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Beyond Tears: The Potential Hazards Of The O-Chlorobenzylidene-Malononitrile (Cs) Gas Under Scrutiny

Asuku ME, Milner SM, Gerold KB 11(4). 28 - 30 (Journal Article)

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The Supply of Pharmaceuticals in Humanitarian Assistance Missions: Implications for Military Operations

Mahmood M, Riley K, Bennett D, Anderson W 11(4). 37 - 42 (Previously Published)

In this article, we provide an overview of key international guidelines governing the supply of pharmaceuticals during disasters and complex emergencies. We review the World Health Organization's guidelines on pharmaceutical supply chain management and highlight their relevance for military humanitarian assistance missions. Given the important role of pharmaceuticals in addressing population health needs during humanitarian emergencies, a good understanding of how pharmaceuticals are supplied at the local level in different countries can help military health personnel identify the most appropriate supply options. Familiarity with international guidelines involved in cross-border movement of pharmaceuticals can improve the ability of military personnel to communicate more effectively with other actors involved in humanitarian and development spheres. Enhancing the knowledge base available to military personnel in terms of existing supply models and funding procedures can improve the effectiveness of humanitarian military operations and invite policy changes necessary to establish more flexible acquisition and funding regulations.

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No Shit, There I Was: The Case for Narrative-Based Clinical Knowledge

Froede K 11(4). 21 - 24 (Journal Article)

Relevant literature demonstrates the absolute necessity of Special Operations Forces (SOF) clinical narratives to the medics they teach and care they deliver, and discusses the concept of narrative pedagogy via review of extant literature and also SOF-specific clinical literature. SOF clinicians (medics, physicians' assistants, physicians, etc.) provide advanced trauma, clinical, and preventive care in the most austere of combat environments. SOF clinicians have adopted specific paradigms for schooling, teaching, learning, and practice. An overarching theme within SOF-generated clinical literature is that of hermeneutics and the narrative pedagogy; SOF clinicians generate their evidence from experience and frequently tell stories to educate their peers, colleagues, and student medics to increase the knowledge of the entire community.

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Benefit of Critical Care Flight Paramedic-Trained Search and Rescue Corpsmen in Treatment of Severely Injured Aviators

Snow RW, Papalski W, Siedler J, Drew B, Walrath B 18(1). 19 - 22 (Case Reports)

During routine aircraft start-up procedures at a US Naval Air Station, an aviation mishap occurred, resulting in the pilot suffering a traumatic brain injury and the copilot acquiring bilateral hemopneumothoraces, a ruptured diaphragm, and hepatic and splenic contusions. The care of both patients, including at point of injury and en route to the closest trauma center, is presented. This case demonstrates a benefit from advanced life-saving interventions and critical care skills beyond the required scope of practice of search and rescue medical technicians as dictated by relevant instructions.

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Military Prehospital Use of Low Titer Group O Whole Blood

Warner N, Zheng J, Nix G, Fisher AD, Johnson JC, Williams JE, Northern DM, Hellums JS 18(1). 15 - 18 (Case Reports)

The military's use of whole-blood transfusions is not new but has recently received new emphasis by the Tactical Combat Casualty Care Committee. US Army units are implementing a systematic approach to obtain and use whole blood on the battlefield. This case report reviews the care of the first patient to receive low titer group O whole blood (LTOWB) transfusion, using a new protocol.

