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Thrombotic Microangiopathy Syndrome in a Basic Underwater Demolition/SEAL Student

Croom D, Tracy H 16(3). 16 - 19 (Journal Article)

Thrombotic microangiopathy (TMA) syndromes represent a spectrum of illnesses that share common clinical and pathologic features of microangiopathic hemolytic anemia, thrombocytopenia, and organ injury from pathologic small-vessel thrombosis. At least nine primary TMA syndromes have been described and classified based on common probable etiologies, diagnostic criteria, and treatments. The most recognized of the TMA syndromes include thrombotic thrombocytopenic purpura (TTP) and hemolytic-uremic syndrome (HUS). Advanced laboratory techniques are required to distinguish between these syndromes; however, all patients should initially be treated with plasma exchange for presumed ADAMTS13 deficiency-mediated TMA. The authors present a case of a TMA syndrome in a Navy SEAL (Sea, Air, Land) candidate.

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A Skeletal Traction Technique for Proximal Femur Fracture Management in an Austere Environment

Lidwell D, Meghoo CA 16(3). 1 - 4 (Case Reports)

Skeletal traction is a useful technique for managing proximal femur fractures in austere environments where fracture stabilization for this injury is difficult. We present a technique and a construct appropriate for field use that facilitates patient evacuation, and we provide guidelines for the use of this technique by an advanced medical provider managing these injuries. The objectives of this article are to enable to reader to (1) recognize the role of skeletal traction in managing proximal femur fractures in an austere environment, (2) identify the key steps in placing transfemoral skeletal traction pins, and (3) identify options and requirements for building a traction construct in resource-limited environments.

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Lower Extremity Compartment Syndrome From Prolonged Limb Compression and Immobilization During an Airborne Operation

Smedick BC, van Wyck D 16(3). 5 - 9 (Journal Article)

Acute compartment syndrome (ACS) involving the leg can occur in association with various traumatic and nontraumatic conditions, and it can have serious longterm consequences when unrecognized or untreated. Nontraumatic causes of ACS, such as those associated with cases of prolonged immobilization and/or extremity compression, can be easily overlooked, and several cases of ACS occurring with prolonged surgical positioning can be found in the literature. We present the case of a 19-year-old Army paratrooper who developed acute anterior and lateral compartment syndrome of the lower extremity after being immobilized in an aircraft for hours with several hundred pounds of equipment compressing his lower extremities. To our knowledge, this is the first documented case of ACS occurring as a result of prejump conditions. It demonstrates a potentially serious complication that could result in medical separation and/or permanent disability of the service member. ACS of the extremity should be considered in any Soldier who is required to bear heavy loads, is immobilized for several hours at a time, and complains of symptoms such as extremity pain, numbness, and weakness.

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Searching for Sustainability: How Niger's CASEVAC Success Is Leading the African Continent and Educating the GHE/IHS Community

Flatau P 16(2). 111 - 114 (Journal Article)

Against all odds and despite significant challenges and scarce resources, Niger's Armed Forces (FAN) continues to lead a successful casualty evacuation (CASEVAC) program. This program and the Special Operations Command Africa (SOCAFR) model that influenced it has become a template for the Global Health Engagement (GHE)/International Health Specialist (IHS) community. This article provides a summary of the overall CASEVAC mission, outlines the final phase sustainable execution of this program, and provides the reader with critical lessons learned for best practice GHE approaches.

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Garlic Burn to the Face

Oberle M, Wachs T, Brisson P 16(4). 80 - 81 (Journal Article)

Topical burns from the use of garlic have been reported rarely in the medical literature. Most cases have resulted from the use of naturopathic or home remedy treatments. A 20-year-old male military Servicemember presented to a military wound care clinic 7 days after applying a homemade topical preparation of garlic to the zygomatic region of the right side of his face. The patient had consulted the Internet for treatment of a minor skin lesion in that area. He created a garlic paste, applied it to the affected area, and covered it with a dressing. Twelve hours later, he noted an intense burning sensation where he had applied the garlic paste. After the initial blistering, the patient recovered without any additional treatment. Second-degree burns were an unintended consequence of the use of garlic as a home remedy.

