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Pleuritic Chest Pain: This Can't Be Happening!

Farrell R, Dare C, Hampton K 17(4). 127 (Journal Article)

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Use of a Tuning Fork for Fracture Evaluation: An Introduction for Education and Exposure

Hetzler MR 17(4). 130 - 132 (Journal Article)

Radiographs, bones scans, and even ultrasound may be rare in the austere or acute environment for the evaluation of suspected musculoskeletal fractures. Having an easy, simple, and confident means of objective evaluation used in conjunction with the patient presentation, history, and physical findings may provide a more efficient and economical means of treatment. This introduction and review of selected literature are meant to provide a fuller understanding and consideration for the methods of using a tuning fork in fracture assessment.

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"Evita Una Muerte, Esta en Tus Manos" Program: Bystander First Aid Training for Terrorist Attacks

Pajuelo Castro JJ, Meneses Pardo JC, Salinas Casado PL, Hernandez Martin P, Montilla Canet R, del Campo Cuesta JL, Incera Bustio G, Martin Ayuso D 17(4). 133 - 137 (Journal Article)

Background: The latest terrorist attacks in Europe and in the rest of the world, and the military experience in the most recent conflicts leave us with several lessons learned. The most important is that the fate of the wounded rests in the hands of the one who applies the first dressing, because the victims usually die within the first 10 minutes, before professional care providers or police personnel arrive at the scene. A second lesson is that the primary cause of preventable death in these types of incidents involving explosives and firearms is massive hemorraghe. Objective: There is a need to develop a training oriented to citizens so they can identify and use available resources to avoid preventable deaths that occur in this kind of incidents, especially massive hemorrhage. Methods: A 7-hour training intervention program was developed and conducted between January and May 2017. Data were collected from participants' answers on a multiple-choice test before and after undertaking the training. Improved mean score for at least 75% of a group's members on the posttraining test was considered reflective of adequate knowledge. Results: A total of 173 participants (n = 74 men [42.8%]; n = 99 women [57.2%]) attended the training. They were classified into three groups: a group of citizens/ first responders with no prior health training, a group of health professionals, and a group of nursing students. Significant differences (ρ < .05) between mean pre- and post-training test scores occurred in each of the three groups. Conclusion: There was a clear improvement in the knowledge of the students after the training when pre- and post-training test scores were compared within the three groups. The greatest improvement was seen in the citizens/first responders group

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Military Prehospital Use of Low Titer Group O Whole Blood

Warner N, Zheng J, Nix G, Fisher AD, Johnson JC, Williams JE, Northern DM, Hellums JS 18(1). 15 - 18 (Case Reports)

The military's use of whole-blood transfusions is not new but has recently received new emphasis by the Tactical Combat Casualty Care Committee. US Army units are implementing a systematic approach to obtain and use whole blood on the battlefield. This case report reviews the care of the first patient to receive low titer group O whole blood (LTOWB) transfusion, using a new protocol.

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Benefit of Critical Care Flight Paramedic-Trained Search and Rescue Corpsmen in Treatment of Severely Injured Aviators

Snow RW, Papalski W, Siedler J, Drew B, Walrath B 18(1). 19 - 22 (Case Reports)

During routine aircraft start-up procedures at a US Naval Air Station, an aviation mishap occurred, resulting in the pilot suffering a traumatic brain injury and the copilot acquiring bilateral hemopneumothoraces, a ruptured diaphragm, and hepatic and splenic contusions. The care of both patients, including at point of injury and en route to the closest trauma center, is presented. This case demonstrates a benefit from advanced life-saving interventions and critical care skills beyond the required scope of practice of search and rescue medical technicians as dictated by relevant instructions.

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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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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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Prolonged Field Care for the Winter 2017 Edition

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

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Evaluation and Treatment of Ocular Injuries and Vision-Threatening Conditions in Prolonged Field Care

Reynolds ME, Hoover C, Riesberg JC, Mazzoli RA, Colyer M, Barnes S, Calvano CJ, Karesh JW, Murray CK, Butler FK, Keenan S, Shackelford S 17(4). 115 - 126 (Journal Article)

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Clinical Update: The Risk of Opioid Toxicity and Naloxone Use in Operational K9s

Palmer LE, Gautier A 17(4). 86 - 92 (Journal Article)

The increasing use of opioids (e.g., fentanyl, carfentanil) for illicit drug manufacturing poses a potential life-threatening hazard to law enforcement officers and first responders (e.g., EMS, fire and rescue) who may unknowingly come into contact with these drugs during the course of their daily activities. Similarly, Operational canines (OpK9s) of all disciplines-detection (drug, explosive, accelerant), patrol, tracking, search and rescue, and others-are at risk for accidental illicit opioid exposure. The most serious adverse effect of opioid exposure is respiratory depression leading to slow, shallow breathing or complete cessation of voluntary breathing (respiratory arrest). Naloxone, an opioid antagonist, is the antidote for reversing the effects of an opioid overdose in both humans and OpK9s. This clinical update describes the potential risks associated with opioid exposure as well as the use of naloxone as it pertains to the OpK9.

