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Prolonged Field Care for the Winter 2017 Edition

Riesberg JC 17(4). 114 (Journal Article)

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Energy Balance and Diet Quality During the US Marine Corps Forces Special Operations Command Individual Training Course

Sepowitz JJ, Armstrong NJ, Pasiakos SM 17(4). 109 - 113 (Journal Article)

Methods: This study characterized the total daily energy expenditure (TDEE), energy intake (EI), body weight, and diet quality (using the Healthy Eating Index-2010 [HEI]) of 20 male US Marines participating in the 9-month US Marine Corps Forces Special Operations Command Individual Training Course (ITC). Results: TDEE was highest (ρ < .05) during Raider Spirit (RS; 6,376 ± 712kcal/d) compared with Survival, Evasion, Resistance, and Escape (SERE; 4,011 ± 475kcal/d) School, Close-Quarters Battle (CQB; 4,189 ± 476kcal/d), and Derna Bridge (DB; 3,754 ± 314kcal/d). Body mass was lost (ρ < .05) during SERE, RS, and DB because EI was less than TDEE (SERE, -3,665kcal/d ± 475kcal/d; RS, -3,966 ± 776kcal/d; and DB, -1,027 ± 740kcal/d; p < .05). However, body mass was restored before the start of each subsequent phase and was not different between the start (86.4 ± 9.8kg) and end of ITC (86.7 ± 9.0kg). HEI score declined during ITC (before, 65.6 ± 11.2 versus after, 60.9 ± 9.7; p < .05) because less greens or beans and more empty calories were consumed (ρ < .05). Dietary protein intake was lowest during RS (0.9 ± 0.4g/kg) compared with all other phases, and carbohydrate intake during RS (3.6 ± 1g/kg), CQB (3.6 ± 1.0g/kg), and DB (3.7 ± 1.0g/kg) was lower than during the academic phase of SERE (5.1 ± 1.0g/kg; p < .05). Conclusion: These data suggest that ITC students, on average, adequately restore body mass between intermittent periods of negative energy balance. Education regarding the importance of maintaining healthy eating patterns while in garrison, consuming more carbohydrate and protein, and better matching EI with TDEE during strenuous training exercises may be warranted.

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Tools to Assess and Reduce Injury Risk (Part 2)

Knapik JJ 17(4). 104 - 108 (Journal Article)

Research has shown that many injuries are preventable if the operational environment is understood. Useful tools are available to assist in assessing injury risks and in developing methods to reduce risks. This is part 2 of a two-part article that discusses these tools, which include the Haddon Matrix, the 10 Countermeasure Strategies, the Injury Prevention Process, and the US Army Risk Management Process. Part 1 covered the Haddon Matrix and the 10 Countermeasure Strategies; part 2 outlines and provides examples of the Injury Prevention Process and the US Army Risk Management Process. The Injury Prevention Process is largely oriented to systematic research and involves (1) surveillance and survey to document the size of the injury problem, (2) identification of the causes of and risk factors for injuries, (3) intervention to identify what works to prevent injuries, (4) program implementation based on documented research, and (5) program evaluation to see how well the program works in the operational environment. The US Army Risk Management Process involves (1) identifying hazards, (2) assessing hazards, (3) developing controls for reducing hazards, (4) implementing controls, and (5) supervising and evaluating controls. There is overlap among the four approaches, but each has unique aspects that can be useful for thinking about and implementing injury prevention and control measures.

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Shigellosis

Burnett MW 17(4). 102 - 103 (Journal Article)

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Optimizing Musculoskeletal Performance Through Injury Prevention

de la Motte SJ, Gribbin TC, Deuster PA 17(4). 97 - 101 (Journal Article)

Musculoskeletal injuries (MSK-Is) are ubiquitous throughout the Special Operations Forces (SOF) because of the physical demands of executing missions and carrying heavy loads. Preventing MSK-I has been a priority among SOF but is especially challenging because most MSK-Is are chronic or recurring. For many SOF, musculoskeletal issues and MSK pain are just part of doing their job. Ways to focus, target, and integrate injury prevention efforts across the continuum of training, active duty and SOF status are critical because MSK-Is are a significant barrier to human performance optimization. In this article, we describe how to incorporate these efforts at all levels of training. The need for improving valid, objective, fit-for-full-duty metrics after injury and sharing such information continuously with SOF is discussed. Last, strategies for engaging all levels to begin a culture shift away from the acceptance of MSK-I and pain as a way of life toward embracing MSK-I prevention as a regular part of everyday training are presented.

