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Flank Pain

Meriano T 14(3). 98 - 101 (Journal Article)

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

A Multiyear Analysis of the Clinical Encounters of the ATF Tactical Medical Program

Tang N, Kubit J, Berrett OM, Levy MJ 14(3). 102 - 106 (Journal Article)

Background: The Bureau of Alcohol, Tobacco, Firearms and Explosives (ATF) Tactical Medical Program provides tactical medical support for ATF's tactical Special Response Teams (SRTs) and investigative National Response Teams (NRTs) through the deployment of specially trained ATF Agent-Medics. All patient care activities are centrally coordinated through ATF Headquarters. Methods: A retrospective analysis of de-identified patient care reports (PCRs) from the ATF Tactical Medical Program from 2009 to 2012 was performed. Clinical and operational data were extracted from PCRs and were entered into a database by the research team. Descriptive and summative analyses were performed to assess patient type, law enforcement incident type, chief complaint, and interventions performed. Results: Analysis was performed on the 254 charts. Nearly half (114; 44.9%) of patients encountered during the study period were law enforcement officers. High-risk warrant service was associated with one third (85; 33.5%) of the ATF medics' clinical encounters. The most common chief complaints of patients encountered were musculoskeletal pain/injury (57; 22.4%) and wounds/lacerations (57; 22.4%), followed by heat illness (17; 6.7%). The most common intervention was wound care (61; 26.9%), followed by control of bleeding with direct pressure (43; 18.9%). The most common medications administered were ibuprofen (28; 25.2%), topical antibiotic (12; 10.8%), and acetaminophen (12;10.8%). Conclusion: This multiyear analysis represents an important contribution to the growing body of scientific literature surrounding tactical medicine. The results of this analysis demonstrate a continued need for expanded scope of practice training, as well as enhanced treatment protocols for tactical medics.

Erythema Multiforme

Sola CA, Beute TC 14(3). 90 - 92 (Journal Article)

An active duty male Soldier presents to your clinic with concerns of blister-like lesions on both hands and feet several weeks after receiving immunizations. He is diagnosed with erythema multiforme (EM), a hypersensitivity reaction that is typically self-resolving. This article reviews the etiologies, pathophysiology, course, diagnosis, and treatment of erythema multiforme.

Ebola Hemorrhagic Fever

Burnett MW 14(3). 93 - 94 (Journal Article)

Ebola hemorrhagic fever is an often-fatal disease caused by a virus of the Filoviridae family, genus Ebolavirus. Initial signs and symptoms of the disease are nonspecific, often progressing on to a severe hemorrhagic illness. Special Operations Forces Medical Providers should be aware of this disease, which occurs in sporadic outbreaks throughout Africa. Treatment at the present time is mainly supportive. Special care should be taken to prevent contact with bodily fluids of those infected, which can transmit the virus to caregivers.

Risk Factors for Injuries During Airborne Static Line Operations

Knapik JJ, Steelman R 14(3). 95 - 97 (Journal Article)

US Army airborne operations began in World War II. Continuous improvements in parachute technology, aircraft exit procedures, and ground landing techniques have reduced the number of injuries over time from 27 per 1,000 descents to about 6 per 1,000 jumps. Studies have identified a number of factors that put parachutists at higher injury risk, including high wind speeds, night jumps, combat loads, higher temperatures, lower fitness, heavier body weight, and older age. Airborne injuries can be reduced by limiting risker training (higher wind speeds, night jumps, combat load) to the minimum necessary for tactical and operational proficiency. Wearing a parachute ankle brace (PAB) will reduce ankle injuries without increasing other injuries and should be considered by all parachutists, especially those with prior ankle problems. A high level of upper body muscular endurance and aerobic fitness is not only beneficial for general health but also associated with lower injury risk during airborne training.

