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Monti JD 17(1). 22 - 25 (Journal Article)

Ultrasound represents an ideal diagnostic adjunct for medical personnel operating in austere environments, because of its increasing portability and expanding number of point-of-care applications. However, these machines cannot be used without a transmission medium that allows for propagation of ultrasound waves from transducer to patient. This article describes a novel ultrasound gel alternative that may be better suited for resource-constrained environments than standard ultrasound gel, without compromising image quality.

Pham C, Zehring J, Berry-Caban CS 17(1). 9 - 13 (Case Reports)

Paraphimosis is a urologic emergency resulting in tissue necrosis and partial amputation, if not reduced. Paraphimosis occurs when the foreskin of the uncircumcised or partially circumcised male is retracted behind the glans penis, develops venous and lymphatic congestion, and cannot be returned to its normal position. Invasive reduction of paraphimosis requires minimal instruments and can be accomplished by experienced providers. This case describes a 10-year-old local national with paraphimosis over 10 days that required invasive reduction in a deployed austere environment in Africa.

Schauer SG, Pfaff JA 17(1). 14 - 16 (Case Reports)

Heat injuries are a common occurrence in the military training setting due to both the physically demanding nature of the training and the environments in which we train. Testing is often done after the diagnosis of a heat injury to screen for abnormalities. We present the case of a 20-year-old male Soldier with an abnormal electrocardiogram (ECG) with a possible injury pattern and an elevated troponin level. He underwent a diagnostic cardiac angiogram, which demonstrated no abnormal findings. He was returned to duty upon recovery from the catheterization. Ischemic-appearing ECG and troponin findings may be noted after heat injury. In this case, it was not associated with any cardiac lesions.

Kotwal RS, Montgomery HR, Mechler KK 11(3). 127 - 128 (Previously Published)

Many combat-related deaths occur in the prehospital environment before the casualty reaches a medical treatment facility. The tenets of Tactical Combat Casualty Care (TCCC) were published in 1996 and integrated throughout the 75th Ranger Regiment in 1999. In order to validate and refine TCCC protocols and procedures, a prehospital trauma registry was developed and maintained. The application of TCCC, in conjunction with validation and refinement of TCCC through feedback from a prehospital trauma registry, has translated to an increase in survivability on the battlefield.

Manley JD, Mitchell BJ, DuBose JJ, Rasmussen TE 17(1). 1 - 8 (Case Reports)

Background: Resuscitative endovascular balloon occlusion of the aorta (REBOA) is used to mitigate bleeding and sustain central aortic pressure in the setting of shock. The ER-REBOA™ catheter is a new REBOA technology, previously reported only in the setting of civilian trauma and injury care. The use of REBOA in an out-of-hospital setting has not been reported, to our knowledge. Methods: We present a case series of wartime injured patients cared for by a US Air Force Special Operations Surgical Team at an austere location fewer than 3km (5-10 minutes' transport) from point of injury and 2 hours from the next highest environment of care-a Role 2 equivalent. Results: In a 2-month period, four patients presented with torso gunshot or fragmentation wounds, hemoperitoneum, and class IV shock. Hand-held ultrasound was used to diagnose hemoperitoneum and facilitate 7Fr femoral sheath access. ER-REBOA balloons were positioned and inflated in the aorta (zone 1 [n = 3] and zone 3 [n = 1]) without radiography. In all cases, REBOA resulted in immediate normalization of blood pressure and allowed induction of anesthesia, initiation of whole-blood transfusion, damage control laparotomy, and attainment of surgical hemostasis (range of inflation time, 18-65 minutes). There were no access- or REBOArelated complications and all patients survived to achieve transport to the next echelon of care in stable condition. Conclusion: To our knowledge, this is the first series to demonstrate the feasibility and effectiveness of REBOA in modern combat casualty care and the first to describe use of the ER-REBOA catheter. Use of this device by nonsurgeons and surgeons not specially trained in vascular surgery in the out-of-hospital setting is useful as a stabilizing and damage control adjunct, allowing time for resuscitation, laparotomy, and surgical hemostasis.