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A Case of Prehospital Traumatic Arrest in a US Special Operations Soldier: Care From Point of Injury to Full Recovery

McKenzie MR, Parrish EW, Miles EA, Spradling JC, Littlejohn LF, Quinlan MD, Barbee GA, King DR 16(3). 93 - 96 (Journal Article)

During an assault on an extremely remote target, a US Special Operations Soldier sustained multiple gunshot and fragmentation wounds to the thorax, resulting in a traumatic arrest and subsequent survival. His care, including care under fire, tactical field care, tactical evacuation care, and Role III, IV, and V care, is presented. The case is used to illustrate the complex dynamics of Special Operations care on the modern battlefield and the exceptional outcomes possible when evidence-based medicine is taken to the warfighter with effective, farforward, expeditionary medical-force projection.

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Load Carriage-Related Paresthesias: Part 1: Rucksack Palsy and Digitalgia Paresthetica

Knapik JJ, Reynolds K, Orr R, Pope R 16(4). 74 - 79 (Journal Article)

This is the first of a two-part article discussing loadcarriage- related paresthesias, including brachial plexus lesions (rucksack palsy), digitalgia paresthetica, and meralgia paresthetica. Paresthesias are sensations of numbness, burning, and/or tingling, usually experienced as a result of nerve injury, compression, traction, or irritation. Rucksack palsy is a traction or compression injury to the brachial plexus, caused by the shoulder straps of the rucksack. The patient presents with paresthesia, paralysis, cramping with pain, and muscle weakness of the upper limb. Muscle-strength losses appear to be greater in those carrying heavier loads. Hypothetical risk factors for rucksack palsy include improper load distribution, longer carriage distances, and load weight. Nerve traction, compression, and symptoms may be reduced by use of a rucksack hip belt; wider, better-padded, and proper adjustment of the shoulder straps; reduction of weight in the rucksack; a more symmetric distribution of the load; and resistance training to improve the strength and hypertrophy of the shoulder muscles. Assessment and neck joint and nerve mobilization may relieve brachial plexus tension and reduce symptoms. Another load-carriage-related disorder is digitalgia paresthetica, likely caused by compression of the sensory digital nerves in the foot during load carriage. Patients have paresthesia in the toes. Although no studies have demonstrated effective prevention measures for digitalgia paresthetica, reducing loads and march distances may help by decreasing the forces and repetitive stress on the foot and lower leg. Specialty evaluations by a physical therapist, podiatrist, or other healthcare provider are important to rule out entrapment neuropathies such as tarsal tunnel syndrome. Part 2 of this article will discuss meralgia paresthetica.

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Urban Shield 2016

Mattison D 16(3). 76 - 77 (Journal Article)

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Management of Crush Syndrome Under Prolonged Field Care

Walters TJ, Powell D, Penny A, Stewart I, Chung K, Keenan S, Shackelford S 16(3). 79 - 85 (Journal Article)

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Left Hand Injury With Focal Swelling and Tenderness

Urbaniak M, Hampton K 16(3). 86 (Journal Article)

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Exertional Rhabdomyolysis: Epidemiology, Diagnosis, Treatment, and Prevention

Knapik JJ, O'Connor FG 16(3). 65 - 71 (Journal Article)

Exertional rhabdomyolysis (ER) is a medical condition whereby damage to skeletal muscle is induced by excessive physical activity in otherwise healthy individuals. The individual performs so much activity that he/ she presumably depletes local muscle energy stores and muscle cells are unable to maintain cellular integrity, resulting in cell damage and the release of cellular contents, with resultant secondary complications. In the military services, the incidence of ER appeared to increase in the period 2004 to 2015. Risk factors for ER include male sex, younger age, a prior heat injury, lower educational level, lower chronic physical activity, and activity in the warmer months of the year. Acute kidney injury is the most serious potential complication of ER and is thought to be due to a disproportionate amount of free myoglobin that causes renal vasoconstriction, nephrotoxic effects, and renal tubular obstructions. Patients typically present with a history of heavy and unaccustomed exercise with muscle pain, swelling, weakness, and decreased range of motion, largely localized to the muscle groups that were involved in the activity. Diagnostic criteria include the requisite clinical presentation with a serum creatine kinase level at least level 5 times higher than the upper limit of normal and/ or a urine dipstick positive for blood (due to the presence of myoglobin) but lacking red blood cells under microscopic urinalysis. Core treatment is largely supportive with aggressive fluid hydration. Although the great majority of individuals return to activity without consequence, patients should initially be stratified into high and low risk for recurrence, and those at high risk provided additional evaluation. Risk of ER in normal healthy individuals can be reduced by emphasizing graded, individual preconditioning before beginning a more strenuous exercise regimen after recommended work/rest and hydration schedules in hot weather, and discussing supplements and medications with knowledgeable medical personnel.

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Walking the Plank

Banting J, Meriano T 16(3). 57 - 61 (Journal Article)

CONCEPTS AND OBJECTIVES: 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.