Laryngeal Mask Airway Exchange Using a Gum Elastic Bougie With a Rotational Twist Technique

Stancil S, Miller J, Riddle M 14(3). 74 - 77 (Journal Article)

Previous studies have sought to determine the feasibility of exchanging the laryngeal mask airway (LMA) for an endotracheal tube (ETT) over a gum elastic bougie (GEB) and found the practice to have a success rate of about 50%. It has been speculated that the poor success rate may be due to the upward angle of the bougie tip meeting resistance against the anterior laryngeal wall. The use of a 90- to 180-degree twist technique to angle the bougie tip away from the anterior tracheal wall and caudally along the trachea theoretically could improve results. We conducted a prospective cadaveric study to determine if the use of a bougie 90- to 180-degree twist technique or the use of a more flexible pediatric bougie would improve previously published success rates. Emergency medicine personnel attempted exchange of an LMA for an ETT over a GEB using a twisting technique. Despite using the twisting technique, successful exchange over a bougie remained at 50%, similar to previous studies. Using a smaller, more flexible pediatric bougie led to a successful exchange in only 28% of attempts. In this study, the adding of a twist technique or using a pediatric bougie did not result in consistent successful exchange to an ETT from an LMA.

The 10 Commandments of Nutrition: 2014

Deuster PA, Lindsey AT, Butler FK 14(3). 80 - 89 (Journal Article)

The US Special Operations Command requires sound recommendations on nutrition to ensure optimal performance of Special Operations personnel. New information continues to emerge, and previous recommendations need to be modified as the evidence base continues to grow. The first 10 Commandments of Nutrition were published in the SEAL professional journal Full Mission Profile in 1992, published for the second time in this journal in 2005, and now revised a second time to reflect the newest science. Whether you are part of the Special Operations Forces (SOF) community or an athlete seeking to improve your performance, these are simple and helpful nutrition guidelines to follow.

Testing of Junctional Tourniquets by Military Medics to Control Simulated Groin Hemorrhage

Kragh JF, Parsons DL, Kotwal RS, Kheirabadi BS, Aden JK, Gerhardt RT, Baer DG, Dubick MA 14(3). 58 - 63 (Journal Article)

Background: Junctional hemorrhage is a common cause of death on the battlefield, but there is no documented direct comparison for the use of junctional tourniquet models by US medics. The purpose of this testing is to assess military medic experience with the use of junctional tourniquets in simulated out-of-hospital trauma care. Methods: Nine medics (seven men and two women) used four different junctional tourniquets: Combat Ready Clamp™ (CRoC™; http://www.combatmedicalsystems .com), Abdominal Aortic and Junctional Tourniquet™ (AAJT™;, Junctional Emergency Treatment Tool (JETT™; http://www.narescue .com), and SAM Junctional Tourniquet® (SJT®; http:// These medics also acted as simulated casualties. Effectiveness percentages, as measured by stopped distal pulse by Doppler auscultation, and time to effectiveness were recorded in two tests per tourniquet (72 total tests). Tourniquet users ranked their preference of model by answering the question: "If you had to go to war today and you could only choose one, which tourniquet would you choose to bring?" Results: All tourniquets used were safe under the conditions of this study. Both the SJT and the CRoC had high effectiveness percentages; their rate difference was not statistically significant. The SJT and the CRoC had fast times to effectiveness; their time difference was not statistically significant. Users preferred the SJT and the CRoC; their ranked difference was not statistically significant. Conclusion: The SJT and the CRoC were equally effective and fast and were preferred by the participants.

Use of a Removable Mandibular Neuroprosthesis for the Reduction of Posttraumatic Stress Disorder (PTSD) and Mild Traumatic Brain Injury/PTSD-Associated Nightmares, Headaches, and Sleep Disturbances

Moeller DR, Duffey JM, Goolsby AM, Gallimore JT 14(3). 64 - 73 (Journal Article)

Introduction: Posttraumatic stress disorder (PTSD) has been associated with nighttime headaches (HAs), nightmares (NMs), and difficulty falling or staying asleep (sleep disturbances [SD]). The authors of the current study evaluated the correlative elements of using a removable mandibular neuroprosthesis (RMN) and the reduction of these symptoms in participants diagnosed with PTSD or mild traumatic brain injury (mTBI)/PTSD. The RMN device is a form of specialized dental splint that has a potential to reduce the painful stimuli of bruxing and potential upregulation of threat response systems that may occur during sleep. Method: A sample of 32 individuals was selected through random assignment from a volunteer base of 200 volunteers for examination by self-report according to an A-B-A-B design. The sample included 25 men and 7 women between the ages of 21 and 65; 21 had military experience and 11 were civilians. Participants were asked to rate the frequency and intensity of their HAs, NMs, and SD during each phase. Their responses were scored using a custom survey (equivalent forms reliability) that provides ratio-scaled results for symptom frequency and intensity. The original number of participants was 35 with three participants dropping out before the conclusion of the study. Results: Survey scores for PTSD-related sleep symptoms were relatively high at baseline (x̄ = 0.52) and significantly lower in the first experimental phase (x̄ = 0.20). Scores in the second experimental phase were likewise lower (x̄ = 0.38). Significant reductions in symptoms were reported across all three dimensions. Discussion: All participants reported some improvement in symptoms while using the device. No participants reported worsening of any symptoms as a result of using the RMN. Participants commonly reported that improvements in symptoms were immediate and did not diminish over time. Data indicate that there is a negative correlation between the use of an RMN and the reduction of HAs, NMs, and SD in persons diagnosed with PTSD or mTBI/PTSD.