Callaway DW, Smith ER, Cain JS, Shapiro G, Burnett WT, McKay SD, Mabry RL 11(3). 104 - 122 (Journal Article)

LeClair TG 11(3). 66 - 68 (Journal Article)

Paul J 11(3). 69 - 71 (Journal Article)

Froede K 11(3). 56 - 60 (Journal Article)

Special Operations Forces (SOF) medical personnel (clinicians) directly impact their patients' outcomes, regardless if the patient is a Soldier, civilian, or indigenous person. Any health practitioner who specializes in trauma, Soldiers' healthcare, or tactical and/or operational healthcare must have a working knowledge of SOF medicine and its philosophical, political, and contextual origins. SOF clinical evidence and knowledge base is extensive and inextricably linked to SOF clinicians' underlying warrior philosophy and worldview. This submission will argue the point that SOF healthcare is a discipline and mature science in its own right, as evidenced by SOF's utilization and/or rejection of other disciplines' (nursing, medicine, conventional military) paradigms, community-wide adoption of its own specific paradigms, disciplinary matrix, and language. Peer-reviewed articles relevant to SOF and military healthcare from 2009-2011 are reviewed to determine possible philosophical frameworks, identify extant methodologies, and demonstrate underlying philosophical constructs.

McCown ME, Monterroso VH, Grzeszak B 11(3). 61 - 65 (Journal Article)

Vector-borne diseases (VBD) make up a large number of emerging infectious and zoonotic diseases. Ticks, fleas, and mosquitoes are effective vectors parasitizing canines, making dogs adequate reservoirs for zoonoses. The U.S. military deploys personnel and government- owned animals around the world with possible risk of exposure to VBD. Canine VBD have veterinary and public health significance for the host nations as well as for the U.S. troops and its working animals deployed in the theater of operations. These factors make disease surveillance a great importance. The objective of this work was to survey canines from the cities of Manta and Guayaquil in Ecuador to determine prevalence of heartworm disease (D. immitis), ehrlichi os is (E. canis), Lyme disease (B. burgdorf eri), and anapl asmosis (A. phagocytophilum). Canine blood samples (1-3ml) collected from the cities of Manta (n=50) and Guayaquil (n=50) were tested on site using a SNAP® 4Dx® Test Kit. Prevalence for single or multiple disease status was calculated for each city. In the city of Manta the overall prevalence of diseases was 78%; 52% for E. canis alone, and 26% for co-infection with E. canis and A. phagocytophilum. The overall prevalence for the city of Guayaquil was 88%; 40% for E. canis alone, 22% for A. phagocytophilum alone, and 26% for co-infection with E. canis and A. phagocytophilum. Neither heartworm disease nor Lyme disease was detected in any samp le. In conclusion, this study showed the extensive presence of E. canis and A. phagocytophilum in both cities in Ecuador, emphasizing the value of surveillance for zoonotic diseases to determine disease prevalence and risk assessments, as well as to implement control measures.

Franklin B, Swierczewski B 11(3). 48 - 51 (Journal Article)

The Medical Civil Action Program (MEDCAP) is an important tool that is utilized to support the larger missions in all areas of current operations. In Ethiopia, MEDCAPs are one of many tools commanders use to earn the trust and confidence of the local population. There are many ways to implement a MEDCAP and this paper will highlight one such successful engagement. This mission was intended in increase the medical capacity of host nation (HN) medical personnel and increase HN confidence in their government to provide for essential services. The mission was broken into four phases similar to traditional MEDCAPs, but with a significant difference.

Johnson TC 11(3). 52 - 55 (Journal Article)

Afghanistan has the highest perinatal mortality rate in the entire world. One Afghani woman dies every 30 minutes from perinatal- related event. One of eight Afghani women will die from perinatal events. Maternal mortality is (use percentage, not fractions) 1600/100,000 vs 13 /100,000 in the United States. Afghanistan is one of the only countries in the world in which the average woman's life expectancy is shorter than a males- despite the active, nationwide combat fought primarily by Afghani males. Meaning, women in Afghanistan are not routinely involved in combat, yet are more likely to die than a man of the same age. This article presents an alternative model Medical Seminar (MEDSEM) for a successful Special Forces (SF) medical counterinsurgency (COIN) plan that can obtain real results by addressing the mission of the Afghan Ministry of Health versus clinging to old notions. This model forms around the medical capabilities of the SF Operational Detachment (ODA)- Alpha (A) and preventinmaternal- infant complications.

Bowling F, Kerr W 11(3). 3 - 37 (Journal Article)

The use of Fresh Whole Blood (FWB) transfusions can be a powerful tool for the Special Operations Forces (SOF) medic to treat uncontrolled hemorrhage. In fact, it may be the only tool currently available for hemostatic resuscitation, which along with hypotensive resuscitation, forms the basis for Damage Control Resuscitation (DCR). Until now, no comprehensive protocol has existed for conducting FWB transfusions in austere environments. The United States Special Operations Command (USSOCOM) sponsored Curriculum Evaluation Board (CEB), which is responsible for authoring the Tactical Emergency Medical Protocols (TMEPs) has produced a protocol. This article serves as its introduction.