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Hand Injuries

Banting J, Meriano T 17(4). 93 - 96 (Journal Article)

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Foreign Language Short Course: Special Operations Clinical Research Fundamentals

Kemplin KR, Bowling F 17(2). 12 - 17 (Journal Article)

When we do not know a language, we are at the mercy of an interpreter. The same is true for research: Special Operations Forces (SOF) clinicians not actively involved in research initiatives may rely on scientific interpreters, so it is important to speak some of the language personally. For any clinician, using evidence in practice requires a working knowledge of how that evidence was generated from research, which requires an understanding of research science language. Here we review common basics of research science to reinforce concepts and elements of experimental and nonexperimental research.

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Assessment of Trainer Skill to Control Groin-Wound Bleeding: Use of Junctional Tourniquet Models on a Manikin

Kragh JF, Aden JK, Shackelford S, Moore VK, Dubick MA 17(2). 39 - 48 (Journal Article)

Background: The purpose of this study was to assess the skills of trainers using different junctional tourniquet models to control groin bleeding in a manikin. Materials and Methods: In 204 assessments, 17 trainers used four junctional tourniquet models three times each to control simulated hemorrhage. The models included the Combat Ready Clamp (CRoC), Junctional Emergency Treatment Tool (JETT), Abdominal Aortic and Junctional Tourniquet (AAJT), and SAM Junctional Tourniquet (SJT). The criteria of assessment included effectiveness (i.e., control [yes-no]), time to stop bleeding, total blood loss, and bleeding rate. Results: All uses were effective. By model, the results of mean blood loss and time to stop bleeding were different with varying levels of statistical significance: control was worst with the JETT and AAJT, moderate with the AAJT and SJT, and best with the SJT and CRoC. The means sharing a level were not significantly different, but a mean in more than one level was not different from itself. The composite outcome results were 90% good for CRoC and 67% good for JETT, whereas results for the SJT and AAJT were in between, and only the result of the CROC and JETT comparison was significant. The ease of use varied significantly; JETT was more difficult to use and all others were easier. The analysis attributed to the users 19% of the variance of results for time, 44% for blood loss volume, and 67% for bleeding rate. Most users preferred the SJT (53% before and 70% after assessment). Conclusion: Effectiveness was attained by all users with each of the four models of junctional tourniquet. The analysis demonstrated that up to 67% of the variance of performance results could be attributed to the users.

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A Prospective Randomized Controlled Two-Arm Clinical Study Evaluating the Efficacy of a Bioelectric Dressing System for Blister Management in US Army Ranger Recruits

Housler GJ, Cross S, Marcel V, Kennedy DO, Husband M, Register A, Roberts T, Grubbs S, Dudewicz D, Setka n, Bay C, Wendelken ME, Izadjoo MJ 17(2). 49 - 58 (Journal Article)