Fluid Resuscitation for Hemorrhagic Shock in Tactical Combat Casualty Care: TCCC Guidelines Change 14-01 - 2 June 2014

Butler FK, Holcomb JB, Schreiber MA, Kotwal RS, Jenkins DA, Champion HR, Bowling F, Cap AP, Dubose JJ, Dorlac WC, Dorlac GR, McSwain NE, Timby JW, Blackbourne LH, Stockinger Z, Strandenes G, Weiskopf RB, Gross K, Bailey JA 14(3). 13 - 38 (Journal Article)

This report reviews the recent literature on fluid resuscitation from hemorrhagic shock and considers the applicability of this evidence for use in resuscitation of combat casualties in the prehospital Tactical Combat Casualty Care (TCCC) environment. A number of changes to the TCCC Guidelines are incorporated: (1) dried plasma (DP) is added as an option when other blood components or whole blood are not available; (2) the wording is clarified to emphasize that Hextend is a less desirable option than whole blood, blood components, or DP and should be used only when these preferred options are not available; (3) the use of blood products in certain Tactical Field Care (TFC) settings where this option might be feasible (ships, mounted patrols) is discussed; (4) 1:1:1 damage control resuscitation (DCR) is preferred to 1:1 DCR when platelets are available as well as plasma and red cells; and (5) the 30-minute wait between increments of resuscitation fluid administered to achieve clinical improvement or target blood pressure (BP) has been eliminated. Also included is an order of precedence for resuscitation fluid options. Maintained as recommendations are an emphasis on hypotensive resuscitation in order to minimize (1) interference with the body's hemostatic response and (2) the risk of complications of overresuscitation. Hextend is retained as the preferred option over crystalloids when blood products are not available because of its smaller volume and the potential for long evacuations in the military setting.

Management of External Hemorrhage in Tactical Combat Casualty Care: Chitosan-Based Hemostatic Gauze Dressings

Bennett BL, Littlejohn LF, Kheirabadi BS, Butler FK, Kotwal RS, Dubick MA, Bailey HH 14(3). 40 - 57 (Journal Article)

Hemorrhage remains the leading cause of combat death and a major cause of death from potentially survivable injuries. Great strides have been made in controlling extremity hemorrhage with tourniquets, but not all injuries are amenable to tourniquet application. Topical hemostatic agents and dressings have also contributed to success in controlling extremity and compressible junctional hemorrhage, and their efficacy continues to increase as enhanced products are developed. Since the addition of Combat Gauze™ (Z-Medica Corporation, Wallingford, CT, USA; in April 2008 to the Tactical Combat Casualty Care (TCCC) Guidelines, there are consistent data from animal studies of severe hemorrhage that chitosan-based hemostatic gauze dressings developed for battlefield application are, at least, equally efficacious as Combat Gauze. Successful outcomes are also reported using newer chitosan-based dressings in civilian hospitalbased surgical case reports and prehospital (battlefield) case reports and series. Additionally, there have been no noted complications or safety concerns in these cases or across many years of chitosan-based hemostatic dressing use in both the military and civilian prehospital sectors. Consequently, after a decade of clinical use, there is added benefit and a good safety record for using chitosan- based gauze dressings. For these reasons, many specific US military Special Operations Forces, NATO militaries, and emergency medical services (EMS) and law enforcement agencies have already implemented the widespread use of these new recommended chitosanbased hemostatic dressings. Based on the past battlefield success, this report proposes to keep Combat Gauze as the hemostatic dressing of choice along with the new addition of Celox™ Gauze (Medtrade Products Ltd., Crewe, UK; /celox-gauze/) and ChitoGauze® (HemCon Medical Technologies, Portland, OR, USA; to the TCCC Guidelines.

