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Performance Enhancement Assessment and Coaching in US Army Special Operations: Rapidly Enhancing Performance Through Targeted, Tailored Feedback

Barry DM, DeVries M 19(4). 66 - 73 (Journal Article)

Background: Performance enhancement coaching poses significant benefits to individuals and organizations, such as improved job satisfaction and goal achievement. Given their training and experience in assessment and feedback, operational psychologists assigned to Special Operations units are uniquely positioned to provide performance enhancement coaching tailored to Operators and enablers. A preliminary program evaluation was conducted of the Performance Enhancement Assessment and Coaching (PEAC) Program. Methods: A sample of 32 Operators and enablers assigned to a US Army Special Operations Forces (ARSOF) unit voluntarily participated in the PEAC Program and completed one 90-minute coaching session. Following their coaching session, Soldiers provided qualitative and quantitative feedback on their coaching experience. Results: Soldiers overwhelmingly agreed that the PEAC Program was worth their time and helpful towards achieving their goals. Results indicate the PEAC Program enhanced Soldiers' perceived self-awareness, self-efficacy, and job performance. Results also suggest performance enhancement coaching may improve pass rates on interpersonally demanding Special Operations courses. Conclusion: Performance enhancement coaching delivers considerable value for Special Operations personnel and their organizations in relatively minimal time. Operational psychologist coaches (OPCs) assigned to Special Operations units can leverage their assessment skills to provide targeted, tailored performance enhancement coaching and increase value to their organizations.

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The Potential Use of the Abdominal Aortic Junctional Tourniquet® in a Military Population: A Review of Requirement, Effectiveness, and Usability

Handford C, Parker PJ 19(4). 74 - 79 (Journal Article)

Uncontrolled hemorrhage is the leading cause of preventable prehospital death on the battlefield; 20% is junctional. This is a challenge to manage in the forward and prehospital military environment. With the widespread use of body armor, peripheral tourniquets and continued asymmetric warfare this consistent figure is unlikely to reduce. Resuscitative endovascular balloon occlusion of the aorta (REBOA) is an often-quoted potential solution; however, this invasive strategy requires a high skill level alongside a significant failure and complication rate. The Abdominal Aortic Junctional Tourniquet® (AAJT) is a noninvasive potential adjunct for the management of hemorrhage below the level of the aortic bifurcation with published case reports of successful use in prehospital blast and gunshot wounds. When placed at the level of the aortic bifurcation, alongside a pelvic binder, it can be used to control pelvic hemorrhage, buying time until definitive management. Importantly it has a low training burden and is easy to use. The AAJT has potential use as a prehospital device in the exsanguinating patient, those in traumatic cardiac arrest, as a bridging device, and as fluid conserving device in resource-limited environments. The evidence surrounding the AAJT is reviewed, and potential uses in the military setting are suggested.

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Getting "SMART" on Shock Treatment: An Evidence-Based Mnemonic Acronym for the Initial Management of Hemorrhage in Trauma

Thompson P, Hudson AJ 19(4). 62 - 65 (Journal Article)

Treating hemorrhagic shock is challenging, the pathology is complex, and time is critical. Treatment requires resources in mental bandwidth (i.e., focused attention), drugs and blood products, equipment, and personnel. Providers must focus on treatment options in order of priority while also maintaining a dynamic assessment of the patient's response to treatment and considering potential differential diagnoses. In this process, the cognitive load is substantial. To avoid errors of clinical reasoning and practical errors of commission, omission, or becoming fixated, it is necessary to use evidence-based treatment recommendations that are concise, in priority order, and easily recalled. This is particularly the case in the austere, remote, or tactical environment. A simple mnemonic acronym, SMART, is presented in this article. It is a clinical heuristic that can be used as an aide-mémoire during the initial phases of resuscitation of the trauma patient with hemorrhagic shock: Start the clock and Stop the bleeding; Maintain perfusion; Administer antifibrinolytics; Retain heat; Titrate blood products and calcium; Think of alternative causes of shock.