This study focused on a clinically relevant healthcare problem in the military: acute soft tissue wounds, or blisters. The trial was a prospective, controlled, randomized two-arm study evaluating the efficacy of a bioelectric dressing, Procellera®, applied topically two to three times per week for 2 weeks to blisters developed in Ranger trainees during training at Fort Benning, Georgia. A total of 80 US Army Ranger recruits with blister wounds below the knee were randomly assigned to one of two treatment groups (n = 40/group). The primary goal was to assess the clinical efficacy (rate of healing) of administered Procellera in conjunction with the standard-of-care (SOC) treatment, moleskin and Tegaderm ®, on the healing rate of blisters compared with the SOC treatment alone. The secondary end points for efficacy were the quantities of wound fluid biomarkers and bacterial bioburden. The tertiary end point was assessment of pain in the treatment group compared with that of the control group during the 2-week study. The results showed no statistical difference between the SOC and SOC+Procellera groups in wound healing and pain. Wound fluid was reported for 24 participants (64.9%) in the SOC group and 21 participants (56.8%) in SOC+Procellera group at the baseline measurement (ρ = .475); however, the wounds were devoid of fluid on follow-up visits. The mild nature of the wounds in this study was apparent by the low pain scores at the beginning of the study, which disappeared by the follow-up visits. The average wound sizes were 2.2cm2 and 1.5cm2 for the SOC and SOC+Procellera groups, respectively. This trial protocol should be conducted on open softtissue wounds in severe heat. To our knowledge, this is the first clinical study conducted within the US Army Rangers training doctrine.

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Manikin Human-Patient Simulator Training

Horn GT, Bowling F, Lowe DE, Parimore JG, Stagliano DR, Studer NM. 17(2). 89 - 95. (Journal Article)

Background: Human-patient simulators (HPSs) may help enhance medical education. Manikin HPS devices respond to common field medical interventions, such as cricothyroidotomy, and have realistic feedback features, such as respirations and pulses. This study surveys Special Operations Medics for evaluations of HPS features. Methods: Of 518 subjects, 376 completed testing and surveys with valid responses. A total of 102 variables were divided into three categories-general characteristics, procedures, and injuries-and assessed on a fivepoint Likert scale. The Student t test was used to analyze data together and as separate groups against each other and against an aggregated mean. Results: Features that received high scores (i.e., higher than 4.5/5) corresponded closely with pillars of the Tactical Combat Casualty Care (TCCC) curriculum, basic life support, and realism. Discussion: US Army Special Operations Command and US Special Operations Command Medics have overall high confidence in manikin HPS devices and specifically in those that align with TCCC training and lifesaving procedures. The skills most valued coincide with difficult-to-practice measures, such as cricothyroidotomy and wound packing. Features such as prerecorded sounds, sex, automated movements, skin color, defibrillation, bowel sounds, and electrocardiogram are rated lower. These evaluations may guide future development or procurement of manikin HPS devices.

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Evaluation of XSTAT® and QuickClot® Combat Gauze® in a Swine Model of Lethal Junctional Hemorrhage in Coagulopathic Swine

Cox JM, Rall JM 17(3). 64 - 67 (Journal Article)

Background: Hemorrhage is associated with most potentially survivable deaths on the battlefield. Effective and field-tested products are lacking to treat junctional and noncompressible injuries. XSTAT® is a newly developed, U.S. Food and Drug Administration-approved product designed to treat junctional hemorrhage. The Committee on Tactical Combat Casualty Care has recently approved the product for use as part of its treatment guidelines, but data are lacking to assess its efficacy in different wounding patterns and physiologic states. Methods: Dilutional coagulopathy was induced in 19 large (70-90kg), healthy, male swine by replacing 60% of each animal's estimated blood volume with room temperature Hextend ®. After dissection, isolation, and lidocaine incubation, uncontrolled hemorrhage was initiated by transection of both axillary artery and vein. Free bleeding was allowed to proceed for 30 seconds until intervention with either XSTAT or QuickClot® Combat Gauze® (CG) followed by standard backing. Primary outcomes were survival, hemostasis, and blood loss. Results: XSTAT-treated animals achieved hemostasis in less time and remained hemostatic longer than those treated with CG. Less blood was lost during the first 10 minutes after injury in the XSTAT group than the CG group. However, no differences in survival were observed between XSTAT-treated and CG-treated groups. All animals died before the end of the observation period except one in the XSTAT-treated group. Conclusion: XSTAT performed better than CG in this model of junctional hemorrhage in coagulopathic animals. Continued testing and evaluation of XSTAT should be performed to optimize application and determine appropriate indications for use.