Krainin BM, Forsten RD, Kotwal RS, Lutz RH, Guskiewicz KM 11(3). 38 - 47 (Journal Article)

Mild traumatic brain injury (mTBI) reportedly occurs in 8-22% of U.S. servicemembers who conduct combat operations in Afghanistan and Iraq. The current definition for mTBI found in the medical literature, to include the Department of Defense (DoD) and Veterans Administration (VA) clinical practice guidelines is limited by the parameters of loss of consciousness, altered consciousness, or post-traumatic amnesia, and does not account for other constellations of potential symptoms. Although mTBI symptoms typically resolve within seven days, some servicemembers experience symptoms that continue for weeks, months, or years following an injury. Mild TBI is one of few disorders in medicine where a benign and misleading diagnostic classification is bestowed on patients at the time of injury, yet still can be associated with lifelong complications. This article comprehensively reviews the clin ical literature over the past 20 years and proposes a new classification for TBI that addresses acute, sub-acute, and chronic phases, and includes neurocognitive, somatic, and psychological symptom presentation.

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.

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.

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.

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.

Mabry RL, Cuniowski P, Frankfurt A, Adams BD 11(2). 16 - 19 (Journal Article)

background: Optimal airway management protocols for the prehospital battlefield setting have not been defined. Airway management strategies in this environment must take into account the injury patterns, the environment and training requirements of military prehospital providers. Methods: This is a post-hoc, sub-group analysis of the Registry of Emergency Airways Arriving at Combat Hospitals or REACH database. This study examines only those patients who had advanced airways placed for trauma by an enlisted military medic at the point of injury. results: Twenty (100%) of the patients had a traumatic injury, 19 (95%) were male, and 13 (65%) had a gun shot wounds (GSWs) as the mechanism of injury. The majority, 12 (60%) patients had an esophageal-tracheal airway device placed. Of the remaining patients, four (20%) underwent endotracheal intubation, three (15%) had a surgical cricothyroidotomy performed, and one (5%) had a Laryngeal Mask Airway (LMA) placed. Seventeen (85%) of the twenty patients were dead on arrival or died shortly after arrival at the Combat Support Hospital (CSH). All of the patients that died had a Glasgow Coma Scale (GCS) of three upon arrival. The Glasgow Coma Scale provides a score in the range 3-15; patients with scores of 3-8 are usually said to be in a coma. Three patients in this group survived to transfer from the CSH. Two of the transfers were lost to follow up, one with a GSW to the head and GCS of three, the other with a GCS of five from injuries sustained in an explosion. The third patient had a surgical cricothyroidotomy (SC) performed in the field for an expanding neck hematoma and recovered fully following surgery. conclusions: Casualties that tolerate invasive airway management without sedation in the context of trauma prognosticates a very high mortality. Airway management algorithms for military providers should reflect the casualties encountered on the battlefield not patients in cardiac arrest which predominate in the civilian EMS airway management practice. Further data are needed to understand the injuries encountered on the battlefield and to develop airway management solutions that optimize outcomes of patients with battlefield trauma.

Boedecker BH, Nicholas TA, Carpenter J, Leighton S, Bernhagen MA, Murray WB, Wadman MC 11(2). 21 - 29 (Journal Article)

background: Studies indicate that the skills needed to use video laryngoscope systems are easily learned by healthcare providers. This study compared several video laryngoscopic (VL) systems and a direct laryngoscope (DL) view when used by medical residents practicing intubation on cadavers. The video devices used included the Storz Medi Pack Mobile Imaging SystemTM, the Storz CMAC® VL System and the GlideScope®. methods:After Institutional Review Board (IRB) approval, University of Nebraska Medical Center, Department of Emergency Medicine (UNMC EM) residents were recruited and given a brief pre-study informational period. The cadavers were lightly embalmed. The study subjects were asked to perform intubations on two cadavers using both DL and VL while using the three different VL systems. Procedural data was recorded for each attempt and pre and post experience perceptions were collected. results: N=14. All subjects reported their varied previous intubation experience. The average airway score using DL: for the Storz VL was 1.54 (SD = 0.576) and for the C-MAC was 1.46 (SD = 0.637). Success in intubation of the standard airway using DL was 93% versus a 100% success rate when intubating with indirect VL visualization. Conclusion: Based on our data, we believe that the incorporation of VL into cadaver airway management training provided an improved learning environment for the study residents. In our study, the resident subjects were 93% successful with DL intubation even though 50% had less than 30 intubations. As well, there was a 100% success rate when intubating with indirect VL visualization. In conclusion, the researchers believe this cadaver model incorporated with VL is a powerful tool which may help improve the overall learning curve for orotracheal intubation.