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Interoperable Readiness to Use Tourniquets by One's Familiarity With Different Models

Kragh JF, Aden JK, Dubick MA 19(4). 51 - 57 (Journal Article)

Background: We investigated interoperability for a first aid provider to perform simulated use of three tourniquet models of maximal, moderate, and minimal familiarity. Methods: The experiment was focused on the tourniquets used by an expert who rendered aid on a manikin by using three models of tourniquet with different extents of familiarity: The familiarity with Combat Application Tourniquet (C-A-T) was maximal; that for Special Operations Forces Tactical Tourniquet (SOFTT) was moderate, and that for Military Emergency Tourniquet (MET) was minimal. Each model had a band-and-rod design. Interoperability changes as intermodel differences were beneficial or costly in that performances were improved or impaired in units of time, ease, blood, and pressure. Each model had 10 tests, and test order was randomized by model. The HapMed Leg Tourniquet Trainer simulated a limb amputation. Results: In comparison of interoperability burdens, sums of 10 test durations by model for C-A-T, SOFTT, and MET were 38, 77, and 64 minutes, respectively; C-A-T was fastest (p ≤ .002, both). The sums of times to stop bleeding for C-A-T, SOFTT, and MET were 334, 953, and 826 seconds, respectively; C-A-T was fastest (p ≤ .0013, both). The sums of blood losses for C-A-T, SOFTT, and MET were 2105, 3287, and 4256mL, respectively; that for C-A-T was least (p ≤ .0005, both). The mean ease of use differed, with C-A-T being easiest (p ≤ .0046, both). The mean pressure differed, with C-A-T being higher than SOFTT (p = .0073). Conclusions: Timesaving strongly favored the model with which the user had maximal familiarity. In theory and simulation, interoperability bears costs in successfully attaining it, in maintaining it, and in failing either. The user's familiarity with tourniquet model was associated with improved interoperability as seen by improved performances. If multiple models are fielded, then organizations may plan on extra spending, supplying, training, and managing.

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Leveraging Combat Casualty Reporting in the Afghan National Army Special Operations Command for Evidence-Based Changes in the ANASOC School of Excellence

Florance JM, Hicks M 19(4). 59 - 61 (Journal Article)

The Afghan National Army Special Operations Command (ANASOC) uses several documents for casualty reporting. By analyzing these documents from a period of March to December 2018, the authors demonstrate the predominance of gunshot fatalities within ANASOC at approximately 63% of combat deaths and a high rate of prehospital death at approximately 97% of combat deaths. The data also demonstrate relatively few cases of long-term disability from ANASOC soldiers wounded in action. The authors used these conclusions to create a Combined Joint Special Operations Task Force-Afghanistan (CJSOTF-A) working group that recommended changes to the medical curriculum at the ANASOC School of Excellence. These recommendations centered on an increased emphasis on bleeding control to prevent death from hemorrhagic shock.

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A Case for Improvised Medical Training

Hetzler MR 19(4). 123 - 125 (Journal Article)

The hyperresourced, uber-controlled, ultrareactive, constant environment that we have come to know in the past 20 years should not be mistaken as the norm in conflict. In truth, unrealistic expectations of both commanders and systems in resourcing is presently being reinforced almost daily. Only in the past few years of this decade have the majority of allied forces experienced challenge in resupply and support in contingency operations. When logistical lines are cut, limited, or untimely, we must know and exercise other means of providing the highest level of medical care possible-if not with indigenous ways and means, then by improvisation. History has proved that improvised medicine can be capable, professional, and ethically sound if practiced properly and to standards, the price being time, education, and investment in the requirement. Most often, these are already time-honored means of care.

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2019 Recommended Limb Tourniquets in Tactical Combat Casualty Care

Montgomery HR, Hammesfahr R, Fisher AD, Cain JS, Greydanus DJ, Butler FK, Goolsby AM, Eastman AL 19(4). 27 - 50 (Journal Article)

Military and civilian trauma can be distinctly different but the leading cause of preventable trauma deaths in the prehospital environment, extremity hemorrhage, does not discriminate. The current paper is the most comprehensive review of limb tourniquets employable in the tactical combat casualty care environment and provides the first update to the CoTCCC-recommended limb tourniquets since 2005. This review also highlights the lack of unbiased data, official reporting mechanisms, and official studies with established criteria for evaluating tourniquets. Upon review of the data, the CoTCCC voted to update the recommendations in April 2019.