Traumatic Pelvic Hematoma After a Military Static-Line Parachute Jump: A Case Series

Barbee GA, Booms Z 14(3). 1 - 6 (Journal Article)

The authors report five cases of pelvic hematoma without associated pelvic fracture after military static-line parachute operations, a significantly underreported injury. The case reports and discussion include initial emergency department presentation, stabilization requirements, and imaging, disposition, and management recommendations. Data were collected retrospectively through review of medical records from a single institution over the course of a single calendar year, 2012-2013. Pelvic hematoma should be strongly considered in the patient with lower abdominal, hip, or pelvic pain after blunt injury from parachute landing fall even in the absence of associated fracture. The cases discussed display this underreported injury and highlight the frequent necessity for admission to a high-acuity care center for close monitoring.

Another Civilian Life Saved by Law Enforcement-Applied Tourniquets

Robertson JN, McCahill P, Riddle A, Callaway DW 14(3). 7 - 11 (Journal Article)

Increasing data and anecdotal operational reports are supporting the early, aggressive, prehospital application of tourniquets in potentially life-threatening extremity trauma. Especially in the civilian urban setting where transport times are short, the benefit in terms of lives saved far outweighs the potential risk to the extremity. The popular press has reported frequently on law enforcement- applied tourniquets, but to date, no group has published a scientific review of any of these cases. This case report suggests that law enforcement personnel can be trained to safely identify indications for tourniquet application, properly apply them with limited training, and function as effective first care providers.

Prevention of Foot Blisters

Knapik JJ 14(2). 95 - 97 (Journal Article)

Foot blisters are the most common medical problem faced by Soldiers during foot march operations and, if untreated, they can lead to infection. Foot blisters are caused by boots rubbing on the foot (frictional forces), which separates skin layers and allows fluid to seep in. Blisters can be prevented by wearing properly sized boots, conditioning feet through regular road marching, wearing socks that reduce reduce friction and moisture, and possibly applying antiperspirants to the feet.

Clinical Encounters in Tactical Medicine: A Mission-Specific Analysis of the Maryland State Police Experience

Levy MJ, Smith R, Gerold KB, Alves D, Tang N 14(2). 98 - 104 (Journal Article)

Introduction: The Maryland State Police (MSP) Tactical Medical Unit (TMU) provides tactical emergency medical support (TEMS) through the deployment of specially trained state trooper tactical paramedics. The MSP TMU maintains an operational database of all mission related medical activity. This information constitutes a robust dataset derived from real world operational medicine experiences. Methods: A retrospective analysis of deidentified entries from the MSP TMU operational response database was performed for the 5-year period of 2007-2013. A summative analysis of missions, as well as a subgroup analysis of types of patients encountered, was performed to further characterize patient encounters based on the type of law enforcement tactical mission. Results: Analysis was performed on 1,042 tactical missions, of which there were 367 total patient encounters during the study period. The majority (67%; 246/367) of patients encountered were law enforcement tactical team personnel. The most frequently occurring mission, by type, was high-risk warrant service, accounting for 45% (470/1,042) of all missions in this series. Law enforcement training support missions comprised 25% (259/1,042), and 15% (157/1,042) of all missions in the database were medical standbys for law enforcement operations. The highest number of patient contacts were associated with training activities, resulting in 29% (108/367) of clinical encounters. The next most common mission associated with patient encounters was high-risk warrant service (24%; 88/367). Conclusion: The 5-year analysis conducted in this study represents the largest known retrospective assessment of a state police tactical medical program. Training activities resulted in the highest number of patient encounters by this program, with law enforcement/tactical team personnel comprising the majority of patient encounters. The majority of chief complaints encountered were non-life threatening and reinforce the need for expanded scope of practice training and enhanced treatment protocols for tactical medics.

An Integrated Approach for Special Operations

Deuster PA, Grunberg NE, O'Connor FG 14(2). 86 - 80 (Journal Article)

The Department of Defense (DoD) faces unprecedented challenges as the Nation confronts balancing a strong military to confront threats with the realities of diminishing financial resources. That each warfighter is a critical resource was underscored the Special Operations principal tenet "humans are more important than hardware." These challenges have popularized the term "human performance optimization" (HPO), which became ingrained in DoD around 2005. This article is the first in a new series relating to HPO, and we define the term and concept of HPO, describe other phrases used (e.g., performance enhancement; performance sustainment, performance restoration; and human performance modification). Last, we introduce an integrated model for HPO.

