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Summer 2020 Cover
Temporizing Life-Threatening Abdominal-Pelvic Hemorrhage Using Proprietary Devices, Manual Pressure, or a Single Knee: An Integrative Review of Proximal External Aortic Compression and Even "Knee BOA"

O'Dochartaigh D, Picard CT, Brindley PG, Douma MJ 20(2). 110 - 114 (Journal Article)

Introduction: Abdominal-pelvic hemorrhage (i.e., originates below the diaphragm and above the inguinal ligaments) is a major cause of death. It has diverse etiology but is typically associated with gunshot or stab wounds, high force or velocity blunt trauma, aortic rupture, and peripartum bleeds. Because there are few immediately deployable, temporizing measures, and the standard approaches such as direct pressure, hemostatics, and tourniquets are less reliable than they are with compressible extremity injuries, risk for death resulting from abdominal-pelvic hemorrhage is high. This review concerns the exciting potential of proximal external aortic compression (PEAC) as a temporizing technique for life-threatening lower abdominal-pelvic hemorrhage. PEAC can be accomplished by means of a device, two locked arms (manual), or a single knee (genicular) to press over the midline supra-umbilical abdomen. The goal is to compress the descending aorta and slow or halt downstream hemorrhage while not delaying more definitive measures such as hemostatic packing, tourniquets, endovascular balloons, and ultimately operative repair. Methods: Clinical review of the Ovid MEDLINE, In-Process, & Other Non-Indexed, and Google Scholar databases was performed for the period ranging from 1946 to 3 May 2019 for studies that included the following search terms: [proximal] external aortic compression OR vena cava compression AND (abdomen or pelvis) OR (hemorrhage) OR (emergency or trauma). In addition, references from included studies were assessed. Conclusion: Sixteen studies met the inclusion criteria. Evidence was grouped and summarized from the specialties of trauma, aortic surgery, and obstetrics to help prehospital responders and guide much-needed additional research, with the goal of decreasing the high risk for death after life-threatening abdominal-pelvic hemorrhage.

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Summer 2020 Cover
Quality Assurance in Tactical Combat Casualty Care for Medical Personnel Training 16 April 2020

Greydanus DJ, Hassmann LL, Butler FK 20(2). 95 - 103 (Journal Article)

At present, however, there is no systematic, comprehensive quality assurance program for TCCC training throughout the DoD. Individual courses and instructors may or may not use all of the materials in the JTS-approved curriculum; they may or may not add content that is not part of the JTS curriculum; and they may or may not add additional training in the form of advanced simulation, hands-on training with moulaged casualties, graded trauma lanes, or live-tissue training. A recent pilot appraisal of four Tactical Combat Casualty Care for Medical Personnel (TCCC-MP) training courses found that TCCC-MP courses are not presenting all of the course material recommended by the Joint Trauma System (JTS), despite TCCC training having been mandated by the Department of Defense (DoD) for all US military personnel. Some of the omitted material is essential to ensuring that students are fully prepared to perform TCCC on the battlefield. Further, there was incorrect messaging presented in the TCCC-MP courses that were appraised, some of which, if actually reflected in the care provided on the battlefield, would likely result in adverse casualty outcomes. Other aspects of the TCCC messaging presented in the appraised courses that is not at present part of the JTS-approved curriculum might, however, be appropriate for inclusion into the TCCC Guidelines and the course curriculum. Examples of material that should be considered for incorporation into the TCCC curriculum include modifying the method of tranexamic acid (TXA) administration (slow IV push vs the currently recommended 10-minute infusion) and a better technique for securing of the new CAT Generation 7 tourniquets after application. The course appraiser also noted that there were a number of excellent videos of actual TCCC interventions being performed that are not part of the current JTS-approved TCCC-MP curriculum. These videos should be forwarded to CoTCCC staff and the Joint Trauma Education and Training (JTET) branch of the JTS for consideration as potential additions to the TCCC-MP curriculum. Consideration should also be given to the inclusion of additional TCCC training modalities such as advanced simulators, moulaged casualties, graded trauma lanes, autologous blood transfusion training, and the use of live-tissue training (when logistically feasible) for selected course items such as surgical airways. Further, the 16-hour training time currently allotted for TCCC-MP training was found to be insufficient to present all of academic material and testing contained in the existing TCCC-MP curriculum. A 5-day course should be considered to include the entire JTS-recommended curriculum and to add graded trauma lanes and autologous blood transfusion training to the core JTS TCCC-MP curriculum. The post-course written testing also needs to use the standardized TCCC fund of knowledge questions and the TCCC Critical Decision Case Study questions developed by the JTS. Finally, there is a need to establish a systematic and standardized quality assurance program to ensure that TCCC training programs are carried out in accordance with the JTS-recommended TCCC curriculum. This program would best be performed as a new function of the CoTCCC with dedicated TCCC course appraisers.