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Proficiency in Improvised Tourniquets for Extremities: A Review

Rohrich C, Plackett TP, Scholz BM, Hetzler MR 19(3). 123 - 127 (Journal Article)

Tourniquets have become ubiquitous tools for controlling hemorrhage in the modern prehospital environment, and while commercial products are preferable, improvised tourniquets play an important role when commercial options are not available. A properly constructed improvised tourniquet can be highly effective provided the user adheres to certain principles. This review article identifies key skills in the construction and application of improvised tourniquets on an extremity. An improvised tourniquet design for an extremity should include three components: a strap, a rod, and a securing mechanism. The strap can be made from a variety of materials, but cravat- like fabric has been shown to work well. Optimal strap dimensions should be at least 2cm in width and a continuous segment long enough to extend around the extremity while still offering ends to accommodate and secure the rod. The rod should be constructed from a material that is hard, strong, and capable of withstanding the torque placed on it without bending or breaking. After torque is applied, the rod must be secured into position to maintain the constricting force and survive patient transport. Finally, the need for an improvised tourniquet is a contingency that all first responders should anticipate. Hands-on training should be conducted routinely in conjunction with other first responder tasks.

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Challenges of Transport and Resuscitation of a Patient With Severe Acidosis and Hypothermia in Afghanistan

Brazeau MJ, Bolduc CA, Delmonaco BL, Syed AS 18(1). 23 - 28 (Case Reports)

We present the case of a patient with new-onset diabetes, severe acidosis, hypothermia, and shock who presented to a Role 1 Battalion Aid Station (BAS) in Afghanistan. The case is unique because the patient made a rapid and full recovery without needing hemodialysis. We review the literature to explain how such a rapid recovery is possible and propose that hypothermia in the setting of his severe acidosis was protective.

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The Shrail: A Comparison of a Novel Attachable Rail System With the Current Deployment Operating Table

Dilday J, Sirkin MR, Wertin T, Bradley F, Hiles J 18(1). 29 - 31 (Case Reports)

The current forward surgical team (FST) operating table is heavy and burdensome and hinders essential movement flexibility. A novel attachable rail system, the Shrail, has been developed to overcome these obstacles. The Shrail turns a North Atlantic Treaty Organization litter into a functional operating table. A local FST compared the assembly of the FST operating table with assembling the Shrail. Device weight, storage space, and assembly space were directly measured and compared. The mean assembly time required for the Shrail was significantly less compared with the operating table (23.36 versus 151.6 seconds; p ≤ .01). The Shrail weighs less (6.80kg versus 73.03kg) and requires less storage space (0.019m3 versus 0.323m3) compared with the current FST operating table. The Shrail provides an FST with a faster, lighter surgical table assembly. For these reasons, it is better suited for the demands of an FST and the implementation of prolonged field care.

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Optimizing Warfighter Lethality Through Human Performance Education

Deuster PA, Lunasco T, Messina LA 19(2). 100 - 104 (Journal Article)

Humans are the heart of our warfighting efforts and, as such, human performance must be optimized and sustained to maintain effective and successful SOF Operators over the long haul. How do we do this? Based on the July 2018 signing of a Joint Requirements Oversight Council Memo (JROC) making Total Force Fitness (TFF) a required framework for taking care of our military Servicemembers, we propose three solutions for further optimizing the performance of SOF. The proposed solutions are human performance optimization (HPO)/TFF capability-based blueprinting (CBB), HPO integrator profession (HPO-I), and HPO-centric education and training across the total force. These solutions would potentiate the Preservation of the Force and Family (POTFF) concept by improving the targeting of resources and support of Operator and unit operational readiness. These solutions, the knowledge, skills, abilities, and experiences in HPO from a holistic perspective and the opportunity to obtain college credits through the Uniformed Services University of the Health Sciences (USU) College of Allied Health Sciences (CAHS) are described here.

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Measles Vaccination: A Matter of Confidence and Commitment

Turner R 19(2). 105 - 106 (Journal Article)

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In Vitro Compatibility of Canine and Human Blood: A Pilot Study

Edwards TH, Wienandt NA, Baxter RL, Mays EL, Gay SD, Cap AP 19(2). 95 - 99 (Journal Article)

