pertinent to different operational environments including SOF and TEMS. Commentary and input from active special operations medical technicians will be part of the feature.

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Tourniquet Conversion: A Recommended Approach in the Prolonged Field Care Setting

Drew B, Bird D, Matteucci M, Keenan S 15(3). 81 - 85 (Journal Article)

Life-saving interventions take precedence over diagnostic maneuvers in the Care Under Fire stage of Tactical Combat Casualty Care. The immediate threat to life with an actively hemorrhaging extremity injury is addressed with the liberal and proper use of tourniquets. The emphasis on hemorrhage control has and will continue to result in the application of tourniquets that may not be needed past the Care Under Fire stage. As soon as tactically allowable, all tourniquets must be reassessed for conversion. Reassessment of all tourniquets should occur as soon as the tactical situation permits, but no more than 2 hours after initial placement. This article describes a procedure for qualified and trained medical personnel to safely convert extremity tourniquets to local wound dressings, using a systematic process in the field setting.

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Rapid Vision Correction by Special Operations Forces

Reynolds ME 17(2). 60 - 64 (Journal Article)

Background: This report describes a rapid method of vision correction used by Special Operations Medics in multiple operational engagements. Methods: Between 2011 and 2015, Special Operations Medics used an algorithm- driven refraction technique. A standard block of instruction was provided to the medics, along with a packaged kit. The technique was used in multiple operational engagements with host nation military and civilians. Data collected for program evaluation were later analyzed to assess the utility of the technique. Results: Glasses were distributed to 230 patients with complaints of either decreased distance or near (reading). Most patients (84%) with distance complaints achieved corrected binocular vision of 20/40 or better, and 97% of patients with near-vision complaints achieved corrected near-binocular vision of 20/40 or better. There was no statistically significant difference between the percentages of patients achieving 20/40 when medics used the technique under direct supervision versus independent use. Conclusion: A basic refraction technique using a designed kit allows for meaningful improvement in distance and/or near vision at austere locations. Special Operations Medics can leverage this approach after specific training with minimal time commitment. It can serve as a rapid, effective intervention with multiple applications in diverse operational environments.

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The Role I Resuscitation Team and Resuscitative Endovascular Balloon Occlusion of the Aorta

Fisher AD, Teeter WA, Cordova CB, Brenner ML, Szczepanski MP, Miles EA, Galante JM, DuBose JJ, Rasmussen TE 17(2). 65 - 73 (Journal Article)

The medical advancements made during the wars in Iraq and Afghanistan have resulted in an unprecedented survival rate, yet there is still a significant number of deaths that were potentially survivable. Additionally, the ability to deliver casualties to definitive surgical care within the "golden hour" is diminishing in many areas of conflict. Resuscitative endovascular balloon occlusion of the aorta (REBOA) has been implemented successfully in the hospital setting. REBOA may be a possible adjunct for the Role I and point-of-injury (POI) care to provide temporary control of noncompressible torso hemorrhage (NCTH) and junctional hemorrhage. Here the authors advocate for the development of the Role I Resuscitation Team (RT) and a training pathway to meet the challenge of the changing battlefield

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The Sole Provider: Preparation for Deployment to a Medically Austere Theater

Corso P, Mandry C, Reynolds S 17(2). 74 - 81 (Journal Article)

The combat focus of the US Military over the past 15 years has primarily centered on the Iraq and Afghanistan areas of operation (AOs). Thus, much human and financial capital has been dedicated to the creation of a robust medical infrastructure to support those operations. However, Special Operation Forces (SOF) are often called upon to deploy in much more medically austere AOs. SOF medical providers operating in such environments face significant challenges due to the diversity of medical threats, extremely limited access to medical resupply, a material shortage of casualty evacuation platforms, lack of medical facilities, and limited access to higher-level care providers. This article highlights the challenges faced during a recent Special Forces deployment to such an austere environment. Many of these challenges can be mitigated with a specific approach to premission training and preparation.