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Rocky Mountain Spotted Fever

Burnett MW 16(3). 63 - 64 (Journal Article)

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Schistosomiasis: Traverers in Africa

Strohmayer J, Matthews I, Locke R 16(3). 47 - 52 (Journal Article)

Schistosomiasis is a parasitic infection acquired through freshwater exposure in the tropics. It is an infection that can have devastating implications to military personnel if it is not recognized and treated, especially later in life. While there is an abundance of information available about schistosomiasis in endemic populations, the information on nonendemic populations, such as deployers, is insufficient. Definitive studies for this population are lacking, but there are actions that can and should be taken to prevent infection and to treat patients. This literary review presents a case study, reviews basic science, and explores the information available about schistosomiasis in nonendemic populations. Specifically, the authors provide recommendations for the prevention, diagnosis, and postexposure management in military personnel.

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The Hidden Complexity of Biological "Dirty Bombs": Implications for Special Operations Medical Personnel

Washington MA, Blythe J 16(4). 82 - 84 (Journal Article)

The recent capture of a terrorist in Belgium carrying explosives, fecal matter, and animal tissue may indicate a shift from conventional weapons to crude bacteriological preparations as instruments of terror. It is important to note that although such weapons lack technological sophistication, bacteria are inherently complex, unpredictable, and undetectable in the field. Therefore, it is important that Special Operations medical personnel understand the complications that such seemingly simple devices can add to the treatment of casualties in the field and subsequent evaluation in the clinic.

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Prolonged Field Care of a Casualty With Penetrating Chest Trauma

Barnhart G, Cullinan W, Pickett JR 16(4). 99 - 101 (Case Reports)

As Special Operations mission sets shift to regions with less coalition medical infrastructure, the need for quality long-term field care has increased. More and more, Special Operations Medics will be expected to maintain casualties in the field well past the "golden hour" with limited resources and other tactical limitations. This case report describes an extended-care scenario (>12 hours) of a casualty with a chest wound, from point of injury to eventual casualty evacuation and hand off at a Role II facility. This case demonstrates the importance of long-term tactical medical considerations and the effectiveness of minimal fluid resuscitation in treating penetrating thoracic trauma.

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Telemedicine to Reduce Medical Risk in Austere Medical Environments: The Virtual Critical Care Consultation (VC3) Service

Powell D, McLeroy RD, Riesberg J, Vasios WN, Miles EA, Dellavolpe J, Keenan S, Pamplin JC 16(4). 102 - 109 (Journal Article)

One of the core capabilities of prolonged field care is telemedicine. We developed the Virtual Critical Care Consult (VC3) Service to provide Special Operations Forces (SOF) medics with on-demand, virtual consultation with experienced critical care physicians to optimize management and improve outcomes of complicated, critically injured or ill patients. Intensive-care doctors staff VC3 continuously. SOF medics access this service via phone or e-mail. A single phone call reaches an intensivist immediately. An e-mail distribution list is used to share information such as casualty images, vital signs flowsheet data, and short video clips, and helps maintain situational awareness among the VC3 critical care providers and other key SOF medical leaders. This real-time support enables direct communication between the remote provider and the clinical subject matter expert, thus facilitating expert management from near the point of injury until definitive care can be administered. The VC3 pilot program has been extensively tested in field training exercises and validated in several real-world encounters. It is an immediately available capability that can reduce medical risk and is scalable to all Special Operations Command forces.

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Case of a 5-Year-Old Foreign National Who Sustained Penetrating Abdominal Trauma

McLeroy RD, Ellis JL, Karnopp JM, Dellavolpe J, Gurney J, Keenan S, Powell D, Riesberg J, Edwards M, Matos R, Pamplin JC 16(4). 110 - 113 (Journal Article)

Objective: Review application of telemedicine support for penetrating trauma. Clinical context: Special Operations Resuscitation Team (SORT) deployed in Africa Area of Responsibility (AOR) Organic expertise: Internal Medicine physician, two Special Operations Combat medics (SOCMs), and one radiology technician Closest surgical support: Non-US surgical support 20km away; a nonsurgeon who will perform surgeries; neighboring country partner-force surgeon 2 hours by fixedwing flight. Earliest evacuation: Evacuated 4 days after presentation to a neighboring country with surgical capability.

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Summer 2020 Cover
Summer 2020 Journal (Vol 20 Ed 2)

Vol 20 Ed 2
Summer 2020 Journal of Special Operations Medicine
ISSN: 1553-9768

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