Breakaway Media, LLC

Sort By:  
A Comparison of Ventilation Rates Between a Standard Bag-Valve-Mask and a New Design in a Prehospital Setting During Training Simulations

Costello JT, Allen PB, Levesque R 17(3). 59 - 63 (Journal Article)

Background: Excessive ventilation of sick and injured patients is associated with increased morbidity and mortality. Combat Medical Systems® (CMS) is developing a new bag-valve-mask (BVM) designed to limit ventilation rates. The purpose of this study was to compare ventilation rates between a standard BVM device and the CMS device. Methods: This was a prospective, observational, semirandomized, crossover study using Army Medics. Data were collected during Brigade Combat Team Trauma Training classes at Camp Bullis, Texas. Subjects were observed during manikin simulation training in classroom and field environments, with total duration of manual ventilation and number of breaths given recorded for each device. Analysis was performed on overall ventilation rate in breaths per minute (BPM) and also by grouping the subjects by ventilation rates in low, correct, and high groups based on an ideal rate of 10-12 BPM. Results: A total of 89 Medics were enrolled and completed the classroom portion of the study, with a subset of 36 evaluated in the field. A small but statistically significant difference in overall BPM between devices was seen in the classroom (ρ < .001) but not in the field (ρ > .05). The study device significantly decreased the incidence of high ventilation rates when compared by groups in both the classroom (ρ < .001) and the field (ρ = .044), but it also increased the rate of low ventilation rates. Conclusion: The study device effectively reduced rates of excessive ventilation in the classroom and the field.

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.

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.

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.

Surgical Instrument Sets for Special Operations Expeditionary Surgical Teams

Hale DF, Sexton JC, Benavides LC, Benavides JM, Lundy JB 17(3). 40 - 45 (Journal Article)

Background: The deployment of surgical assets has been driven by mission demands throughout years of military operations in Iraq and Afghanistan. The transition to the highly expeditious Golden Hour Offset Surgical Transport Team (GHOST- T) now offers highly mobile surgical assets in nontraditional operating rooms; the content of the surgical instrument sets has also transformed to accommodate this change. Methods: The 102nd Forward Surgical Team (FST) was attached to Special Operations assigned to southern Afghanistan from June 2015 to March 2016. The focus was to decrease overall size and weight of FST instrument sets without decreasing surgical capability of the GHOST-T. Each instrument set was evaluated and modified to include essential instruments to perform damage control surgery. Results: The overall number of main instrument sets was decreased from eight to four; simplified augmentation sets have been added, which expand the capabilities of any main set. The overall size was decreased by 40% and overall weight decreased by 58%. The cardiothoracic, thoracotomy, and emergency thoracotomy trays were condensed to thoracic set. The orthopedic and amputation sets were replaced with an augmentation set of a prepackaged orthopedic external fixator set). An augmentation set to the major or minor basic sets, specifically for vascular injuries, was created. Conclusion: Through the reorganization of conventional FST surgical instrument sets to maintain damage control capabilities and mobility, the 102nd GHOST-T reduced surgical equipment volume and weight, providing a lesson learned for future surgical teams operating in austere environments.

The Golden Hour Offset Surgical Treatment Team Operational Concept: Experience of the 102nd Forward Surgical Team in Operation Freedom's Sentinel 2015-2016

Benavides JM, Benavides LC, Hale DF, Lundy JB 17(3). 46 - 50 (Journal Article)

Theater Special Operations Force (SOF) medical planners have begun using Army Forward Surgical Teams (FSTs) to maintain a golden hour for U.S. SOF during Operation Freedom's Sentinel required adaptation in FST training, configuration, personnel, equipment, and employment to form Golden Hour Offset Surgical Treatment Teams (GHOST-Ts). This article describes one such FST's experience in Operation Freedom's Sentinel while deployed for 9 months in support of SOF in southern Afghanistan.

Estimation of Dog-Bite Risk and Related Morbidity Among Personnel Working With Military Dogs

Schermann H, Eiges N, Sabag A, Kazum E, Albagli A, Salai M, Shlaifer A 17(3). 51 - 54 (Journal Article)