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Hand Injuries

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

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

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Experience With Prehospital Damage Control Capability in Modern Conflict: Results From Surgical Resuscitation Team Use

DuBose JJ, Martens D, Frament C, Haque I, Telian S, Benson PJ 17(4). 68 - 71 (Journal Article)

Background: Early resuscitation and damage control surgery (DCS) are critical components of modern combat casualty care. Early and effective DCS capabilities can be delivered in a variety of settings through the use of a mobile surgical resuscitation team (SRT). Methods: Twelve years of after-action reports from SRTs were reviewed. Demographics, interventions, and outcomes were analyzed. Results: Data from 190 casualties (185 human, five canine) were reviewed. Among human casualties, 12 had no signs of life at intercept and did not survive. Of the remaining 173 human casualties, 96.0% were male and 90.8% sustained penetrating injuries. Interventions by the SRT included intravascular access (50.9%) and advanced airway establishment (29.5%). Resuscitation included whole blood (3.5%), packed red blood cells (20.8%), and thawed plasma (11.0%). Surgery was provided for 63 of the 173 human casualties (36.4%), including damage control laparotomy (23.8%) and arterial injury shunting or repair (19.0%). SRTs were effectively used to augment an existing medical treatment facility (70.5%), to facilitate casualty transport (13.3%), as an independent surgical entity at a forward ground structure (9.2%), and in mobile response directly to the point of injury (6.9%). Overall survival was 97.1%. Conclusion: An SRT provides a unique DCS capability that can be successfully used in a variety of flexible roles.

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Diagnostic Accuracy of Emergency Bedside Ultrasonography to Detect Cutaneous Wooden Foreign Bodies: Does Size Matter?

Fleming ME, Heiner JD, Summers S, April MD, Chin EJ 17(4). 72 - 75 (Journal Article)

Background: Soft-tissue occult foreign bodies are a concerning cause of morbidity in the emergency department. The identification of wooden foreign bodies is a unique challenge because they are often not detectable by plain radiography. The purpose of this study was to determine the diagnostic accuracy of emergency physician-performed ultrasonography to detect wooden foreign bodies of varying sizes. We hypothesized that sonographic sensitivity would improve with increasing foreign body size. Methods: We conducted a blinded, prospective evaluation using a previously validated, chicken, soft-tissue model to simulate human tissue. We inserted wooden toothpicks of varying lengths (1mm, 2.5mm, 5mm, 7.5mm, 10mm) to a depth of 1cm in five tissue models. Five additional models were left without a foreign body to serve as controls. Fifty emergency physicians with prior ultrasonography training performed sonographic examinations of all 10 models and reported on the presence or absence of wooden foreign bodies. Results: Subjects performed 10 ultrasonography examinations each for a total of 500 examinations. For the detection of wooden foreign bodies, overall test characteristics for sonography included sensitivity 48.4% (95% confidence interval [CI], 42.1%-54.8%) and specificity 67.6% (95% CI, 61.3%- 73.2%). Sensitivity did not change as object size increased (ρ = s.709). Conclusion: Emergency physician bedside ultrasonography demonstrated poor diagnostic accuracy for the detection of wooden foreign bodies. Accuracy did not improve with increasing object size up to 10mm. Providers should consider alternative diagnostic modalities if there is persistent clinical concern for a retained, radiolucent, soft-tissue foreign body.

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Expeditionary Resuscitation Surgical Team: The US Army's Initiative to Provide Damage Control Resuscitation and Surgery to Forces in Austere Settings

D'Angelo M, Losch J, Smith B, Geslak M, Compton S, Wofford K, Seery JM, Morrison M, Wedmore I, Paimore J, Gross K, Cuenca PJ, Welder MD 17(4). 76 - 79 (Journal Article)

Improvements in surgical care on the battlefield have contributed to reduced morbidity and mortality in wounded Servicemembers. 1 Point-of-injury care and early surgical intervention, along with improved personal protective equipment, have produced the lowest casualty statistics in modern warfare, resulting in improved force strength, morale, and social acceptance of conflict. It is undeniable that point-of-care injury, followed by early resuscitation and damage control surgery, saves lives on the battlefield. The US Army's Expeditionary Resuscitation Surgical Team (ERST) is a highly mobile, interprofessional medical team that can perform damage control resuscitation and surgery in austere locations. Its configuration and capabilities vary; however, in general, a typical surgical element can perform one major surgery and one minor surgery without resupply. The critical care element can provide prolonged holding in garrison, but this diminishes in the austere setting with complex and acutely injured patients.