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"There I Was": A Cup of Improvisation

Hubbard B, Freeman C 19(4). 120 - 122 (Journal Article)

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Applying Swiss Armed Forces Training Didactics and Methodology for Tactical Combat Casualty Care Training

Anonymous A 19(4). 114 - 117 (Journal Article)

Some of the current methods of instruction used within international armed forces courses are not always goal oriented and satisfactory for both the teaching staff and the student. The Swiss Armed Forces approach presented here has been historically effective in preparing and sustaining national conscription with large numbers of recruits and new cadres every year.

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Could He Stay or Should He Go Now?

Hampton K, Van Humbeeck L 19(4). 118 (Journal Article)

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Severe Lower Body Swelling and Bacteremia Secondary to Shewanella algae Bacteremia During Basic Underwater Demolition SEAL Training

Bridwell RE, Carius BM, Oliver JJ 19(4). 19 - 21 (Case Reports)

Shewanella algae is a unique bacterium largely documented in skin and soft tissue infections (SSTIs) with a wide range of presentations from gas-producing necrotizing fasciitis to osteomyelitis. Seawater exposure to lower extremity ulcers and wounds is most often correlated with infection, which has been documented in causing complications of bacteremia, sepsis, and infective endocarditis. Further complicating treatment is poor response to most empiric regimens prior to definitive diagnosis and an uneven response to antibiotics, including documented resistance to carbapenem. This case documents the presentation of a Basic Underwater Demolition SEAL (BUD/S) training candidate who presented acutely for complaints of severe lower body swelling and abrasions during "Hell Week" and was found to have polymicrobial bacteremia with Staphylococcus aureus, Enterococcus, and S algae.

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United States Military Parachute Injuries: Part 2: Interventions Reducing Military Parachute Injuries in Training and Operations

Knapik JJ 19(4). 109 - 113 (Journal Article)

This is part 2 of an article detailing the reduction in airbornerelated injuries over time. Part 1 examined the early history of airborne operations and provided evidence for the reduction in injuries over time; part 2 discusses interventions associated with the decline in injury rates. In 1943 at the United States (US) Army Airborne School, data showed that injuries were substantially reduced from 120 to 18 injuries/1000 trainees. Credit for the reduction was given to development of the parachute landing fall (PLF), better supervision of students while in initial airborne training, intensive ground training prior to actual jumping, and elimination of dangerous and unnecessary training procedures (like practice jumps from 11-foot heights). Compared to the older T-10 parachute introduced in the 1950s, the newer T-11 parachute introduced in 2010 reduced injuries by 43% in operational training (9.1 vs 5.2 injuries/1000 jumps). In aircraft with jump doors on both sides, alternating jumps between the doors so that the jumpers exit at slightly different times reduced high-altitude and mid-altitude entanglement injuries by 85% (0.13 to 0.02 injury/ 1000 jumps). Data from six scientific studies involving more than 1,300,000 jumps and two systematic reviews indicated that the parachute ankle brace (PAB) reduced ankle injuries and ankle fractures by about half with an estimated return on investment of at least $7 in medical and personnel costs for every $1 spent on the PAB. However, the PAB is not currently used or even well-known within the airborne community because of a lack of acceptance and promotion. While some airborne injury-reducing innovations are discussed here it is likely that there have been others that have not been documented. It is important to detail these interventions so future paratroopers and leaders can better understanding their rationale and effectiveness.

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What Can Be Done With Expired Pharmaceuticals? A Review Of Literature As It Pertains To Special Operations Force's Medics

Culbertson NT 11(2). 1 - 6 (Journal Article)

Over the past decade, increasing evidence suggests that pharmaceuticals may continue to be potent beyond their date of expiration. Despite this evidence, we have not yet experienced a change in United States federal policy that would recommend usage of expired pharmaceuticals. While the scientific community and federal regulators continue to study the matter, the medical community is often guilty of misunderstanding the nuances of the issue. As a result, many healthcare professionals misinform their peers and their patients on either the appropriateness or inappropriateness of taking expired medications. Even though both the American Medical Association (AMA) and the Food and Drug Administration (FDA) do not recommend the dosing of expired pharmaceuticals at this time, discussion of the issue is warranted in order to understand the potential behind some expired drugs and to encourage further research. This discussion is particularly relevant to the Special Operations medical community, since Special Operations Force's (SOF) medic s frequently encounter expired medication overseas. Given thei r unique sk ill set and working environ ment, the SOF medic should be familiar with the potential applications of expired medications, including their drawbacks.