Background: Soldiers serving in the Israel Defense Force Military Working Dogs (MWD) Unit spend many hours taming dogs' special skills, taking them on combat missions, and performing various dogkeeping activities. During this intensive work with the aggressive military dogs, bites are common, and some of them result in permanent disability. However, this phenomenon has not been quantified or reported as an occupational hazard. Methods: This was a retrospective cohort study based on self-administered questionnaires. Information was collected about soldiers' baseline demographics, duration of the experience of working with dogs, total number of bites they had, circumstances of bite events, and complications and medical treatment of each bite. Bite risk was quantified by incidence, mean time to first bite, and a Cox proportional hazards model. Rates of complications and the medical burden of bites were compared between combat soldiers and noncombat dogkeepers. Bite locations were presented graphically. Results: Seventy-eight soldiers participated and reported on 139 bites. Mean time of working with dogs was 16 months (standard deviation, ±9.4 months). Overall bite incidence was 11 bites per 100 person-months; the mean time to first bite event was 6.3 months. The Cox proportional hazards model showed that none of baseline characteristics significantly increased bite hazard. About 90% of bites occurred during routine activities, and 3.3% occurred on combat missions. Only in 9% of bite events did soldiers observed the safety precautions code. Bite complications included fractures, need for intravenous antibiotic treatment and surgical repair, prominent scarring, diminished sensation, and stiffness of proximal joints. Bite complications were similar between combat soldiers and dogkeepers. Most bites (57%) were located on hands and arms. Conclusion: MWD bites are an occupational hazard resulting in significant medical burden. Hands and arms were most common bite locations. Observance of safety precautions may be the most appropriate first-line preventive intervention. Barrier protection of upper extremities may reduce bite severity and complication rates.

Prehospital Administration of Tranexamic Acid by Ground Forces in Afghanistan: The Prehospital Trauma Registry Experience

Schauer SG, April MD, Naylor JF, Wiese J, Ryan KL, Fisher AD, Cunningham CW, Mitchell N, Antonacci MA 17(3). 55 - 58 (Journal Article)

Background: Tranexamic acid (TXA) was shown to reduce overall mortality and death secondary to hemorrhage in a large prospective study. This intervention is time sensitive. As such, the Tactical Combat Casualty Care (TCCC) guidelines recommend use of this low-cost, safe intervention among patients with possible hemorrhagic shock, penetrating trauma to the thorax or trunk, or extremity amputation. Objective: Prehospital administration of TXA by ground forces in the Afghanistan combat theater is described. Methods: We obtained data from the Prehospital Trauma Registry. We searched for all patients with documented hypotension, amputation, or penetrating trauma to the torso. Results: From January 2013 to September 2014, there were 272 patients who met inclusion criteria. Most injuries (97.8%; n = 266) were battle injuries. Of the 272 patients who met criteria to receive prehospital TXA, 51 (18.8%) received TXA, whereas the remaining 221 (81.2%) did not. Higher proportions of patients receiving TXA versus patients not receiving TXA received hemostatic dressings, pressure dressings, and tourniquet placement. Conversely, the proportion of patients receiving intravenous fluids was higher in the no-TXA group. Conclusion: Overall, proportions of eligible patients receiving TXA were low despite emphasis in the guidelines. The reasons for this low adherence to TCCC guidelines are likely multifactorial. Future research should seek to identify reasons TXA is not given when indicated and to develop training and technology to increase prehospital TXA administration.

Prehospital Cricothyrotomy Kits Used in Combat

Schauer SG, April MD, Cunningham CW, Long AN, Carter R 17(3). 18 - 20 (Case Reports)

Background: Surgical cricothyrotomy remains the only definitive airway management modality for the tactical setting recommended by Tactical Combat Casualty Care guidelines. Some units have fielded commercial cricothyrotomy kits to assist Combat Medics with surgical cricothyrotomy. To our knowledge, no previous publications report data on the use of these kits in combat settings. This series reports the the use of two kits in four patients in the prehospital combat setting. Methods: Using the Department of Defense Trauma Registry and the Prehospital Trauma Registry, we identified four cases of patients who underwent prehospital cricothyrotomy with the use of commercial kits. In the first two cases, a Medic successfully used a North American Rescue CricKit (NARCK) to obtain a surgical airway in a Servicemember with multiple amputations from an improvised explosive device explosion. In case 3, the Medic unsuccessfully used an H&H Medical kit to attempt placement of a surgical airway in a Servicemember shot in the head by small arms fire. A second attempt to place a surgical airway using a NARCK was successful. In case 4, a Soldier sustained a gunshot wound to the chest. A Medic described fluid in the airway precluding bag-valve-mask ventilation; the Medic attempted to place a surgical airway with the H&H kit without success. Conclusion: Four cases of prehospital surgical airway cannulation on the battlefield demonstrated three successful uses of prehospital cricothyrotomy kits. Further research should focus on determining which kits may be most useful in the combat setting.