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Summer 2020 Cover
Step Duration Effects on Blood Loss in Simulated Designs of Tourniquet Use Procedure

Kragh JF, Aden JK, Dubick MA 20(2). 76 - 82 (Journal Article)

Background: We sought new knowledge by further developing a model of using calculations in the simulation of a first-aid task. The purpose of this study was to develop the model to investigate the performance of tourniquet use in its component steps. Methods: We aimed to design an experiment on a desktop computer by mathematically manipulating simulated data in tourniquet use. A time factor of tourniquet use was ranged widely through time challenges in five degrees from ideal to worst performances. Redesigning the task was assessed by time costs and blood losses. Results: The step of tourniquet application took 17% of the trial time and securing the tourniquet after bleeding control took the longest amount of the trial time, 31%. A minority of the time (48% [17% + 31%] to apply tourniquet plus secure it) was spent after the tourniquet touched the patient, whereas most of the time (52%) was spent before the tourniquet touched the patient. The step of tourniquet application lost 14% of the total blood lost, whereas no blood was lost during securing the tourniquet, because that was the moment of bleeding control despite securing the tourniquet taking much time (31%). Most (86%) of blood lost occurred before the tourniquet touched the patient. But blood losses differed 10-fold, with a maximum of 2,434mL, which, when added to a pretask indication blood loss of 177mL, summed to 2,611mL. Before redesigning the task, costs of donning gloves and calling 9-1-1 included uncontrolled bleeding, but gloving mitigated risk of spreading pathogens among people. By step and person, redesigns of the task altered the risk-benefit profile. Conclusions: The model was useful because it simulated where most of the bleeding occurred before the tourniquet touched the patient. Modeling simulated redesigns of the task, which showed changes in the task's risk-benefit profile by step and among persons. The model generated hypotheses for future research, including the capability to screen candidate ideas among task designs.

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Summer 2020 Cover
Clothing Effects on Limb Tourniquet Application

Wall PL, Buising CM, Hingtgen E, Smith H, Renner CH 20(2). 83 - 94 (Journal Article)

Background: Sometimes tourniquets are applied over clothing. This study explored clothing effects on pressures and application process. Methods: Generation 7 Combat Application Tourniquets (C-A-T7), Generation 3 SOF® Tactical Tourniquets-Wide (SOFTTW), Tactical Ratcheting Medical Tourniquets (Tac RMT), and Stretch Wrap And Tuck Tourniquets (SWATT) were used with different clothing conditions (Bare, Scrubs, Uniform, Tights) mid-thigh and on models (ballistic gel and yoga mats). Results: Clothing affected pressure responses to controlled force applications (weight hangs, n=5 thighs and models, nonlinear curve fitting, p < .05). On models, clothing affected secured pressures by altering surface interactions (medians: Gel Bare C-A-T7 247mmHg, SOFTTW 99mmHg, Tac RMT 101mmHg versus Gel Clothing C-A-T7 331mmHg, SOFTTW 170mmHg, Tac RMT 148mmHg; Mats Bare C-A-T7 246mmHg, SOFTTW 121mmHg, Tac RMT 99mmHg versus Mats Clothing C-A-T7 278mmHg, SOFTTW 145mmHg, Tac RMT 138mmHg). On thighs, clothing did not significantly influence secured pressures (n=15 kneeling appliers, n=15 standing appliers) or occlusion and completion pressures (n=15). Eleven of 15 appliers reported securing on clothing as most difficult. Fourteen of 15 reported complete applications on clothing as most difficult. Conclusions: Clothing will not necessarily affect tourniquet pressures. Surface to tourniquet interactions affect the ease of strap sliding, so concern should still exist as to whether applications over clothing are dislodged in a distal direction more easily than applications on skin.