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Medical Screening of a Repatriated Afghan National Army Special Operations Command Prisoner of War

Florance JM, Hicks M 19(4). 16 - 18 (Case Reports)

The Combined Joint Special Operations Task Force-Afghanistan (CJSOTF-A) Surgeon partnered with the Afghan National Army Special Operations Command (ANASOC) Surgeon to complete medical screening of a repatriated ANASOC soldier following a 2019 combined raid on a Taliban prison that freed 35 prisoners of war (POWs). This article discusses the presentation and management of the ANASOC POW while also providing a literature review of common pathologies within the POW population. The purpose of this document is to address a unique aspect of military medicine in the expectation that future military providers are prepared to receive repatriated soldiers and prepared to care for fellow prisoners should they themselves become captured.

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Military Static Line Parachuting Injuries Seen By The Airborne Battalion Provider

Healy ML 11(2). 45 - 51 (Journal Article)

Military static line parachuting exposes jumpers to a variety of novel methods of injury. Providers assigned to Airborne units need to develop and maintain a high index of suspicion when dealing with jump-related injuries. Understanding the incident rate and the mechanism of injury can help a provider better identify injuries based on the history of the incidence and develop that index of suspicion. Injuries can happen at almost any point during the jump process and each step has both common and unique injuries associated with it. In addition to identifying, managing, and treating the injuries involved, providing information on estimated time until return to duty can be beneficial for the commander. In the end, a provider's best tools for managing Airborne-related injuries are an understanding of Airborne operations, quality orthopedic skills, and a high index of suspicion.

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Guidelines For Implementing Medical Operations In The Counterinsurgency (COIN) Fight: A Framework For Engagement

Hamid S 11(2). 7 - 11 (Journal Article)

Several articles have been published over the last decade that describe the current role of medical operations (variously known as MEDCAPS- Medical Civic Action Programs, CMEs- Co-Operative Medical Engagements, etc.) in COIN and stability operations. Many of these articles focus on the experiences of healthcare and support personnel and their observations of inappropriately used U.S. Military healthcare resources. These medical assets were often used to provide fragmented and direct patient care to local populations. These operations were conducted in a non-sustainable fashion. Most importantly, poorly organized efforts damage COIN efforts and alienate local populations. Effective medical operations must be nested within the larger realm of overall COIN actions. In this paper, a fundamental framework is presented to align medical operations within COIN missions.

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Adaptations To A New Physical Training Program In The Combat Controller Training Pipeline

Walker TB, Lennemann LM, Anderson V, Lyons W, Zupan MF 11(2). 37 - 44 (Journal Article)

objectives: The United States Air Force combat controller (CCT) training pipeline is extremely arduous and historically has a high attrition rate of 70 to 80%. The primary objective of this study was to evaluate the impact of incorporating a 711 Human Performance Wing (HPW) / Biobehavior, Bioassessment, and Biosurveillance Branch (RHPF)-developed physical fitness-training program into the combat controller (CCT) 5-level training physical fitness program. methods: One-hundred-nine CCT trainees were tested and trained during their initial eight weeks at the 720th Special Tactics Training Squadron (STTS) at Hurlburt Field. Modifications to their physical training program were principally aimed at reducing overtraining and overuse injury, educating trainees and cadre on how to train smarter, and transitioning from traditional to "functional" PT. A battery of physiological measurements and a psychological test were administered prior to and immediately after trainees undertook an 8-week modified physical fitness training program designed to reduce overtraining and injury and improve performance. We performed multiple physical tests for cardiovascular endurance (VO2max and running economy), "anaerobic" capacity (Wingate power and loaded running tests), body composition (skinfolds), power (Wingate and vertical jump), and reaction time (Makoto eye-hand test). We used the Mental Toughness Questionnaire 48 (MTQ-48) for the psychological test. results: We observed several significant improvements in physical and physiological performance over the eight weeks of training. Body composition improved by 16.2% (p<0.05). VO2max, time-to-exhaustion, and ventilatory threshold were all significantly higher after implementation of the new program than before it. We observed strong trends towards improvement in work accomplished during loaded running (ρ = 0.07) and in average power per body mass during lower body Wingate (ρ = 0.08). Other measures of lower body power did not change significantly over the training period, but did show mild trends towards improvement. Upper body average and peak power per kilogram of body mass both improved significantly by 5.8% and 8.1%, respectively. Reaction time was significantly better posttraining as demonstrated by a 7% improvement during the reactive test. Reactive accuracy also improved significantly with the post test accuracy percentage jumping from 61% to 76%. Furthermore, overuse injuries, a major source of attrition fell by a dramatic 67%. conclusions: The modifications resulted in significant improvement in trainees' graduation rate. In the eight classes prior to implementation of these changes, average CCT graduating class size was nine trainees. For the eight classes following the changes, average CCT graduating class rose to 16.5 trainees, an increase of 83%. Due to its success, STTS leadership expanded the modifications from the eight weeks prior to CDS to include the entire second year of the pipeline.