Military working dogs (MWDs) are force multipliers that are exposed to the same risks as their human counterparts on the battlefield. Hemostatic resuscitation using blood products is a cornerstone of damage control resuscitation protocols for both humans and dogs. Canine-specific blood products are in short supply in mature theaters due to logistic and regulatory concerns and are almost nonexistent in austere environments, whereas human blood products are readily available at most surgical facilities. The objective of this study was to evaluate the in vitro compatibility of human and canine blood by using standard crossmatching techniques with the canine blood acting as the recipient and the human blood acting as the donor. Blood samples were collected from 20 government-owned canines (GOCs) and 7 healthy human volunteers in addition to washed red blood cells (RBCs) from a commercial blood typing kit. Major and minor crossmatches were conducted as well as a protein denatured crossmatch. All samples in this study showed strong cross-reactivity, with the majority demonstrating profound hemolysis and a minority showing substantial agglutination. Based on the results of this study, transfusion of human blood to an MWD cannot be recommended at this time.

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ReSTRAiN Yourself Before Diagnosing Strain

Hampton K, Van Humbeeck L 19(3). 122 (Journal Article)

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Documentation in Prolonged Field Care

Loos PE, Glassman E, Doerr D, Dail R, Pamplin JC, Powell D, Riesberg JC, Keenan S, Shackelford S 18(1). 126 - 132 (Journal Article)

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Prehospital Medicine and the Future Will ECMO Ever Play a Role?

Macku D, Hedvicak P, Quinn JM, Bencko V 18(1). 133 - 138 (Journal Article)

Due to the hybrid warfare currently experienced by multiple NATO coalition and NATO partner nations, the tactical combat casualty care (TCCC) paradigm is greatly challenged. One of the major challenges to TCCC is the ad hoc extension phase in resource-poor environments, referred to as prolonged field care (PFC) and forward resuscitative care (FRC). The nuanced clinical skills with limited resources required by warfighters and auxiliary health care professionals to mitigate death on the battlefield and prevent morbidity and mortality in the PFC phase represent a balance that is still under review. The aim of our article is to describe the connection between extracorporeal membrane oxygenation (ECMO) or the extracorporeal life support (ECLS) treatment and its possible improvement in prehospital trauma care, at a Role 1 or 2 facility and, more provocatively, in the PFC phase of care in the future through innovative technology and how it connects with FRC. We report and describe here the primary components of ECMO/ECLS and present the main concept of a human extracorporeal circulation cocoon as a transitional living form for the cardiopulmonary stabilization of wounded combatants on the battlefield and their transportation to higher echelons of care and treatment facilities (to include damage control resuscitation [DCR] and damage control surgery [DCS]). As clinical governance, these matters would fall within the remit of the Committee on Surgical Combat Casualty Care (CoSCCC) and the Committee on Enroute Combat Casualty Care (CoERCCC), and it is within this framework that we propose this concept piece of ECMO in the prehospital space. We caution that this report is a proposed innovation to TCCC but also serves to push the envelope of the PFC and FRC paradigm. What we propose will not change the practice this year, but as ECMO technology progresses, it may change our practice within the next decade. We conclude with proposed novel future research to save life on the battlefield with ECMO as a major challenge and one worth the focus of further research. Medicine is controversial and constantly changing; for those who work in prehospital and battlefield medicine, change is the only constant on which we rely, and without provocative discussion that makes our systems and practice more robust, we will fail.

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Epidemiological Evidence and Possible Mechanisms for the Association Between Cigarette Smoking and Injuries (Part 1)

Knapik JJ, Bedno SA 18(1). 108 - 112 (Journal Article)