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Summer 2020 Cover
Tourniquets Last to Tourniquets First

Kragh JF, Aden JK, Dubick MA 20(2). 20 - 21 (Journal Article)

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Summer 2020 Cover
Tourniquest

Wall PL, Buising CM 20(2). 22 - 23 (Journal Article)

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Characterizing a System for Measuring Limb Tourniquet Pressures

20(1). 47 - 54 (Journal Article)

Background: Pressure is an important variable in emergency use limb tourniquet science. This study characterizes one system for measuring tourniquet-applied pressure. Methods: A neonatal blood pressure cuff bladder was inflated to target pressures over atmospheric. Unconstrained or constrained within 1-inch tubular polyester webbing, the neonatal cuff was placed in a 500mL Erlenmeyer flask. A 3-hole stopper provided connections to flask interior (chamber) and bladder pressure sensors and a 60mL syringe for altering chamber pressure: atmospheric to >1500mmHg absolute to atmospheric. Results: Within a finite range of chamber pressures, the neonatal cuffbased system accurately indicates applied pressure (minimum and maximum 95% confidence interval linear regression slopes of 0.9871 to 0.9953 and y-intercepts of -0.1144 to 2.157). The visually defined linear response ranges for bladder inflation pressures were as follows for unconstrained/ constrained: 100 to 400mmHg unconstrained/450mmHg constrained for 10mmHg, 150 unconstrained/100 constrained to 450mmHg for 12mmHg, 150 to 500mmHg for 15mmHg, 150 to 500mmHg unconstrained/550mmHg constrained for 18mmHg, 150 to 550mmHg for 21mmHg. Below the linear response range, the inflated bladder system indicated higher pressures than chamber pressures. Above the linear response range, the system indicated progressively lower pressures than chamber pressures. Conclusions: Within the linear response range, the bladder pressure accurately indicates surface-applied pressure.

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Explore the Space?

20(1). 145 (Journal Article)

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Freeze Dried Plasma Administration Within the Department of Defense Trauma Registry

20(1). 43 - 45 (Journal Article)

Hemorrhage is common among the combat injured, and plasma plays a vital role in blood product resuscitation. Regarding freeze dried plasma (FDP), US forces have had limited access to this product compared with other countries. In 2018, the US Food and Drug Administration provided emergency authorization for Department of Defense (DoD) use through the newly congressionally directed military use pathway. We describe the documented uses of FDP by US forces by performing a secondary analysis of two previously described datasets from the DoD Trauma Registry. In 11 identified cases, the median age was 28; cases were most frequently male, part of Operation Enduring Freedom, with US military affiliation, and injured by explosive or gunshot wound. The median injury severity score was 21; most did not receive a massive transfusion. Most survived to hospital discharge. Ongoing surveillance is warranted to optimize the implementation of FDP into military prehospital guidelines, training, and doctrine.

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Achilles Tendinopathy: Pathophysiology, Epidemiology, Diagnosis, Treatment, Prevention, and Screening

20(1). 125 - 140 (Journal Article)

Achilles tendinopathy (AT) is a clinical term describing a nonrupture injury of the Achilles tendon where the patient presents with pain, swelling, and reduced performance and symptoms exacerbated by physical activity. About 52% of runners experience AT in their lifetime and in the United States military the rate of clinically diagnosed AT cases was 5/1000 person-yr in 2015. The pathophysiology can be viewed on a continuum proceeding from reactive tendinopathy where tenocytes proliferate, protein production increases, and the tendon thickens; to tendon disrepair in which tenocytes and protein production increase further and there is focal collagen fiber disruption; to degenerative tendinopathy involving cell death, large areas of collagen disorganization, and areas filled with vessels and nerves. Inflammation may be present, especially in the early phases. Some evidence suggests AT pain may be due to neovascularization and the ingrowth of new nerve fibers in association with this process. Prospective studies indicate that risk factors include female sex, black race, higher body mass index, prior tendinopathy or fracture, higher alcohol consumption, lower plantar flexion strength, greater weekly volume of running, more years of running, use of spiked or shock absorbing shoes, training in cold weather, use of oral contraceptives and/ or hormone replacement therapy, reduced or excessive ankle dorsiflexion range of motion, and consumption of antibiotics in the fluoroquinolone class. At least 10 simple clinical tests are available for the diagnosis of AT, but based on accuracy and reproducibility, patient self-reports of morning stiffness and/or pain in the tendon area, pain on palpation of the tendon, and detection of Achilles tendon thickening appear to be the most useful. Both ultrasound and magnetic resonance imaging (MRI) are useful in assisting in diagnosis with MRI providing slightly better sensitivity and specificity. Conservative treatments that have been researched include: (1) nonsteroidal anti-inflammatory medication, (2) eccentric exercise, (3) stretching, (4) orthotics, (5) bracing, (6) glyceryl trinitrate patches, (7) injection therapies (corticosteroids, hyaluronic acid, platelet-rich plasma injections), (8) shock wave therapy, and (9) low-level laser therapy. Nonsteroidal anti-inflammatory medication and corticosteroid injections may provide short-term relief but do not appear effective in the longer term. Eccentric exercise and shock wave therapies are treatments with the highest evidence- based effectiveness. Prevention strategies have not been well researched, but in specific populations balance training (soccer players) and shock-absorbing insoles (military recruits) may be effective. Ultrasound scans might be useful in predicting future AT occurrences.