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Case Report: Acute Intermittent Porphyria In A 21-year-old Active Dutymale

Thompson WD 11(2). 52 - 56 (Journal Article)

Acute Intermittent Porphyria (AIP) is one of a group of rare metabolic disorders arising from reduced activity of any of the enzymes in the heme biosynthetic pathway. The porphyrias can be very difficult for the practitioner to understand. There are several types of porphyrias, which have been known by various different names and are classified from different perspectives1 based on where the defective synthesis site is, or what the clinical manifestations are. Since practitioners rarely encounter this disease process, it is commonly not considered in the differential diagnoses. AIP can be confused with other causes of acute abdominal disorders such as appendicitis with peritonitis or nephrolithiasis. Patients with AIP typically give a history of constipation, fatigue, irritability, and insomnia that precede their acute attack. Symptoms occur intermittently in some patients with acute attacks lasting for several days or longer and were usually followed by complete recovery. This case report deals with an initial presentation of AIP in an otherwise healthy 21-year-old active duty male Soldier. Clinical presentation, diagnosis and treatment are discussed as is a brief historical anecdote.

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Interest Survey And Guide To Medical Schooladmissions For SOF Medics

True NA, Conway AC, Landis TM, Cairns CB, Cairns BA 11(2). 30 - 34 (Journal Article)

The University of North Carolina at Chapel Hill and the Special Warfare Training Group, Airborne (SWTG)(A) at Fort Bragg, NC began a bilateral partnership in 2009 to enhance medical training, care and innovation in austere environments. As a result of this partnership, instructors from the Joint Special Operations Training Center have been completing month-long rotations in the North Carolina Jaycee Burn Center and University of North Carolina Hospitals. This rotation has been successful and prompted us to assess the interest of Special Operation Forces (SOF) medics is in pursuing careers in healthcare, especially medical school. We surveyed the Special Forces Medical Sergeant (SFMS) listserve on Army Knowledge Online (AKO) to collect these data. This article will review SFMS survey responses and offer information on how to negotiate medical school admissions.

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Medical Rules Of Engagement Negative Patients: The Dilemma Of Forward Surgical Teams In Counterinsurgency Operations

Becker T, Ray PD, Link M, Ziemba M 11(2). 12 - 15 (Journal Article)

By definition, Forward Surgical Teams (FSTs) are located far forward in the battlespace to allow for emergent treatment of life and limb threatening trauma sustained by United States and coalition forces as well as those injured according to the medical rules of engagement (MROE). While official doctrine dictates that MROE negative patients are not entitled to care by American military medical assets, experience has shown that some FSTs do not always adhere to that doctrine during counterinsurgency (COIN) operations. Medical civic action programs (MEDCAPS) have been used in modern COIN conflicts in an attempt to gain favor with and influence the host nations' local population. However, the results have frequently been counterproductive to the intended mission. The FST, by doctrine, is not equipped to take part in traditional MEDCAPS. The focus of this paper is to explore the potential role of the FST in COIN operations. Possible roles for the FST in COIN include improving the host nation medical capabilities through education and training. Further, surgery can be a useful commodity to gain positive influence with or to trade for intelligence from key local national leaders.

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