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A Descriptive Analysis of Occupational Fatalities Due to Felonious Assault Among U.S. Law Enforcement Officers During Tactical Incidents, 1996-2014

Thompson MS, Hartman TM, Sztajnkrycer MD 17(3). 69 - 73 (Journal Article)

Introduction: Little is known about occupational fatalities among tactical officers. A greater understanding of such injuries is needed to improve officer safety. The purpose of this study was to provide a descriptive analysis of line-of-duty deaths secondary to felonious assault during tactical incidents. Methods: Retrospective analysis was performed of open-source de-identified Federal Bureau of Investigation Uniform Crime Reporting Law Enforcement Officers Killed and Assaulted (LEOKA) data inclusive of the years 1996-2014. Officers were included if the fatal injury occurred during operations by a Special Weapons and Tactics (SWAT) team, fugitive task force, narcotics task force, or if the LEOKA narrative described the event as a tactical situation. Results: Of 1,012 officer deaths during the study period, 57 (5.6%) involved tactical officers. On average (± standard deviation), victim officers were 37.3 ± 7.8 years of age at the time of death, with 11.7 ± 6.6 years of law enforcement experience. High-risk warrant service accounted for 63.2% of fatalities. A single officer was killed in 91.2% of incidents; 49.1% of cases involved injuries to other officers. The majority of officers (59.6%) killed were the first officer(s) to enter the scene. The most commonly identified cause of death was head trauma (n = 28). Chest trauma accounted for 14 deaths; 10 (71.4%) sustained an entry wound via the ballistic vest armhole. Where recorded, 52.0% of officers died within the first hour of injury. The provision or nature of buddy care, tactical emergency medical services (EMS) care, or conventional EMS care was rarely noted. Conclusion: Tactical officer deaths most commonly occur during high-risk warrant service, and most often involve the first officer(s) to enter a scene, suggesting an opportunity for improved operational tactics. The frequency of fatal axillary penetration suggests the opportunity for ballistic protection redesign. Information is lacking regarding on-scene care, limiting the ability to determine optimal medical procedures for downed officers during tactical operations. Nearly 50% of victim officers survived more than 1 hour from time of injury, suggesting opportunities to intervene and potentially affect outcomes.

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Optimization of Simulation and Moulage in Military-Related Medical Training

Petersen C, Rush SC, Gallo I, Dalere B, Staak B, Moore L, Kerr W, Chandler M, Smith W 17(3). 74 - 80 (Journal Article)

Preparation of Special Operations Forces (SOF) Medics as first responders for the battle space and austere environments is critical to optimize survival and quality of life for our Operators who may sustain serious and complex wounding patterns and illnesses. In the absence of constant clinical exposure for these medics, it is necessary to maximize all available training opportunities. The incorporation of scenario-based training helps weave together teamwork and the ability to practice treatment protocols in a tactical, controlled training environment to reproduce, to some degree, the environment in and stressors under which care will need to be delivered. We reviewed the evolution of training scenarios within one Pararescue (PJ) team since 2008 and codified various tools used to simulate physical findings and drive medical exercises as part of scenario-based training. We also surveyed other SOF Medic training resources.

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Atropine Eye Drops: A Proposed Field Expedient Substitute in the Absence of Atropine Autoinjectors

Calvano CJ, Enzenauer RW, Eisnor DL, Mazzoli RA 17(3). 81 - 83 (Journal Article)

Nerve agents are a threat to military and civilian health. The antidote, atropine sulfate, is delivered by autoinjector, which is a limited resource. We propose the use of 1% atropine ophthalmic solution (supplied commercially in 5mL or 15 mL bottles) via oral, ocular, and intranasal administration as an expedient substitute in austere environments.