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Role of NATO Special Operations Combat Medics in Special Operations Surgical Teams

20(1). 141 - 144 (Journal Article)

Battlefield medicine is constantly evolving. Wound patterns, terrain, weapons, and medical evacuation change, so surgical capabilities must adapt. With the changing environment, we must evolve by adapting to offer the best practical care, closest to the frontline. The golden hour has never been a magical number, and the most successful care is provided by the most advanced practitioners as close to the point of injury as possible. The proper placement and access of surgical teams are a key factor in access to a casualty within minutes. NATO Special Operations combat medics (NSOCMs) are highly trained medical Operators who can work as a force multiplier, not only to the Special Operations elements in which they serve but also as members of a Special Operations surgical team (SOST), and these Soldiers can provide the essential skills necessary to best employ and support the surgical asset.

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Scrub Typhus

20(1). 120 - 122 (Journal Article)

Scrub typhus, also known as tsutsugamushi disease, is caused by Orientia sp. and approximately 1 million new cases are reported annually. This article discusses the importance of scrub typhus and its clinical presentation, diagnosis, treatment, and prevention.

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Optimizing Special Operations Forces Operator Talents and Mission Capabilities: Human Performance Optimization and Total Force Fitness Capability-Based Blueprint and Targeting System

20(1). 113 - 119 (Journal Article)

The Special Operations Forces (SOF) community represents an impressive degree of diversity in talents, culture, mission essential tasks, and occupational risk exposures across Service branches, their career fields, and units. Sustaining the capabilities of the SOF Operator across a career lifespan requires collaboratively addressing the current gap between medical readiness and mission readiness with support services and their SOF end users. Given the diverse needs of SOF Operators and their units, realigning performance and health (P&H) service delivery to meet their specific needs will require the adoption of an alternative business framework, operationally focused metrics, and retargeting to ensure SOF Operators are not just medically ready, but mission ready. With restructuring of P&H service delivery occurring across the Department of Defense at all levels to support the 2018 National Defense Strategy, there is a greater need for collaborative synchronization, targeting, and validating operational return on investment with SOF Operators and SOF stakeholders. Here, we present the Human Performance Optimization (HPO) and Total Force Fitness (TFF) Capabilities-Based Blueprint (CBB) and Targeting System as an initial step to realigning service delivery. We examine the use of CBB as a translational tool to bridge the divide between P&H services and SOF Operator communities, and demonstrate how the CBB has significant applications to help construct appropriate programming and program evaluation, align resources and needs, and provide culturally appropriate services that should sustainably preserve SOF Operators' unique capabilities and their mission.

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Effect of Special Operations Training on Testosterone, Lean Body Mass, and Strength and the Potential for Therapeutic Testosterone Replacement: A Review of the Literature

20(1). 94 - 100 (Journal Article)

Objective: Due to physical demands, Special Operations Forces (SOF) endure changes in body composition, work capacity, and endocrine function. These changes result in energy deficits and sleep deprivation, where sleep averaged 3 hours/ day, independently known to decrease testosterone levels. The use of exogenous testosterone shows increases in lean body mass (LBM) and muscle function in healthy males and reverses cachexia in diseased populations. Therefore, the review's primary purpose is to summarize and contrast literature in both SOF and nonmilitary personnel regarding the correlation between negative energy balance, sleep deprivation, and decreased testosterone. The secondary purpose summarizes the effects of exogenous testosterone therapy in healthy males as well as reversing the effects of muscle wasting diseases. Methods: An online literary search from 1975 to 2015 identified 46 of 71 sources addressing both purposes, and data were summarized into tables providing mean observations. Conclusions: SOF training results in decreased testosterone (-6.3%), LBM (-4.6%), and strength (-11.7%), tied to energy deficits (-3,351 kcal/day) and sleep deprivation (3 hours/ day). Exogenous testosterone therapy increases LBM (6.2%), strength (7.9-14.8%), reverses cachexia (2.0%) and increases strength (12.7%) in those with chronic diseases. Therefore, testosterone supplementation in SOF may attenuate changes in body composition and muscle function during training and sustained Special Operations (SUSOPS).