Surveys indicated that 24% of military personnel are current cigarette smokers. Smoking is well known to increase the risk of cancers, cardiovascular and respiratory diseases, reproductive problems, and other medical maladies, but one of the little known effects of smoking is that on injuries. There is considerable evidence from a variety of sources that (1) smoking increases overall injury risk, (2) the greater the amount of smoking, the higher is the injury risk, and (3) smoking is an independent injury risk factor. Smoking not only affects the overall injury risk but also impairs healing processes following fractures (e.g., longer healing times, more nonunions, more complications), ligament injury (e.g., lower subjective function scores, greater joint laxity, lower subsequent physical activity, more infections), and wounding (e.g., delayed healing, more complications, less satisfying cosmetic results). Smoking may elicit effects on fractures through low bone mineral density (BMD), lower dietary intake of calcium and vitamin D, altered calcium metabolism, and effects on osteogenesis and sex hormones. Effects on wound healing may be mediated through altered neutrophils and monocytes functions resulting in reduced ability to fight infections and remove damaged tissue, reduced gene expression of cytokines important for tissue healing, and altered fibroblast function leading to lower density and amount of new tissue formation. Limited data suggest smoking cessation has favorable effects on various aspects of bone health over periods of 1 to 30 years. Favorable effects on neutrophil and monocyte functions may occur as early as 4 weeks, but fibroblast function and collagen metabolism (important for wound remodeling) appear to take considerably longer and may be dependent on the amount of prior smoking. Part 2 of this series will use this information to explore the possibility of a causal relationship between smoking and injuries.

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Integrating Chemical Biological, Radiologic, and Nuclear (CBRN) Protocols Into TCCC Introduction of a Conceptual Model - TCCC + CBRN = (MARCHE)2

DeFeo DR, Givens ML 18(1). 118 - 123 (Journal Article)

The authors would like to introduce TCCC [Tactical Combat Casualty Care] + CBRN [chemical, biological, radiological, and nuclear] = (MARCHE)2 as a conceptual model to frame the response to CBRN events. This model is not intended to replace existing and well-established literature on CBRNE events but rather to serve as a response tool that is an adjunct to agent specific resources.

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Spiritual Fitness: An Essential Component of Human Performance Optimization

Worthington D, Deuster PA 18(1). 100 - 105 (Journal Article)

Spirituality is a key interweaving and interacting domain, and an integral component for maintaining Special Operations Forces readiness; however, it remains an under-researched and likely one of the most poorly understood domains of Preservation of the Force and Family and Total Force Fitness initiatives. Although there are numerous factors that contribute to spiritual performance or spiritual fitness, core values and value-directed living are essential. An initial step toward spiritual performance or fitness is developing core values and identity, followed by a second step toward spiritual performance or fitness, which is developing an increased awareness and deeper understanding of those values. This process of developing core values and identity, and building awareness can be enhanced through cognitive flexibility and agility (psychological performance domain). This article explains the importance of "spirituality" as a component of Special Operations Forces performance and describes approaches to enhancing performance through various spiritual activities, including mindfulness, meditation, and prayer. These three practices can be adapted and modified to be more vertical or more horizontal in their application.

$37.00
Giardiasis

Burnett MW 18(1). 106 - 107 (Journal Article)

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Routine Screening Laboratory Studies for Nonheat Stroke Field Heat Injuries Are Unnecessary: A Retrospective Review

Schauer SG, Pfaff JA 18(1). 88 - 90 (Journal Article)

Background: Heat injuries are common in the military training environment. Base policies often mandate that heat causalities require evaluation at a higher level of care, which comes at significant use of resources. Laboratory studies are often ordered routinely, but their utility is unclear at this time. Methods: This project evaluated the use of screening laboratory studies for heat casualties brought to Bayne-Jones Army Community Hospital, Fort Polk, Louisiana. Casualties brought from the field directly to the emergency department (ED) were included. Abnormalities in laboratory study findings, admission/discharge rates, and length of stay were documented. Results: From May through September 2014, 104 casualties were seen in the ED because of heat injury. Laboratory tests were ordered for 101 patients. Of these, 11 patients were admitted to the hospital because of laboratory, history, and/or physical examination abnormalities. Nine were discharged in less than 24 hours. The remaining two were discharged within 48 hours; both had documented altered mental status on arrival to the ED. Laboratory test abnormalities were seen in most of the patients and appeared to have no impact on the decision to admit. Conclusion: Routine laboratory studies appeared to have low clinical utility in this patient population. A more targeted approach based on the history and physical examination may reduce military resource use.

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