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Albumin for Prehospital Fluid Resuscitation of Hemorrhagic Shock in Tactical Combat Casualty Care

Studer NM, April MD, Bowling F, Danielson PD, Cap AP 17(2). 82 - 88 (Journal Article)

Optimal fluid resuscitation on the battlefield in the absence of blood products remains unclear. Contemporary Combat medics are generally limited to hydroxyethyl starch or crystalloid solutions, both of which present significant drawbacks. Obtaining US Food and Drug Administration (FDA)-approved freeze-dried plasma (FDP) is a top casualty care research priority for the US Military. Interest in this agent reflects a desire to simultaneously expand intravascular volume and address coagulopathy. The history of FDP dates to the Second World War, when American expeditionary forces used this agent frequently. Also fielded was 25% albumin, an agent that lacks coagulation factors but offers impressive volume expansion with minimal weight to carry and requires no reconstitution in the field. The current potential value of 25% albumin is largely overlooked. Although FDP presents an attractive future option for battlefield prehospital fluid resuscitation once FDA approved, this article argues that in the interim, 25% albumin, augmented with fibrinogen concentrate and tranexamic acid to mitigate hemodilution effects on coagulation capacity, offers an effective volume resuscitation alternative that could save lives on the battlefield immediately.

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Intubation of the Right Atrium During an Attempted Modified Surgical Airway in a Pig

Bowman J, Juergens A, McClure M, Spear D 17(2). 96 - 100 (Journal Article)

In modern medicine, the surgical cricothyrotomy is an airway procedure of last resort. In austere environments, however, its simplicity may make it a more feasible option than carrying a full complement of laryngoscopes. To create a Transportation Security Agency-compliant compact first-response bag, we attempted to establish a surgical cricothyrotomy in a pig, using trauma shears, basic medical scissors, a pocket bougie, and an endotracheal tube. Bougies can provide tactile feedback via the "tracheal ring sign" and "stop sign" to indicate positive tracheal placement during orotracheal intubation. We report on a previously unknown serious potential complication that questions the use of scissors to establish a surgical airway and the reliability of tactile bougie signs when translated into certain surgical airways.

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QuikClot® Combat Gauze® Use by Ground Forces in Afghanistan The Prehospital Trauma Registry Experience

Schauer SG, April MD, Naylor JF, Fisher AD, Cunningham CW, Ryan KL, Thomas KC, Brillhart DB, Fernandez JD, Antonacci MA 17(2). 101 - 106 (Journal Article)

Background: QuikClot® Combat Gauze® (QCCG) was fielded in 2008 to replace previous generations of hemostatic products. To the best of our knowledge, despite nearly a decade of use, there are no published data on use among US combatant forces. We describe the use of QCCG by ground forces in Afghanistan and compare patients who received QCCG compared with the remaining population in the database who did not receive QCCG. Methods: Data were obtained from the Prehospital Trauma Registry (PHTR). Joint Trauma System personnel linked patients to the Department of Defense Trauma Registry (DODTR) for outcome data, when available, upon reaching a fixed facility. Results: Of the 705 patients within the entire PHTR, 118 (16.7%) had documented use of QCCG. Most patients (69.5%) were Afghan; all were male. Lower extremities accounted for the most common site of application (39.7%). Hemorrhage control occurred in 88.3% of encounters with hemorrhage control status documented. Patients receiving QCCG generally had higher rates of concomitant interventions. Of the 705 patients, 190 were linkable to the DODTR for outcome data; 25 of the 28 (89.3%) in the QCCG group were discharged alive compared with 153 of the 162 (94.4%) in the non-QCCG group (ρ = .300). Conclusion: QCCG appears to have common use on the battlefield as a concomitant intervention for obtaining hemorrhage control. Patients receiving QCCG had higher rates of gunshot wounds compared with the baseline population and were generally sicker. Hemorrhage control success was like that reported in other military and civilian settings.

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Headache

Banting J, Meriano T 17(2). 108 - 111 (Journal Article)

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