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Efficacy of the Mnemonic Device "MARCH PAWS" as a Checklist for Pararescuemen During Tactical Field Care and Tactical Evacuation

Kosequat J, Rush SC, Simonsen I, Gallo I, Scott A, Swats K, Gray CC, Mason B 17(4). 80 - 84 (Journal Article)

Background: The application of Tactical Combat Casualty Care (TCCC) represents evidence-based medicine to improve survival in combat. Over the past several years, US Air Force Pararescuemen (PJs) have expanded the mnemonic device "MARCH" to "MARCH PAWS" for use during tactical field care and tactical evacuation (TACEVAC). The mnemonic stands for massive bleeding, airway, respiration, circulation, head and hypothermia, pain, antibiotics, wounds, and splinting. We undertook this performance improvement project to determine the efficacy of this device as a treatment checklist. Methods: The mission reports of a 16-PJ combat rescue deployment to Operation Enduring Freedom (OEF) from January through June 2012 were reviewed. The triage category, mechanism of injury, injury, and treatments were noted. The treatments were then categorized to determine if they were included in MARCH PAWS. Results: The recorded data for missions involving 465 patients show that 45%, 48%, and 7%, were in category A, B, and C, respectively (urgent, priority, routine); 55% were battle injuries (BIs) and 45% were nonbattle injuries (NBIs). All treatments for BI were accounted for in MARCH PAWS. Only 9 patients' treatments with NBI were not in MARCH PAWS. Conclusion: This simple mnemonic device is a reliable checklist for PJs, corpsmen, and medics to perform TACEVAC during combat Operations, as well as care for noncombat trauma patients.

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Use of Physical Therapists to Identify and Treat Musculoskeletal Injuries at "The Tip of the Trident"

Shaw J, Brown L, Jansen B 17(4). 45 - 48 (Journal Article)

Musculoskeletal injuries continue to be the most common cause of decreased readiness and loss of productivity in all military environments. In commands with smaller footprints, such as Naval Special Warfare (NSW), every asset is critical for mission success. Studies have shown that early intervention by a medical provider can enhance healing and maintain unit readiness by preventing medical evacuations. Reports are limited with regard to Special Forces commands, especially during deployment. This article describes the injury characteristics and treatment of injuries seen by a physical therapist while deployed at forward operation commands embedded with NSW Group 2 Team 4. Over 4 months, 282 patients were evaluated and treated in southeast Afghanistan. In descending order, the three most common injured body regions were the lumbar/sacral spine (n = 82), shoulder (n = 59), and knee (n = 28). Therapy exercises (n = 461) were the most frequently performed treatment modality, followed by mobilization/manipulation (n = 394) and dry needling (n = 176). No patient evaluated was medically evacuated from the area or sent to an advanced medical site. Our data are similar to other published data reported on deployed units in terms of mechanisms and locations of injuries; thus, Special Forces commands do not appear to have unique injury patterns. These results support continued use of physical therapists in forward operations because of their ability to evaluate injuries and provide treatment modalities that help maintain the integrity of small commands at the site of injury.

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Staff Attitudes Regarding the Impact of a Therapy Dog Program on Military Behavioral Health Patients

Brisson S, Dekker AH 17(4). 49 - 51 (Journal Article)

Background: Human-animal interactions in the form of animal-assisted therapy (AAT) have become common in both civilian and military health care facilities. Evidence supports AAT as a beneficial therapeutic alternative for patients with physical disabilities and psychological disorders. Few studies have been conducted in the civilian health care setting to evaluate staff attitudes regarding the impact of an AAT program on behavioral health (BH) patients. To our knowledge, no research has examined staff attitudes on the impact and effectiveness of AAT on active-duty Servicemembers in a BH program at a military facility. Methods: At the completion of a year-long AAT dog program and after institutional review board exemption, an anonymous, six-question survey was used to examine staff attitudes (n = 29) regarding the impact and continuation of the program with military BH patients. Results: Most staff members (86%) believed the AAT dog program had a positive impact on the BH patients, including improved patient mood, greater patient relaxation, improved patient attitude toward therapy, and increased social interactions among patients. All the staff reported a desire to continue the program at the military facility. Conclusion: Most BH staff thought the year-long AAT dog program had a positive impact on patients. All staff supported continuation of the program.

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The SOF Truths for Army Special Operations Forces Surgical Teams

Baker JB, Modlin RE, Ong RC, Remick KN 17(4). 52 - 55 (Journal Article)

The US Army Special Operations Command and Army Medical Command are at a critical junction in Army medical training. Army Special Operations Forces (ARSOF) will receive Forward Resuscitative Surgical Teams (FRSTs) in the near future and must establish a training model to enable successful support for ARSOF operations. The military has been directed by Congress through the 2017 National Defense Authorization Act to embed trauma combat casualty care teams in civilian trauma centers. ARSOF FRSTs should be embedded in the nation's leading civilian trauma centers to build and sustain true expertise in delivering trauma care on the battlefield. The SOF Truths provide valuable insights into the required conditions for success of this new training paradigm.

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