Infectious Diseases: Cholera

Burnett MW 14(2). 91 - 94 (Journal Article)

Vibrio cholerae is a comma-shaped, gram-negative rod that produces an enterotoxin, which causes an acute-onset diarrheal disease ranging in severity from mild to life threatening. Worldwide, there are an estimated 3-5 million cases per year, with more than 100,000 deaths. The disease remains a significant cause of death and illness in sub-Saharan Africa, southeast Asia (especially Bangladesh and India), and Haiti, and the infection should be recognized by the Special Operations Forces (SOF) medical provider.

Medical Operations of the 6th Ranger Infantry Battalion

Downs JW 14(2). 66 - 73 (Journal Article)

The author gives a history of the formation of the 6th Ranger Infantry Battalion and varied aspects of Ranger medical operations, including personnel composition of the medical detachment, the work of the battalion's surgeon during combat and noncombat operations, medical aspects of operational planning, available medical supplies, medical evacuation procedures, and preventive care.

Intra-articular Morphine versus Lidocaine for Acute Knee Pain

Graham RF, Hughes JR, Johnson AE, Cuenca PJ, Mosely T 14(2). 74 - 79 (Journal Article)

Objective: The authors conducted an unfunded randomized controlled trial approved by the Brooke Army Medical Center (BAMC) Institutional Review Board (IRB) to determine the possible efficacy of intra-articular morphine for pain in acute knee injuries. Methods: Patients presenting to the emergency department at San Antonio Military Medical Center (SAMMC) from May 2012 to August 2013 with knee pain due to an acute injury were consented and then enrolled based on a convenience sample. Patients were randomized to one of three intervention arms (morphine, lidocaine, or morphine and lidocaine) and were blinded to the intervention. The respective solution was injected into the knee joint using standard techniques. The patients self-reported their levels of knee pain via a standard 100mm visual analogue scale (VAS) at the time of injection and 30 minutes, 60 minutes, 90 minutes, 2 hours, 6 hours, and 24 hours postinjection. At 24 hours, the patients also reported the estimated amount of time they applied ice to the knee and the amount of oral analgesia consumed in the previous 24 hours. Results: The primary outcome was relative pain reduction as measured by the VAS. Secondary outcomes were the total cumulative use of ice and analgesics during the first 24 hours. Although this was a small study, the results showed a possible trend toward better pain control at all time intervals with injections containing morphine compared with lidocaine-only injections. Ice and oral analgesia usage was equivalent between the three intervention arms. Conclusion: Further investigation with a larger sample is required to explore whether these results are statistically significant and the possible superiority of intra-articular morphine to lidocaine for acute knee pain.

Fast-Roping: Potential Consequences of Vibrations for Sensation and Regulation of Movement

Goldmann J, Braunstein B, Sanno M, Kurzner S, Brüggemann G, Mester J 14(2). 80 - 83 (Journal Article)

Objectives: Short-term exposure (2-30 seconds) to segmental mechanical vibrations with frequencies between 20 and 80 Hz affects proprioception of the central nervous system and manual dexterity and strength of man. It could be supposed that during fast-roping, Soldiers are exposed to hand-arm vibrations caused by the geometry of the rope. After the maneuver, Soldiers are encouraged to operate with high precision (e.g., aiming and shooting) within a few seconds. For safety, disturbances of the sensory system should be strongly avoided. The purpose of the study was to determine the vibrations induced by different rope geometries during fast-roping. Methods: Eight men of the German Special Forces performed 10 fast-roping maneuvers with two different shaped ropes (slightly molded versus deeply molded). Vibration data and frequency spectrum for each trial were measured by using fast Fourier transformation. Results: The analysis of data showed that fast-roping with a slightly molded rope produced frequencies of up to 10 Hz, while the frequencies with a deeply molded rope accounted for 18 to 60 Hz. The ropes differed significantly (ρ < .001) in frequencies between 20 and 50 Hz. The exposure time of vibration lasted between 3 and 5 seconds. Conclusion: Considering the negative effects associated with vibrations, prudence is required when using deeply molded ropes due to the increased vibrations of about 20 Hz.

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