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Canine Tactical Combat Casualty Care (K9TCCC) Guidelines

20(1). 101 - 111 (Journal Article)

First introduced in 1996, Tactical Combat Casualty Care (TCCC) redefined prehospital, point-of-injury (POI), battlefield trauma care for the human combat casualty. Today, many consider TCCC as one of the most influential interventions for reducing combat-related case fatality rates from preventable deaths in human combat casualties. Throughout history, Military Working Dogs (MWDs) have proved and continue to prove themselves as force multipliers in the success of many military operations. Since the start of the Global War on Terror in 2001, these elite canine operators have experienced an upsurge in combat-related deployments, placing them at a higher risk for combat-related injuries. Until recently, consensus- based Canine-TCCC (K9TCCC) guidelines for POI battlefield trauma care did not exist for the MWD, leaving a critical knowledge gap significantly jeopardizing MWD survival. In 2019, the Canine Combat Casualty Care Committee was formed as an affiliate of the Committee on Tactical Combat Casualty Care with the intent of developing evidence- based, best practice K9TCCC guidelines. Modeled after the same principles of the human TCCC, K9TCCC focuses on simple, evidence-based, field-proven medical interventions to eliminate preventable deaths and to improve MWD survival. Customized for the battlefield, K9TCCC uniquely adapts the techniques of TCCC to compensate for canine-specific anatomic and physiological differences.

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Feasibility Study of Vascular Access and REBOA Placement in Quick Response Team Firefighters

20(1). 81 - 86 (Journal Article)

Background: Early hemorrhage control using resuscitative endovascular balloon occlusion of the aorta (REBOA) can save lives. This study was designed to evaluate the ability to train Quick Response Team Fire Fighters (QRT-FF) to gain percutaneous femoral artery access and place a REBOA catheter in a model, using a comprehensive theoretical and practical training program. Methods: Six QRT-FF participated in the training. SOF medics from a previous training served as the control group. A formalized training curriculum included basic anatomy and endovascular materials for percutaneous access and REBOA placement. Key skills included (1) preparation of an endovascular toolkit, (2) achieving vascular access in the model, and (3) placement and positioning of REBOA. Results: QRT-FF had significantly better scores compared with medics using endovascular materials (P = .003) and performing the procedure without unnecessary attempts (P = .032). Basic surgical anatomy scores for QRT-FF were significantly better than SOF medics (P = .048). QRT-FF subjects demonstrated a significantly higher overall technical skills point score than medics (P = .030). QRT-FF had a median total time from start of the procedure to REBOA inflation of 3:23 minutes, and medics, 5:05 minutes. All six QRT-FF subjects improved their procedure times-as did four of the five medics. Conclusions: Our training program using a task training model can be utilized for percutaneous femoral access and REBOA placement training of QRT-FF without prior ultrasound or endovascular experience. Training the use of advanced bleeding control options such as REBOA, as a secondary occupational task, has the potential to improve outcomes for severely bleeding casualties in the field.

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Low-Level Blast Exposure in Humans A Systematic Review of Acute and Chronic Effects

20(1). 87 - 93 (Journal Article)

There is growing concern that military breaching and training and firing artillery and mortars, grenades, and shoulder-fired weapons may have some type of cumulative deleterious effects. There are anecdotal reports of those with repetitive exposure to low-level blast complaining of various symptoms, as well as increasing empirical evidence. The purpose of this report is to provide a systematic review of the literature on repetitive lowlevel blast as it pertains to military and police training protocols. An extensive literature search was conducted, resulting in detailed review of 18 studies. Results suggest few consistent findings, likely due to the heterogeneity of methods, high risk of bias, and lack of reliance on objective blast-exposure data. Adverse effects, when present, dissipated over time. All studies that used blast gauges found significant associations, though only a subset actually reported using the blast-gauge data (to correlate objective exposure with outcomes). When comparing studies within an outcome domain (e.g., cognitive), findings were largely inconsistent. Research with larger sample sizes, followed longitudinally, is needed.

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