Use of Acetylsalicylic Acid in the Prehospital Setting for Suspected Acute Ischemic Stroke

Levri JM, Ocon A, Schunk P, Cunningham CW 17(3). 21 - 23 (Journal Article)

Acute ischemic stroke (AIS) treatment guidelines include various recommendations for treatment once the patient arrives at the hospital. Prehospital care recommendations, however, are limited to expeditious transport to a qualified hospital and supportive care. The literature has insufficiently considered prehospital antiplatelet therapy. An otherwise healthy 30-year-old black man presented with headache for about 3 hours, left-sided facial and upper extremity numbness, slurred speech, miosis, lacrimation, and general fatigue and malaise. The presentation occurred at a time and location where appropriate resources to manage potential AIS were limited. The patient received a thorough physical examination and electrocardiogram. Acetylsalicylic acid (ASA) 325mg was administered within 15 minutes of history and examination. A local host-nation ambulance arrived approximately 30 minutes after presentation. The patient's neurologic symptoms had abated by the time the ambulance arrived. The patient did not undergo magnetic resonance imaging (MRI) until 72 hours after being admitted, owing to lack of neurology staff over the weekend. The MRI showed evidence of a left-sided, posteriorinferior cerebellar artery stroke. The patient was then taken to a different hospital, where he received care for his acute stroke. The patient eventually was prescribed a statin, ASA, and an angiotensin-converting enzyme inhibitor. The patient has no lingering symptoms or neurologic deficits.

Unwrapping a First Aid Tourniquet From Its Plastic Wrapper With and Without Gloves Worn: A Preliminary Study

Kragh JF, Aden JK, Lambert CD, Moore VK, Dubick MA 17(3). 25 - 34 (Journal Article)

Background: The purpose of this study was to gather data about unwrapping a packaged limb tourniquet from its plastic wrapper while wearing different types of gloves. Because already unwrapped tourniquets require no time to unwrap, unwrapping data may provide insights into the issue of having tourniquets unwrapped when stowed in a first aid kit of a Serviceperson at war. Materials and Methods: In a laboratory setting, 36 tests of nine glove groups were performed in which four people, gloved and ungloved, unwrapped tourniquets. Other tourniquets were environmentally exposed for 3 months. Results: All the users successfully unwrapped each tourniquet. Mean times to unwrap by glove group were not significantly different (ρ = .0961). When mean values of eight experimental groups were compared with that of one control group (i.e., bare hands), results showed no significant difference (ρ > .07). Mean time was least for bare hands (12 seconds) and most for cold gloves layered under mittens (22 seconds). Among the 36 pairwise comparisons of difference between glove group means, after adjustment for multiple comparisons, no comparison was noted to be statistically significant (ρ > .052, all 36 pairs). Glove thickness ranged from 0 mm for bare hands to 2.5 mm for cold gloves layered under mittens. By glove group, the thickness-time association was moderate, as tested by linear regression (R2 = 0.6096). The tourniquets exposed to the environment had evidence of rapid photodegradation due to direct exposure to sunlight. Such exposure also destroyed the wrappers. Conclusion: In a preliminary study, different gloves performed similarly when wearers unwrapped a tourniquet from its wrapper. The tourniquet wrappers gave no visible protection from sunlight, and environmental exposure destroyed the wrappers.

Combat Trousers as Effective Improvised Pelvic Binders A Comparative Cadaveric Study

Loftus A, Morris R, Friedmann Y, Pallister I, Parker P 17(3). 35 - 39 (Journal Article)

Background: Improvised explosive devices and landmines can cause pelvic fractures, which, in turn, can produce catastrophic hemorrhage. This cadaveric study compared the intrapelvic pressure changes that occurred with the application of an improvised pelvic binder adapted from the combat trousers worn by British military personnel with the commercially available trauma pelvic orthotic device (TPOD). Methods: Six unembalmed cadavers (three male, three female) were used to simulate an unstable pelvic fracture with complete disruption of the posterior arch (AO/OTA 61-C1) by dividing the pelvic ring anteriorly and posteriorly. A 3-4cm manometric balloon filled with water was placed in the retropubic space and connected to a 50mL syringe and water manometer via a three-way tap. A baseline pressure of 8cm H2O (average central venous pressure) was set. The combat trouser binder (CTB) and TPOD were applied to each cadaver in a random sequence and the steady intrapelvic pressure changes were recorded. Statistical analysis was performed using the Wilcoxon rank-sum test and a paired t test depending on the normality of the data to determine impact on the intrapelvic pressure of each intervention compared with baseline. Results: The median steady intrapelvic pressure achieved after application of the CTB was 16cm H2O and after application of the TPOD binder was 18cm H2O, both of which were significantly greater than the baseline pressure (ρ < .01 and .036, respectively) but not significantly different from each other (ρ > .05). Conclusion: Pelvic injuries are increasingly common in modern theaters of war. The CTB is a novel, rapidly deployable, yet effective, method of pelvic binding adapted from the clothes the casualty is already wearing. This technique may be used in austere environments to tamponade and control intrapelvic hemorrhage.