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Chest Seal Placement for Penetrating Chest Wounds by Prehospital Ground Forces in Afghanistan

Schauer SG, April MD, Naylor JF, Simon EM, Fisher AD, Cunningham CW, Morissette DM, Fernandez JD, Ryan KL 17(3). 85 - 89 (Journal Article)

Background: Thoracic trauma represents 5% of all battlefield injuries. Communicating pneumothoraces resulting in tension physiology remain an important etiology of prehospital mortality. In addressing penetrating chest trauma, current Tactical Combat Casualty Care (TCCC) guidelines advocate the immediate placement of a vented chest seal device. Although the Committee on TCCC (CoTCCC) has approved numerous chest seal devices for battlefield use, few data exist regarding their use in a combat zone setting. Objective: To evaluate adherence to TCCC guidelines for chest seal placement among personnel deployed to Afghanistan. Methods: We obtained data from the Prehospital Trauma Registry (PHTR). Joint Trauma System personnel linked patients to the Department of Defense Trauma Registry, when available, for outcome data upon reaching a fixed facility. Results: In the PHTR, we identified 62 patients with documented gunshot wound (GSW) or puncture wound trauma to the chest. The majority (74.2%; n = 46) of these were due to GSW, with the remainder either explosive-based puncture wounds (22.6%; n = 14) or a combination of GSW and explosive (3.2%; n = 2). Of the 62 casualties with documented GSW or puncture wounds, 46 (74.2%) underwent chest seal placement. Higher proportions of patients with medical officers in their chain of care underwent chest seal placement than those that did not (63.0% versus 37.0%). The majority of chest seals placed were not vented. Conclusion: Of patients with a GSW or puncture wound to the chest, 74.2% underwent chest seal placement. Most of the chest seals placed were not vented in accordance with guidelines, despite the guideline update midway through the study period. These data suggest the need to improve predeployment training on TCCC guidelines and matching of the Army logistical supply chain to the devices recommended by the CoTCCC.

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No Ordinary Sleeper Cell: Managing the Varied Problems of Plasmodium vivax Malaria

Jarvis J 17(3). 90 - 94 (Journal Article)

Plasmodium vivax malaria is an essential yet elusive target of tropical disease eradication efforts, and is the focus of this literature review. This review will reacquaint Special Operations Forces (SOF) Medics with the basic principles of malaria as context for understanding the several confounding issues particular to P. vivax infections. The review concludes with current malaria guidelines and malaria mitigation strategies.

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Humanitarian Struggle in Burma's Conflict Zones

Gyo M 17(3). 95 - 99 (Journal Article)

The Back Pack Health Worker Team (BPHWT), a community- based health organization, provides primary health care to ethnic people in conflict, remote, and internally displaced areas, in Burma (aka Myanmar), controlled by ethnic armed organizations fighting against the Burma government. Its services include both curative and preventative health care through a network of 1,425 health personnel including community health workers and village-embedded traditional birth attendants and village health workers. The BPHWT organizational and program model may prove useful to Special Operations medical actions in support of insurgent movements and conversely with a host nation's counterinsurgency strategies, which include the extension of its health services into areas that may be remote and/or inhabited by indigenous people and have insurgency potential. In the former respect, special attention is directed toward "humanitarian struggle" that uses health care as a weapon against the counterinsurgency strategies of a country's oppressive military.

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A Shift From Resilience to Human Performance Optimization in Special Operations Training: Advancements in Theory and Practice

Park GH, Messina LA, Deuster PA 17(3). 109 - 113 (Journal Article)

Within the Department of Defense over the past decade, a focus on enhancing Warfighter resilience and readiness has increased. For Special Operation Forces (SOF), who bear unique burdens for training and deployment, programs like the Preservation of the Force and Family have been created to help support SOF and their family members in sustaining capabilities and enhancing resilience in the face of prolonged warfare. In this review, we describe the shift in focus from resilience to human performance optimization (HPO) and the benefits of human performance initiatives that include holistic fitness. We then describe strategies for advancing the application of HPO for future initiatives through tailoring and cultural adaptation, as well as advancing methods for measurement. By striving toward specificity and precision performance, SOF human performance programs can impact individual and team capabilities to a greater extent than in the past, as well as maintaining the well-being of SOF and their families across their careers and beyond.

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Hepatitis E

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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