Acute Traumatic Wound Management in the Prolonged Field Care Setting

Rapp J, Plackett TP, Crane J, Lu J, Hardin D, Loos PE, Kelly R, Murray CK, Keenan S, Shackelford S 17(2). 132 - 149 (Journal Article)

Introduction to the Unconventional Medicine Series

Hetzler MR 17(2). 153 (Journal Article)

Maggot Therapy for Wound Care in Austere Environments

Sherman RA, Hetzler MR 17(2). 154 - 162 (Journal Article)

The past 25 years have seen an increase in use of maggot therapy for wound care. Maggot therapy is very effective in wound debridement; it is simple to apply and requires very little in the way of resources, costs, or skilled personnel. These characteristics make it well suited for use in austere environments. The use of medical-grade maggots makes maggot therapy nearly risk free, but medical grade maggots may not always be available, especially in the wilderness or in resource-limited communities. By understanding myiasis and fly biology, it should be possible even for the nonentomologist to obtain maggots from the wild and apply them therapeutically, with minimal risks.

Exertional Heat Illness Resulting in Acute Liver Failure and Liver Transplantation

Boni B, Amann C 17(3). 15 - 17 (Case Reports)

Heat illness remains a large medical burden for militaries around the world. Mitigating the incidence as well as the complications of heat illness must remain on the forefront of operational planning when operating in hot environments. We report the case of a 27-year-old male U.S. Marine who sustained a heat-related illness resulting in fulminant liver failure and permanent disability. The patient was transferred from the field to a civilian hospital. On hospital day 5, liver failure was identified. The patient was transferred to a transplant center, where he successfully received a liver transplant.

Ketones and Human Performance

Scott JM, Deuster PA 17(2). 112 - 116 (Journal Article)

Everyone is seeking nutritional strategies that might benefit performance. One approach receiving much attention is ketones, or ketosis. Ketones are very simple compounds made of hydrogen, carbon, and oxygen, and ketosis is a metabolic state whereby the body uses predominantly ketones. Ketosis can be achieved by fasting for longer than 72 hours or by following a very lowcarbohydrate, high-fat diet (ketogenic diet) for several days to weeks. Alternatively, ketone supplements purportedly induce ketosis rapidly and do not require strict adherence to any specific type of diet; however, much of the touted benefits are anecdotal. A potential role for ketosis as a performance enhancer was first introduced in 1983 with the idea that chronic ketosis without caloric restriction could preserve submaximal exercise capability by sparing glycogen or conserving the limited carbohydrate stores. Few human studies on the effects of a ketogenic diet on performance have yielded positive results, and most studies have yielded equivocal or null results, and a few negative results. Many questions about ketones relevant to Special Operations Forces (SOF) remain unanswered. At present, a ketogenic diet and/or a ketone supplement do not appear confer performance benefits for SOF. Instead, Operators should engage with their unit dietitian to develop individualized nutritional strategies based on unique mission requirements. The authors review the concept of a ketogenic diet, describe some potential benefits and risks of ketosis, review the performance literature and how to measure ketone status, and then summarize the landscape in 2017.


Burnett MW 17(2). 117 - 119 (Journal Article)

Stress Fractures: Etiology, Epidemiology, Diagnosis, Treatment, and Prevention

Knapik JJ, Reynolds K, Hoedebecke KL 17(2). 120 - 130 (Journal Article)

Stress fractures are part of a continuum of changes in healthy bones in response to repeated mechanical deformation from physical activity. If the activity produces excessive repetitive stress, osteoclastic processes in the bone may proceed at a faster pace than osteoblastic processes, thus weakening the bone and augmenting susceptibility to stress fractures. Overall stress fracture incidence is about three cases per 1,000 in active duty Servicemembers, but it is much higher among Army basic trainees: 19 per 1,000 for men and 80 per 1,000 for women. Well-documented risk factors include female sex, white ethnicity, older age, taller stature, lower aerobic fitness, prior physical inactivity, greater amounts of current physical training, thinner bones, cigarette smoking, and inadequate intake of vitamin D and/or calcium. Individuals with stress fractures present with focal tenderness and local pain that is aggravated by physical activity and reduced by rest. A sudden increase in the volume of physical activity along with other risk factors is often reported. Simple clinical tests can assist in diagnosis, but more definitive imaging tests will eventually need to be conducted if a stress fracture is suspected. Plain radiographs are recommended as the initial imaging test, but magnetic resonance imaging has higher sensitivity and is more likely to detect the injury sooner. Treatment involves first determining if the stress fracture is of higher or lower risk; these are distinguished by anatomical location and whether the bone is loaded in tension (high risk) or compression (lower risk). Lowerrisk stress fractures can be initially treated by reducing loading on the injured bone through a reduction in activity or by substituting other activities. Higher-risk stress fractures should be referred to an orthopedist. Investigated prevention strategies include modifications to physical training programs, use of shock absorbing insoles, vitamin D and calcium supplementation, modifications of military equipment, and leadership education with injury surveillance.

Per Page      281 - 300 of 732